Third universal definition of myocardial infarction

Impact of Peripheral Arterial Disease on Clinical Outcomes of Patients Undergoing Complex vs Noncomplex Percutaneous Coronary Intervention

Peripheral arterial disease (PAD) often predicts poor outcomes in patients undergoing percutaneous coronary intervention (PCI). Here we examine the impact of PAD in patients receiving complex PCI (CPCI) and noncomplex PCI. Patients undergoing PCI at the Mount Sinai Hospital between 2012 and 2022 were stratified by the presence of CPCI and PAD. The primary outcome was major adverse cardiovascular events (MACE), a composite of death, myocardial infarction, target vessel revascularization, or stroke within 1 year; secondary endpoints included bleeding events. An adjusted Cox proportional hazard method was used to evaluate risks of each outcome within each subgroup. Among 20,376 patients, 8,200 (40.2%) had CPCI and 1,959 (9.6%) had PAD. PAD patients were older and more likely to be female and have risk factors such as diabetes and smoking and were more commonly discharged with anticoagulants. 1-year risk of MACE was significantly higher for patients with PAD in both CPCI (19.6% vs 14.4%, adj. hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.08 to 1.58, p = 0.006) and no-CPCI strata (13.9% vs 9.2%, adj. HR 1.35, 95% CI 1.12 to 1.64, p = 0.002; p-interaction = 0.349). Bleeding events were also more frequent in PAD patients for CPCI (8.5% vs 5.5%, adj. HR 1.40, 95% CI 1.07 to 1.84, p = 0.014) and no-CPCI (7.1% vs 4.3%, adj. HR 1.52, 95% CI 1.18 to 1.96, p = 0.001; p-interaction = 0.608). In conclusion, presence of PAD is associated with a significantly increased risk of MACE and bleeding after PCI, regardless of procedural complexity.

Incremental value of coronary computed tomography angiography in addition to invasive coronary angiography in MINOCA

Patients with the working diagnosis myocardial infarction with nonobstructive coronary arteries (MINOCA) have diverse underlying causes warranting further investigations. Despite the documented superiority of coronary computed tomography angiography (CCTA) over invasive coronary angiography (ICA) in plaque detection, the former is not routinely recommended for MINOCA patients, highlighting a knowledge gap regarding CCTA's incremental value. The objective of this study is to assess the prevalence and extent of coronary atherosclerosis in MINOCA patients using CCTA, and to evaluate the incremental value of CCTA over ICA alone in detecting coronary atherosclerosis. The data from 163 MINOCA patients who underwent both CCTA and ICA in two prospective studies were retrospectively analyzed to compare the occurrence and distribution of coronary atherosclerotic plaques detected with ICA versus CCTA, evaluating CCTA's incremental value. CCTA detected coronary atherosclerosis in 48% of subjects; ICA did so in 47%. Notable disagreement, reflected by kappa values of 0.34 (95% confidence interval [CI] 0.19-0.48) across all segments and 0.41 (95% CI 0.27-0.55) for proximal segments (both p < 0.0001), highlighted discrepancies between CCTA and ICA in the detection of atherosclerosis presence and location. Combining CCTA with ICA provided significant incremental value in detecting atherosclerosis in coronary segments (p < 0.001). MINOCA patients frequently exhibit non-obstructive coronary plaques. Agreement between CCTA and ICA is poor. CCTA provides valuable additional information on atherosclerotic segments. Therefore, CCTA should be recognized as a complementary tool to ICA, aiding risk assessment and treatment decisions in the context of MINOCA.

Capturing Acute and Subchronic Myocardial Infarct by MRI Rotating Frame Relaxation Times in Mice In and Ex Vivo

Cardiovascular diseases are the leading cause of death worldwide due to population growth and aging. Myocardial infarct is one of the most crucial cardiovascular diseases. Acute myocardial infarct is conventionally imaged with magnetic resonance imaging (MRI) with T2 mapping due to its sensitivity related to the correlation times of edema and free water molecules. Chronic myocardial infarction, which contains fibrosis and scar tissue, is conventionally imaged with MRI by using contrast agents since contrast agent washout from fibrosis and scar tissue is delayed compared to myocardium. Rotating frame relaxation times T1ρ and T2ρ mappings were developed to provide robust measurements with relatively wide B1 and B0 ranges for these quantities. Since rotating frame methods are sensitive to slow molecular motions, these methods owe potential to characterize both acute and chronic myocardial infarctions. In this study, rotating frame relaxation time mappings were applied to image acute (2 h) and subchronic (7 days after occlusion) myocardial infarcts in in vivo and ex vivo mouse models without using contrast agents. The in vivo imaging protocol contained adiabatic T1ρ and adiabatic T2ρ, both with hyperbolic secant (HS) 1 and 4 pulses, continuous wave T1ρ and conventional T2, together with cine imaging. Mice were imaged 2 h and 7 days after myocardial infarction. Mice were sacrificed at the 2-h or 7-day time point. Ex vivo measurements contained adiabatic T1ρ and adiabatic T2ρ with HS1 and HS4 pulses, continuous wave T1ρ, T1, and T2. After MRI studies, mouse hearts were fixed, and myocardial infarcts were verified using dystrophin and hematoxylin and eosin histology stainings. A clear difference between infarcted and normal myocardium was visible at the 2-h time point in rotating frame relaxation time mapping. Relative relaxation time difference in adiabatic T2ρ with HS4 pulse showed the significant differences between MI and control hearts in vivo. In addition, the results of adiabatic T1ρ with both HS1 and HS4 pulses and continuous wave T1ρ measurements showed significant differences between MI and control hearts at both time points in both in vivo and ex vivo measurements. This study shows that rotating frame relaxation time mappings have the potential to be noninvasive MR diagnostic markers for acute and subchronic myocardial infarcts.

Incorporating the STOP-BANG questionnaire improves prediction of cardiovascular events during hospitalization after myocardial infarction

Obstructive sleep apnea (OSA) may impact outcomes in acute coronary syndrome (ACS) patients. The Global Registry of Acute Coronary Events (GRACE) score assesses cardiovascular risk post-ACS. This study evaluated whether incorporating the STOP-BANG score (a surrogate for OSA) enhances GRACE's predictive ability. A total of 227 myocardial infarction (MI) patients were included, with 66 (29.07%) experiencing in-hospital cardiovascular events. Patients with events were older, predominantly male, and had worse clinical markers, including lower hemoglobin and ejection fraction and higher RDW, creatinine, CRP, and GRACE scores (p < 0.001). While STOP-BANG was higher in event patients, risk group classification was non-significant (p = 0.3). Three models were trained: (1) all selected features, (2) GRACE alone, and (3) GRACE + STOP-BANG. The Extra Trees Classifier performed best (ROC-AUC = 0.82). Adding STOP-BANG improved the F1-score, accuracy, and precision but had a non-significant effect on ROC-AUC. The decision curve analysis showed an increased net benefit when STOP-BANG was incorporated. Feature importance analysis ranked STOP-BANG highest in models, reinforcing its relevance. While this study showed that STOP-BANG improved risk stratification, further multicenter validation is needed to confirm its clinical utility in ACS risk models.

Effect of constipation on hospitalization due to heart failure in patients after myocardial infarction: a retrospective cohort study

BACKGROUND

Patients with constipation after acute heart failure (HF) are at high risk of rehospitalization due to HF. Although HF after myocardial infarction (MI) affects patient outcomes, the relationship between constipation and patient prognosis after MI remains unclear. In this study, we evaluated the effects of constipation on the prognosis of patients with MI, focusing on hospitalization due to HF.

METHODS

We investigated 1,324 patients with MI admitted to our hospital between January 2012 and December 2023 (mean age, 68 ± 14 years; 76% males). Patients with constipation were defined as those using laxatives regularly.

RESULTS

During the follow-up period (median, 2.7 years), 115 patients died, and 99 were re-hospitalized due to HF. Landmark Kaplan-Meier analyses revealed incidences of 7.8% and 2.1% hospitalization due to HF from 0 to 0.5 years (log-rank: p < 0.0001) and 4.8% and 3.9% from 0.5 to 3 years (log-rank: p = 0.17) among patients with and without constipation, respectively. The adjusted Cox proportional hazards analysis revealed a significantly higher risk of hospitalization due to HF from 0 to 0.5 years in patients with constipation than in those without it (hazard ratio, 2.12; 95% confidence interval, 1.07-4.19; p = 0.032). However, no significant difference was found from 0.5 to 3 years (hazard ratio, 0.86; 95% confidence interval, 0.47-1.57; p = 0.63).

CONCLUSIONS

Constipation was strongly associated with a higher risk of hospitalization due to HF in patients with MI during the first 6 months after discharge.

Validation of Takotsubo Syndrome Scoring System

Background: Takotsubo syndrome (TS) mimics acute coronary syndrome in 1% to 3% of patients presenting with chest pain, ECG changes and echocardiographic transient apical wall hypokinesia. Objectives: This study aimed to validate a previously developed scoring system on a larger cohort size. Methods: Patients admitted to an intensive cardiovascular care unit were divided into three groups: (a) patients diagnosed with TS, (b) females with anterior MI, and (c) other all-comer STEMIs. A 10-point scoring system was used: stressful events (three points), female gender (two points), no history of diabetes mellitus (two points), estimated left ventricular ejection fraction (LVEF) ≤ 40% on admission echocardiography (one point), positive troponin on admission (one point), and no smoking (one point). A t-test was applied to the three study groups, sensitivity and specificity testing was performed using the ROC curve method. Results: A total of 1150 patients were included in our study: 54 with TS, 97 females with anterior MI and 999 other all-comer STEMIs. Patients in the TS group were predominantly females with a higher rate of stressful events prior to admission, lower rates of diabetes mellitus and smoking, and lower LVEF% systolic function compared to the STEMI cohort. In a multivariate logistic regression analysis, the average TS scoring system was significantly higher in the TS group compared with the anterior STEMI and all-comer STEMI groups (8.3 vs. 5.7 vs. 3.83, p < 0.001, respectively) with an AUC of 0.83 for TS score ≥ 8. Conclusions: The 10-point TS scoring system is an easy, reliable, and useful diagnostic tool that might help in distinguishing patients with TS and ACS.

Skeletal Muscle as a Mediator of Interorgan Crosstalk During Exercise: Implications for Aging and Obesity

Physical exercise is critical for preventing and managing chronic conditions, such as cardiovascular disease, type 2 diabetes, hypertension, and sarcopenia. Regular physical activity significantly reduces cardiovascular and all-cause mortality. Exercise also enhances metabolic health by promoting muscle growth, mitochondrial biogenesis, and improved nutrient storage while preventing age-related muscle dysfunction. Key metabolic benefits include increased glucose uptake, enhanced fat oxidation, and the release of exercise-induced molecules called myokines, which mediate interorgan communication and improve overall metabolic function. These myokines and other exercise-induced signaling molecules hold promise as therapeutic targets for aging and obesity-related conditions.

Periprocedural myocardial injury after recanalization of chronically occluded right coronary arteries, relation to side-branch occlusion and procedural technique

BACKGROUND

Recanalization of chronic total coronary occlusions (CTO) is associated with a high incidence of periprocedural myocardial ischemia (PMI).

AIMS

This study should assess its causes with special focus on the relation to side branch occlusions (SBO) of the right coronary artery (RCA) with its specific anatomy of side branches.

METHODS

1574 recanalizations of a RCA CTO were analyzed with high-sensitive troponin T (hsTnT) drawn before and after the procedure. All angiograms were checked for SBO after the procedure. PMI was defined as hsTnT increase >5× upper limit of normal. Additional thresholds were > 18× (PMI18) and > 35× (PMI35).

RESULTS

PMI occurred in 51.6 %, PMI18 in 19.9 %, and PMI35 in 8.9 %. Excluding procedures with major complications (3.1 %), the major determinants of PMI were chronic kidney disease, a long fluoroscopy time, and single and multiple SBO. Overall side branch occlusions occurred in 26.8 % even without PMI, and with increasing rate with higher PMI thresholds up to 56.4 % with PMI35. Proximal SBO caused the highest hsTnT increase, followed by mid and distal location. The highest incidence occurred with retrograde approach (50.8 %) and antegrade dissection re-entry (71.4 %). The combination of PMI and SBO would lead to the diagnosis of type IVa myocardial infarction in 23.4 %, with PMI18 in 10.2 %, and with PMI35 in 4.7 %.

CONCLUSIONS

SBO occur frequently after CTO PCI of the RCA and are a major determinant of PMI. Even without clinical complications the combination of various thresholds of PMI and SBO would yield a high incidence of type IVa myocardial infarction.

Early readmission after adrenalectomy for pheochromocytoma. A retrospective study

PURPOSE

Adrenalectomy for pheochromocytoma (PHEO) presents a significant challenge due to the high incidence of early hospital readmission (ER). This study evaluated the incidence and risk factors of ER for PHEO within 30 days of adrenalectomy.

METHODS

A retrospective analysis of 346 patients > 18 years with unilateral PHEO who underwent adrenalectomy between September 2012 and September 2024. The patients were categorised into ER (n = 49) and no ER (n = 297) groups. Logistic regression analyses were performed to predict risk factors for ER.

RESULTS

The most common causes of ER were postoperative maintained hypotension (42.9%), bleeding (6.1%), ileus (24.5%), wound infection (4.1%), hyperkalemia (8.2%), pneumonia (2%), intra-abdominal abscess (2%), acute MI (4.1%), and colonic injury (6.1%). Most postoperative complications were Clavien-Dindo grade II (n = 40, 81.6%). Two perioperative deaths (4%) occurred in the ER group. Logistic regression showed that low body mass index (OR 0.849, 95% CI, 0.748-0.964; p = 0.012), tumor size < 5 cm (OR 0.096, 95% CI, 0.030-0.310; p < 0.001), and low ASA (OR 0.435, 95% CI, 0.249-0.761; p = 0.003) were associated with risk reduction for ER while malignancy (OR 5.302, 95% CI, 1.214-23.164; p = 0.027), open approach(OR 12.247, 95% CI, 5.227-28.694; p < 0.001), and intraoperative complications (OR 19.149, 95% CI, 7.091-51.710; p < 0.001) were associated with risk increase of ER.

CONCLUSION

Postoperatively maintained hypotension and ileus were the most common causes of ER. Low body mass index, tumour size < 5 cm, and low ASA were risk reductions for ER, while malignancy, open approach, and intraoperative complications were the independent risk increase factors.

Long term outcomes of drug-coated balloons versus drug-eluting stents in patients with small vessel coronary artery disease

OBJECTIVE

Drug-eluting stents (DES) are a normative care of coronary stenosis. However, their efficacy was limited by stent thrombosis and in-stent restenosis especially in small vessel coronary artery disease (SvCAD). The aim of this study was to assess angiographic efficacy and clinical outcomes of drug coated balloons (DCB) as compared with DES in SvCAD setting.

METHODS

A total of 100 SvCAD patients with percutaeous angioplasty of culprit coronary arteries <3 mm diameter and >70 % stenosis were enrolled in this study. The patients were categorized into DES arm and DCB arm. One year clinical outcomes were assessed. The primary endpoint was in-lesion late lumen loss (LLL). The secondary endpoints were vessel thrombosis, major bleeding, all-cause death and major adverse cardiac events (MACEs).

RESULTS

One year clinical follow-up revealed that in-lesion LLL was significantly lower in DCB arm as compared with DES arm (p = 0.004). Composite MACE was significantly higher in DES group compared to DCB group (p < 0.001). Non-fatal myocardial infarction (MI), target lesion revascularization (TLR), and major bleeding in DES group were significantly higher than DCB group (p = 0.04 & p < 0.001 & p = 0.03, respectively). However, there was a numerically; but not significantly, higher incidence of cardiac death (p = 0.65), and vessel thrombosis (p = 0.18) in DES arm compared to DES arm.

CONCLUSION

In SvCAD setting, DCB has favourable angiographic and clinical outcomes; as evidenced by lower LLL and composite MACE at one year follow up, compared to DES.

Detecting cardiac injury: the next generation of high-sensitivity cardiac troponins improving diagnostic outcomes

Cardiac injury, encompassing a spectrum of heart muscle damage, requires prompt and accurate diagnosis to improve patient outcomes. Early detection using cardiac biomarkers is vital for timely intervention and reducing mortality. This review highlights the role of high-sensitivity cardiac troponins (hs-cTns) in diagnosing cardiac injury. This article offers an overview of cardiac injury, including its causes, diagnostic challenges, and the evolution of biomarkers, up to the development and commercialization of "high-sensitivity" (hs-) cTns. The molecular structure of cardiac isoforms cTnI and cTnT, release kinetics, guidelines incorporation, diagnostic performance, and clinical application will be analyzed. It is concluded that the advent of hs-cTn assays has further expanded diagnostic capabilities by enabling the detection of low-level cTn elevations, which were previously undetectable using conventional methods. This enhanced sensitivity allows earlier identification of even minor cardiac injuries, facilitating prompt intervention and improving patient outcomes. However, this increased sensitivity also introduces interpretive challenges in understanding the nature of cardiac involvement, especially in distinguishing mild cTn elevations that may signify non-ischemic cardiac injury or be associated with other non-cardiac conditions.

Practice Change in Surgical Treatment Strategies for Ischaemic Mitral Regurgitation and Late Outcomes

BACKGROUND

Ischaemic mitral regurgitation (IMR) results from dysfunctional myocardial remodelling, which portends a poor clinical prognosis. This study assessed the surgical treatment of IMR and its associations with clinical and echocardiographic outcomes in the context of 2014 reports suggesting non-surgical management of non-severe IMR.

METHOD

Patients who underwent mitral valve (MV) procedures for IMR at Liverpool Hospital (Sydney, Australia) between 2008 and 2020 were included based on coronary disease and echocardiographic criteria. Data were obtained from patient records and linkage with the Australian Institute of Health and Welfare National Death Index. The primary outcome was the type of MV surgery performed in 2008-2014 and 2015-2020. Secondary outcomes were survival and freedom from combination of mortality and congestive heart failure (CHF) readmission, comparing MV repair and MV replacement and the outcomes for two periods by MV procedure.

RESULTS

Of 106 patients treated surgically for IMR, 78 had MV repair (59 in 2008-2014, 19 in 2015-2020) and 28 had MV replacement (14 in 2008-2014, 14 in 2015-2020). Patients were followed up for 7.2 years (interquartile range 5.2-9.1). Compared to 2008-2014, there was a reduced proportion of MV procedures for IMR (4.2% and 2.0%; p<0.001) and MV repair for IMR (80.8% and 57.6%; p=0.012) post-2014. Freedom from a combination of mortality and CHF readmission over 10 years was significantly better in the MV repair than in the MV replacement group (log rank p<0.001). Over 5 years, freedom from mortality and the combination of mortality and CHF readmission were similar in both periods (log rank p=0.675 and p=0.433). In the earlier period, freedom from combined outcome was better in the MV repair group than the MV replacement group (log rank p<0.001) but not different in the second period (log rank p=0.149). Mitral regurgitation recurrence was less in the later period (25.8% and 3.6%; p=0.013).

CONCLUSIONS

The proportion of MV procedures and MV repairs performed for IMR declined significantly after 2014, indicating a significant change in practice towards conservative surgical correction of IMR. The combined long-term outcomes were unchanged after the change in practice, but the incidence of mitral regurgitation recurrence was significantly improved.

Advancements in Biomarkers for Early Detection and Risk Stratification of Cardiovascular Diseases-A Literature Review

Introduction

CVDs is a leading cause of morbidity, mortality, and healthcare expenditure worldwide. Identifying individuals at risk or in the incipient stages of disease is instrumental in enabling timely interventions, preventive measures, and tailored treatment regimens. The landscape of CVDs is complicated by their heterogeneity, encompassing a spectrum of conditions such as coronary artery disease, heart failure, arrhythmias, and valvular disorders. In recent years, the integration of biomarkers into cardiovascular medicine has emerged as a paradigm-shifting approach with the potential to revolutionize early detection and risk stratification. By synthesizing a multitude of studies, we aim to provide a comprehensive resource that illuminates the transformative potential of biomarkers in ushering in a new era of precision cardiovascular medicine.

Aim

To identify the biomarkers for the detection and diagnosis of CVDs.

Materials and Methods

This review examines key studies from 2015 to the present that investigate the impact of cardiac biomarkers on cardiovascular outcomes. Data were gathered from PubMed, Cochrane Library, and Embase to ensure a comprehensive analysis. The review focuses on various cardiac biomarkers, assessing their levels and changes in relation to cardiovascular health, with special emphasis on advanced biomarkers such as proteomic and metabolomic markers in cardiovascular disease (CVD) diagnosis. Peer-reviewed studies published in English that evaluated the diagnostic, prognostic, or therapeutic role of cardiac biomarkers were included, with priority given to clinical trials, cohort studies, systematic reviews, and meta-analyses providing quantitative biomarker data. Studies unrelated to cardiac biomarkers, case reports, editorials, conference abstracts, and those with small sample sizes or insufficient methodological rigor were excluded. The review also accounts for potential confounding factors and research limitations, ensuring a balanced assessment of the literature. By synthesizing data from academic papers, clinical reports, and research articles, this study provides a comprehensive evaluation of the evolving role of cardiac biomarkers in CVD diagnosis and risk stratification.

Results

Biomarkers play a pivotal role in cardiovascular disease risk prediction, diagnosis, and treatment by providing dynamic biological insights. High-sensitivity cardiac troponins (hs-cTn) enhance myocardial injury detection, while circulating microRNAs (miR-208, miR-499) serve as early indicators of myocardial infarction and heart failure. Lipoprotein(a) [Lp(a)] predicts long-term cardiovascular risk, and inflammatory biomarkers such as C-reactive protein (CRP) and interleukin-6 (IL-6) are linked to adverse outcomes. Multi-biomarker panels, such as hs-cTn with B-type natriuretic peptide (BNP), improve heart failure prognosis, while metabolomic profiling enables precision medicine. Additionally, biomarkers like BNP and NT-proBNP facilitate real-time therapeutic monitoring. These findings underscore the critical role of biomarkers in refining risk stratification, improving diagnostic accuracy, and enabling personalized treatment strategies in cardiovascular medicine.

Conclusion

The advancement of cardiovascular biomarkers has significantly enhanced early detection, risk stratification, and personalized treatment. Emerging biomarkers, including genetic variants, metabolomics, microRNAs, and imaging-based markers, provide deeper insights into disease mechanisms. Integrating multi-omic approaches with artificial intelligence may further refine predictive accuracy and therapeutic decision-making. However, clinical translation requires rigorous validation through large-scale, multicenter studies to ensure reliability and applicability across diverse populations. Standardization, cost-effectiveness assessments, and the development of biomarker panels are essential for clinical adoption. Future research should focus on bridging discovery and implementation, advancing precision medicine to improve cardiovascular outcomes.

Prognostic Value of the RISK-PCI Score in Patients with Non-ST-Segment Elevation Acute Myocardial Infarction

Background: Non-ST-segment elevation acute myocardial infarction (NSTEMI) represents a heterogeneous patient population with varying risks of adverse outcomes. The RISK-PCI score, initially developed for ST-segment elevation myocardial infarction (STEMI) patients, was evaluated for its prognostic value in NSTEMI patients undergoing percutaneous coronary intervention (PCI). Methods: A retrospective observational study of 242 NSTEMI patients treated with PCI at the Clinical Center of Serbia from June 2011 to June 2016 was conducted. The RISK-PCI score, incorporating clinical, echocardiographic, and angiographic variables, was calculated for each patient. The primary outcome was 30-day major adverse cardiovascular events (MACE). Secondary outcomes included individual components of MACE. Statistical analyses were performed to assess the predictive value of the RISK-PCI score. Results: The primary outcome of 30-day MACE occurred in 9.9% of patients. Independent predictors of 30-day MACE included age > 75 years, glucose ≥ 6.6 mmol/L, creatinine clearance < 60 mL/min, and post-procedural TIMI flow < 3. The RISK-PCI score demonstrated good discrimination for 30-day MACE (AUC = 0.725). Patients stratified into the very high-risk group (RISK-PCI score ≥ 7) had significantly higher risks of 30-day MACE (29.4%). Conclusions: The RISK-PCI score effectively stratifies NSTEMI patients by their risk of 30-day MACE, identifying a very high-risk subgroup that may benefit from closer monitoring and tailored interventions. External validation on larger cohorts is recommended to confirm these findings.

Impact of D-Dimer on the Prognostic Value of PARIS Thrombosis Risk Score in Acute Coronary Syndrome Patients Undergoing PCI: From a Large Prospective Cohort Study

BACKGROUND

Guideline-recommended PARIS thrombotic risk score predicts coronary thrombosis events (CTE) in Acute Coronary Syndrome (ACS) patients undergoing Percutaneous Coronary Intervention. We aim to evaluate whether D-dimer, a thrombotic biomarker, can predict long-term adverse events and improve the prognostic value of PARIS score.

METHODS AND RESULTS

This is a post-hoc analysis on a prospective cohort of 10,724 Chinese patients undergoing PCI. Patients who presented as ACS were included and stratified according to baseline D-dimer level (cutoff 0.28 µg/mL). The primary endpoint is all-cause death. Secondary endpoints are cardiac death and CTE. A total of 5139 ACS patients with PCI were analyzed, 2735 patients had D-dimer ≥ 0.28 µg/mL, while 2404 patients had D-dimer < 0.28 µg/mL. After adjusting for confounders, patients with higher D-dimer had significantly higher risk of 5-year all-cause death (HR = 1.951, 95% CI: 1.366-2.787) and cardiac death (HR = 2.513, 95% CI: 1.574-4.012), whilst a trend toward higher risk of 5-year CTE (HR = 1.285, 95% CI: 0.956-1.729) was observed. Compared with PARIS score alone, adding D-dimer to the model increased the area under the receiver operating characteristic curve on 5-year all-cause death (0.663-0.701, p = 0.006) and cardiac death (0.652-0.699, p = 0.015), both with significant net reclassification improvement (p < 0.001).

CONCLUSION

In our cohort of ACS patients undergoing PCI, D-dimer independently predicts long-term all-cause death and cardiac death, and improves the predictive value of PARIS score over 5-year all-cause death and cardiac death.

Impact of new-onset atrial fibrillation in patients with ST-segment elevation myocardial infarction

BACKGROUND

New-onset atrial fibrillation (NOAF) complicating ST-segment elevation myocardial infarction (STEMI) remains clinically challenging. The aim of this study was to assess the incidence of NOAF, identify risk factors for the development of atrial fibrillation (AF), and analyze the impact on patient care, therapy, and outcomes during long-term follow-up.

METHODS

This retrospective single-center study reviewed consecutive patients undergoing coronary angiography (CAG) for acute STEMI between May 2015 and September 2023. Patients were stratified in NOAF, defined as AF diagnosed during the index hospitalization or within 12 months of follow-up, AF prior to the hospitalization for STEMI, and patients with no AF.

RESULTS

We analyzed 1301 consecutive patients undergoing CAG for STEMI. NOAF was detected in 112 patients (9.8%), and 68 patients (5.2%) had prior AF. NOAF patients were 74% males, with a mean age of 69 ± 11 years. During a median follow-up of 683 days, the rates of stroke were 10% in patients with NOAF compared to 3.8% (p = 0.001) in patients without AF. Major bleeding occurred in 7% vs. 1.7%, p = 0.001, and death in 16% vs. 6.8%, p < 0.001 of patients with NOAF vs. no AF.

CONCLUSION

NOAF was detected in almost 1 out of 10 STEMI patients and was associated with a higher rate of stroke, major bleeding, and death as in patients with no AF and with similar rates compared with prior AF. Future studies assessing optimal anticoagulation therapy in this challenging patient population are warranted.

The Effect of Coronary Artery Bypass Graft Surgery on Contractile Function and Symptoms in Patients with Left Ventricular Dysfunction

BACKGROUND

The degree of left ventricular (LV) dysfunction is an independent risk factor for poor outcomes in patients with chronic coronary syndrome. Coronary artery bypass graft (CABG) is the standard care for the management of ischemic heart failure to improve symptoms and prognosis. However, the predictors of improvement are still uncertain.

OBJECTIVE

To assess the effect of myocardial revascularization on LV function and symptoms in patients with CCS and reduced left ventricular ejection fraction (LVEF), as well as to identify the improvement predictors.

METHODS

We retrospectively analyzed the data and clinical status of 136 consecutive patients with LVEF<50% that underwent CABG. During clinical follow-up echocardiographic LV function was reassessed at the short-term (3.6 months) and long-term (30.8 months), and compared to baseline.

RESULTS

Mean pre-operative LVEF was 40.9 ± 8.6% and wall motion score index (WMSI) was 1.99 ± 0.36, both improving at long-term to 48.1 ± 15.0% (p<0.001) and 1.75 ± 0.49 (p<0.001), respectively. We observed that 55.7% of the patients presented an improvement of LVEF≥10% and 58.1% in WMSI ≥10%. Univariate logistic regression analysis revealed that cerebrovascular disease was the only variable to be predictor of LVEF improvement. At the end of follow-up, we observed a reduction in the rate of patients in functional class III/IV when compared to baseline (65.4 vs. 10.3% - p<0.001).

CONCLUSIONS

Patients with CCS and reduced LVEF undergoing CABG experienced improvement in both LV contractile function and size, with beneficial response in functional class.

Efficacy and long-term outcomes of drug coated balloon in de novo lesions of small versus large coronary vessels

OBJECTIVE

Drug eluting stent (DES) could result in both in-stent restenosis and high bleeding risk due to long-term anti-platelet therapy. Drug-coated balloon (DCB) delivers anti-proliferative drugs without implanting metal into vascular wall. Our aim was to investigate its feasibility in large vessel coronary artery disease (LvCAD), compared to small vessel coronary artery disease (SvCAD).

METHODS

This study enrolled 237 patients with de novo coronary lesions treated with DCB-only strategy and categorized according to the reference vessel diameter of 3 mm into SvCAD and LvCAD groups. The primary endpoint was in-lesion late lumen loss (LLL). The secondary endpoints included composite major adverse cardiac events (MACE), cardiac death, non-fatal myocardial infarction (MI), target lesion revascularization (TLR), target vessel revascularization (TVR), and vessel thrombosis.

RESULTS

The immediate (3.06 ± 0.25 vs. 2.33 ± 0.21 mm, p = 0.001) and follow up minimal lumen diameter (3.13 ± 0.25 vs. 2.41 ± 0.21 mm, p = 0.001) and acute gain (1.92 ± 0.29 vs. 1.5 ± 0.26 mm, p = 0.04) were significantly higher in LvCAD group. In-lesion LLL was negative without significant difference (-0.07 ± 0.02 vs. - 0.06 ± 0.04 mm, p = 0.69). The incidence of adverse clinical events was not statistically significant accounting for 6.5 % vs. 10.5 % for composite MACE (p = 0.27), 0.8 % vs. 0.9 % for cardiac death (p = 0.96), 4.9 % vs.7 % for non-fatal MI (p = 0.49), 4.1 % vs. 6.1 % for TLR (p = 0.47), 2.4 % vs. 3.5 % for TVR (p = 0.63) and 1.6 % vs. 2.6 % for vessel thrombosis (p = 0.59).

CONCLUSION

DCB-only strategy is effective in treating LvCAD with comparable outcomes to SvCAD.

Survival after myocardial infarction according to left ventricular function and heart failure symptoms

AIMS

Left ventricular (LV) dysfunction following acute myocardial infarction (AMI) is common even in the absence of signs and symptoms of heart failure (HF). Recent trials of patients with LV dysfunction post-AMI have demonstrated low event rates during follow-up. We aimed to assess the real-world prevalence and outcomes post-AMI, stratified by LV ejection fraction (LVEF) and the presence or absence of HF symptoms.

METHODS AND RESULTS

Cohort study of patients with AMI registered in the Norwegian Myocardial Infarction Registry 2013-2022. Outcomes were short- and long-term all-cause mortality. Mortality was assessed by Kaplan-Meier survival curves, Life Table and multivariable Cox regression models.

RESULTS

Among 70 809 AMI patients (mean age 68.1 ± 12.9 years, 31% female), preserved (≥50%), mildly reduced (41%-49%) and reduced (≤40%) LVEF were present in 63.5%, 23.2% and 13.3%, respectively. Symptomatic HF was present in 3.3%, 28.1% and 63.2% of patients with preserved, mildly reduced and reduced LVEF. For each LVEF category, 1-year cumulative mortality rate from discharge was 3.9%, 7.8% and 17.8% for asymptomatic, and 16.2%, 13.7% and 20.2% for symptomatic patients, respectively. Symptomatic patients discharged alive had higher risk of mortality than asymptomatic: adjusted hazard ratio 1.85 (1.70-2.02) for preserved LVEF, 1.33 (1.25-1.41) for mildly reduced LVEF and 1.15 (1.06-1.24) for reduced LVEF.

CONCLUSIONS

Reduced LVEF in the acute phase of AMI was associated with up to 20% 1-year mortality after discharge, substantially higher than in recent post-MI trials. Symptoms of HF during the index hospitalization were associated with worse outcomes in patients with preserved LVEF but contributed little additive risk for patients with reduced LVEF.

Stepwise Provisional Versus Systematic Dual-Stent Strategies for Treatment of True Left Main Coronary Bifurcation Lesions

BACKGROUND

The optimal coronary stenting technique for true left main bifurcation lesions is uncertain. EBC MAIN (European Bifurcation Club Left Main Trial) aimed to evaluate clinical outcomes of a stepwise provisional strategy compared with a systematic dual-stent approach.

METHODS

EBC MAIN was a randomized, investigator-initiated, open-label, multicenter, parallel-group trial conducted across 35 hospitals in 11 European countries. A total of 467 participants undergoing percutaneous coronary intervention for unprotected true left main bifurcation lesions were randomly assigned to the stepwise provisional strategy (n=230) or an upfront dual-stent approach (n=237). The mean (SD) age was 71 (10) years and 23% of participants were women. The primary end point was a composite of major adverse cardiac events, defined as all-cause mortality, all myocardial infarction, or clinically driven target lesion revascularization. Events were adjudicated by an independent clinical events committee and all analyses were by the intention-to-treat principle.

RESULTS

At 3 years, the primary end point occurred in 54 of 230 (23.5%) stepwise provisional and 70 of 237 (29.5%) dual-stent patients (hazard ratio, 0.75 [95% CI, 0.53-1.07]; P=0.11). There was no significant difference in all-cause mortality (10.0% versus 13.1%) or myocardial infarction (12.2% versus 11.0%). However, target lesion revascularization was significantly lower in the stepwise provisional group (8.3% versus 15.6%; hazard ratio, 0.50 [95% CI, 0.29-0.86]; P=0.013). In this population, the mean side vessel diameter by quantitative angiography was 2.9 mm, and median side vessel lesion length was 5 mm. Significant interactions were identified between the assigned bifurcation strategy and both side vessel diameter and lesion length with respect to the primary outcome (P=0.009 and P=0.005, respectively), with smaller vessels (<3.25 mm diameter) and shorter lesions (<10 mm length) favoring the provisional approach.

CONCLUSIONS

In a European population with true left main stem bifurcation coronary disease requiring intervention, there was no difference in major adverse cardiovascular events between stepwise provisional and systematic dual-stent strategies at 3 years. Target lesion revascularization was significantly less frequent with the stepwise provisional approach, which should be the default strategy for noncomplex left main bifurcation coronary intervention.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02497014.

Results of systematic patient outcome monitoring: Does post-dilatation during angiography-guided percutaneous coronary intervention improve clinical outcomes?

OBJECTIVES

This study evaluates clinical outcomes after implementing a liberal post-dilatation strategy during PCI.

BACKGROUND

Post-dilatation after percutaneous coronary intervention (PCI) is performed to achieve optimal stent expansion and reduce complications. However, its prognostic effects are unclear and conflicting.

METHODS

This study is a pre-post-intervention analysis of two cohorts, before (2015-2017) and after (2018-2020) implementation of a liberal post-dilatation strategy. The primary end point consisted of major adverse cardiovascular events (MACE) at 30 days. Secondary end points consisted of the individual components of the primary end point as well as 1 year mortality and target vessel revascularization.

RESULTS

A total of 10,153 patients were included: 5,383 in the pre-cohort and 4,770 in the post-cohort. The 30-day MACE was 5.00% in the pre-cohort and 4.09% in the post-cohort (p = 0.008; OR 0.75 (CI 0.61-0.93)). There was a significant difference between the pre- and post-cohort in 30-day mortality, respectively, 2.91% and 2.25% (p = .01; OR 0.70 (CI 0.53-0.93)), and MI at 30 days, 1.17% versus 0.59% (p = .003; OR 0.49 (CI 0.31-0.78)). At 1 year, there was a significant difference in mortality between the pre-cohort, 5.84%, and post-cohort, 5.19% (p = .02; OR 0.79 (CI 0.66-0.96)).

CONCLUSIONS

A liberal post-dilatation strategy after PCI was associated with a significant decrease in 30-day MACE, 30-day MI, 30-day mortality, and 1-year mortality. Future studies are warranted to validate the causality between post-dilatation and improvement of clinical outcomes.

Clinical Utility of Immature Platelet Fraction (IPF) as a Biomarker in the Diagnosis of Acute Coronary Syndrome (ACS)

Introduction Acute coronary syndrome (ACS) is a critical medical emergency requiring prompt diagnosis and treatment to prevent severe complications, including death, and the underlying pathology of ACS involves the rupture or erosion of an atheromatous plaque within the coronary arteries. Platelets get consumed in an atherosclerotic blood vessel (artery) soon after the rupture of atherosclerotic plaque, which can result in the release of larger immature platelets from bone marrow. The primary objective of this study was to determine the clinical utility of immature platelet fraction (IPF) as a biomarker in the diagnosis of ACS. As secondary objectives, we tried to determine the association between mean platelet volume (MPV) and IPF in the diagnosis of ACS and to determine the role of IPF in differentiating single vessel disease (SVD), double vessel disease (DVD), and triple vessel disease (TVD). Materials and methods A pilot study was conducted with 15 samples, and the sensitivity of IPF (90%) to diagnose ACS was obtained with a 95% confidence interval and 10% allowable error; the overall minimum sample size came to 53 (including a minimum 35 ACS). Fifty-four patients with chest pain, including patients who presented to the emergency room (ER) and who got admitted in the ward and critical care unit (CCU), satisfying the inclusion criteria, were included in the study. Statistical analysis was done using the IBM SPSS Statistics for Windows, Version 20 (IBM Corp., Armonk, NY). The results are given in mean ± SD for all the continuous variables and in frequency (percentage) for categorical variables. The normality of the data was checked by the Kolmogorov-Smirnov Z test. The receiver operating characteristic (ROC) curve was applied to find an ideal cut-off of IPF for the diagnosis of ACS with respect to ECG and cardiac enzymes. Diagnostic measures such as sensitivity and specificity were applied. To test the statistical significance of the difference in the proportion of IPF and MPV with ACS, the Chi-square test was used, and the same test was used to differentiate SVD, DVD, and TVD using IPF with respect to coronary angiogram (CAG). Pearson's correlation coefficient was applied to find the correlation of IPF with MPV and platelet count, and its statistical significance was checked by linear reg t test. Results Among the 54 participants, 38 (70.4%) were diagnosed with ACS, while 16 (29.6%) were found to have non-cardiac chest pain. The ROC curve was plotted, and a cut-off value of 1.7250% was determined for IPF with a sensitivity of 94.7% and a specificity of 93.7%. The area under the ROC curve (AUC) was 0.984, with a standard error of 0.014 (p < 0.001). There was a strong positive correlation between IPF and MPV (r = 0.731, p < 0.001) in ACS patients. Conclusion Our study demonstrates that IPF and MPV are valuable biomarkers for the diagnosis of ACS.

Luminescence "on-off-on" sensing of acute myocardial infarction biomarker miRNA-208a based on copper nanoclusters-MoS2 FRET system

MiRNA-208a is a molecular marker for the early stage of acute myocardial infarction (AMI), with satisfactory specificity and a relatively short time window, making it highly suitable for the early diagnosis of AMI. In this study, a CuNCs-cDNA-MoS2 fluorescent probe is designed and a Förster resonance energy transfer (FRET) enzyme-free fluorescent biosensor is established for "on-off-on" detection of miRNA-208a. The results showed that the detection limit for miRNA-208a was 900 pM, with a linear range of 1 to 10 nM. Interestingly, after the addition of RNase inhibitor, the detection time and limit for serum miRNA-208a were reduced to 5 min and 380 pM, respectively. It also has a wide linear range (1-20 nM), with a recovery of 98.13 to 101.20%. Compared to traditional methods, this strategy is simple, rapid, efficient, and cost-effective. In summary, the FRET-based fluorescent sensor provides a high-performance method for detecting miRNA-208a.

Effect of Peri-Interventional Blood Loss on In-Stent Thrombosis After Percutaneous Coronary Intervention in Patients with Acute Myocardial Infarction

This paper evaluates the effect of blood loss on in-stent stenosis after percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI). Nine hundred and ninety-seven patients who underwent PCI for AMI as well as follow-up coronary angiography at 6-12 months from two centers were categorized into three groups based on peri-interventional blood loss at the primary intervention (mild, <1 mmol/L moderate, 1-2 mmol/L; severe > 2 mmol/L). The endpoint was to evaluate the incidence and severity of in-stent stenosis at follow-up angiography and the revascularization rate. The incidence of in-stent stenosis and revascularization in mild, moderate, and severe groups was 19.3%, 33.1%, and 61.1%, respectively (p = 0.001), with HR: 1.35 (95% CI; 1.10-1.65), p < 0.001. Peri-interventional blood loss was associated with a higher incidence of in-stent stenosis and revascularization 6-12 months after successful PCI in patients with AMI.

Utility of Noninvasive Testing Before Invasive Coronary Angiography in the Assessment for Revascularization

Objective

To examine the role of noninvasive testing (NIT) before invasive coronary angiography (ICA) by evaluating the association between a positive myocardial perfusion imaging (MPI) or computed tomography angiography (CTA) result and the decision to perform coronary revascularization.

Patients and Methods

We screened all patients who received ICA between August 1, 2015, and July 31, 2019, and identified those who received MPI or CTA within the preceding 12 months. We considered MPI to be a positive result if it found moderate or severe ischemia in a specific coronary territory and CTA to be a positive result if it identified a stenosis greater than 50% in any major coronary artery.

Results

Of the 17,181 individual procedures, 2183 were included. Positive CTA had an odds ratio (OR) of 2.68 (95% CI, 1.82-3.94) for revascularization and positive MPI an OR of 1.29 (95% CI, 1.07-1.56). Overall sensitivity for CTA in the prediction of revascularization was 80.4% (95% CI, 75.7%-84.6%), with vessel-level sensitivity ranging from 57.3% (95% CI, 47.5%-66.7%) to 71.8% (95% CI, 65.8%-77.4%). Overall sensitivity of MPI was 48.2% (95% CI, 44.7%-51.7%), with territory-specific sensitivity ranging from 33.7% (95% CI, 29.9%-37.7%) to 36.5% (95% CI, 32.6%-40.6%). Overall specificity for CTA was low, at 39.5% (32.9%-46.3%), but higher when evaluating at the vessel level, ranging from 60.3% (95% CI, 54.5%-66.0%) to 83.5% (95% CI, 79.6%-86.9%). Overall specificity for MPI was 58.1% (95% CI, 54.9%-61.3%), with territory-specific specificity ranging from 78.6% (95% CI, 76.1%-80.9%) to 78.9% (95% CI, 76.5%-81.3%).

Conclusion

In this population of patients referred for ICA, positive CTA was more closely associated with revascularization than MPI. Further studies are necessary to determine the role of NIT before ICA.

A refined, minimally invasive, reproducible ovine ischaemia-reperfusion-infarction model using implantable defibrillators: Methodology and validation

Ischaemic heart disease remains a leading cause of premature mortality and morbidity. Understanding the associated pathophysiological mechanisms of cardiac dysfunction arising from ischaemic heart disease and the identification of sites for new therapeutic interventions requires a preclinical model that reproduces the key clinical characteristics of myocardial ischaemia, reperfusion and infarction. Here, we describe and validate a refined and minimally invasive translationally relevant approach to induce ischaemia, reperfusion and infarction in the sheep. The novelty and refinement in the procedure stems from utilization of implantable cardiac defibrillators prior to coronary engagement, balloon angioplasty to induce infarction, and intra-operative anti-arrhythmic drug protocols to reduce adverse arrhythmic events. The protocol is readily adoptable by researchers with access to standard fluoroscopic instrumentation, and it requires minimally invasive surgery. These refinements lead to a substantial reduction of intra-operative mortality to 6.7% from previously published values ranging between 13% and 43%. The model produces key characteristics associated with the fourth universal definition of myocardial infarction, including ECG changes, elevated cardiac biomarkers and cardiac wall motility defects. In conclusion, the model closely replicates the clinical paradigm of myocardial ischaemia, reperfusion and infarction in a translationally relevant large animal setting, and the applied refinements reduce the incidence of intra-operative mortality typically associated with preclinical myocardial infarction models.

Upper normal serum magnesium is associated with a reduction in incident death from fatal heart failure, coronary heart disease and stroke in non-dialysis patients with CKD stages 4 and 5

Background

Serum magnesium disturbances are common in patients with cardiovascular disease (CVD). However, the well-established link between low serum magnesium and nutritional or inflammatory disorders has limited its consideration as a non-traditional risk factor for mortality. This study aims to elucidate the relationship between serum magnesium concentrations and mortality due to fatal heart failure (HF), coronary heart disease (CHD) and stroke in non-dialysis patients with chronic kidney disease (CKD) stages 4 and 5.

Methods

A cohort of 1271 non-dialysis patients with CKD stages 4 and 5 was followed from 2008 to 2018. Patients with prior major adverse cardiovascular events (MACE) were excluded. Serum magnesium levels were stratified into tertiles and the primary outcomes were incidence rates of fatal HF, CHD and stroke. Secondary outcomes included composite MACE and all-cause mortality. Hazard ratios (HRs) were calculated using multivariate Cox regression, adjusting for demographics, comorbidities and biochemical parameters. E-values were used to assess the robustness of the results.

Results

Over the 10-year follow-up, 186 patients died. Higher serum magnesium levels were significantly associated with reduced mortality risk from HF [HR 0.49 (95% CI 0.27-0.89) for T2; HR 0.31 (95% CI 0.16-0.60) for T3] compared with the lowest tertile. Similar trends were observed for CHD and stroke mortality. The incidence rate of MACE per 1000 person-years was reduced from 68.2 in tertile 1 to 26.2 in tertile 2 and 16.8 in tertile 3. Secondary endpoints, including all-cause mortality and composite MACE, followed trends similar to the primary outcomes.

Conclusions

Higher serum magnesium concentrations were associated with lower risks of death from fatal HF, CHD and stroke in non-dialysis patients with CKD stages 4 and 5.

Prolonged pain-to-balloon time still impairs midterm left ventricular function following STEMI

BACKGROUND

ST-elevation myocardial infarction (STEMI) demands near-time reperfusion to reduce the risk of long-term heart failure. This study evaluates the proportion of impaired left ventricular ejection fraction (LVEF) following STEMI in the context of current healthcare settings at a tertiary care center equipped with the most advanced and up-to-date standards of care.

METHODS

Patients experiencing STEMI as their first manifestation of coronary artery disease were analyzed, as these individuals had no prior experience with heart-related chest pain. LVEF was assessed by levocardiography at admission and semiautomatically using TOMTEC in patients with eligible full-cycle echocardiography of 2- and 4-chamber view available at discharge and 1-year follow-up (FU). Pain-to-balloon time was divided into quartiles (Q) [0-111, 112-159, 160-246 and 247-784 min]. Multiple logistic regression analysis identified independent predictors of reduced LVEF < 50% at 1-year FU.

RESULTS

A total of 1,379 consecutive STEMI patients were reviewed from 2010 to 2017, with 130 meeting the inclusion criteria. Mean age was 63 ± 12 years, 75% were male, 14% had diabetes, 72% had arterial hypertension, and 56% had history of smoking. LVEF was reduced in 94% of patients at admission, 69% at discharge, and remained reduced in 45% at the 1-year follow-up. Anterior wall myocardial infarction (OR 3.2 [95%-CI 1.2-6.9], p = 0.018) and increasing pain-to-balloon time across quartiles (Q2: OR 15.7 [95%-CI 1.8-140.4], p = 0.014; Q4: OR 33.7 [3.4-278.7] p = 0.002) were independently associated with reduced LVEF at 1 year.

CONCLUSION

Despite optimal medical management and advanced healthcare structures, nearly half of patients with STEMI as their first presentation of coronary artery disease continue to exhibit reduced LVEF at 12-months. Anterior wall myocardial infarction and pain-to-balloon time exceeding 2 h remain independent predictors of left ventricular dysfunction. Further improvements in healthcare systems and public education are essential to reduce treatment delays and improve long-term outcomes.

Planetary Health Diet and Cardiovascular Disease Risk in the Seguimiento Universidad de Navarra (SUN) Cohort

BACKGROUND/OBJECTIVES

Noncommunicable diseases, particularly cardiovascular disease (CVD), represent a significant global public health challenge, with unhealthy diets as a major risk factor. This study investigates the association between adherence to the Planetary Health Diet proposed by the EAT-Lancet Commission and CVD risk.

METHODS

Utilizing data from the Seguimiento Universidad de Navarra (SUN) cohort, which included 18,656 participants (mean age 38 years; 61% women), we assessed dietary intake using a validated food frequency questionnaire and the Planetary Health Diet Index to evaluate adherence (range 0-42). CVD was defined as new-onset stroke, myocardial infarction, or CVD death.

RESULTS

After a median follow-up time of 11.5 years, 220 cases of CVD were identified. Higher adherence to the Planetary Health Diet revealed no statistically significant reduction in CVD risk associated with the diet. Cox proportional hazard models indicated a trend towards lower CVD risk in the highest adherence quartile, but this did not reach significance (HR 0.77, 95% CI 0.51-1.18, p-trend = 0.127). Sensitivity analyses corroborated these results. Discrepancies in previous studies highlight the complexity of dietary assessments and underscore the need for standardized scoring systems.

CONCLUSIONS

In a large Spanish cohort, adherence to the Planetary Health Diet showed no significant reduction in CVD risk. Further research is needed to reach a consensus on the operational definition of the Planetary Health Diet and to clarify the relationship between diet and CVD risk.

Short- and long-term outcomes of patients with acute myocardial infarction complicated by cardiac arrest: a nationwide cohort study 2013-22

AIMS

To assess short- and long-term outcomes of acute myocardial infarction (AMI) complicated by out-of-hospital cardiac arrest (OHCA) or in-hospital cardiac arrest (IHCA) in a nationwide cohort.

METHODS AND RESULTS

Cohort study of AMI patients admitted to hospitals in Norway 2013-22 registered in the Norwegian Myocardial Infarction Registry. Outcomes were in-hospital and long-term mortality. Cumulative mortality was assessed with the Kaplan-Meier and the life-table methods. Cox regression was used for risk comparisons. Among 105 439 AMI patients (35% women), we identified 3638 (3.5%) patients with OHCA and 2559 (2.4%) with IHCA. The mean age was 65.7 (13.2), 70.9 (12.6), and 70.7 (13.6) years for OHCA, IHCA, and AMI without cardiac arrest (CA), respectively. The median follow-up time was 3.3 (25th, 75th percentile: 1.1, 6.3) years. In-hospital mortality was 28, 49, and 5%, in OHCA, IHCA, and AMI without CA, and the estimated 5-year cumulative mortality was 48% [95% confidence interval (CI) 46-50%], 69% (95% CI 67-71%), and 35% (95% CI 34-35%), respectively. Among patients surviving to hospital discharge, no significant difference in mortality during follow-up was found between OHCA and AMI without CA [adjusted hazard ratio (HR) 1.04, 95% CI 0.96-1.13], while the long-term mortality of AMI patients with IHCA was higher (age-adjusted HR 1.31, 95% CI 1.19-1.45).

CONCLUSION

In this large, contemporary cohort of AMI patients, in-hospital mortality of patients with OHCA or IHCA was still high. Among patients surviving to hospital discharge, long-term mortality was comparable between OHCA and AMI without CA, while the outcome of patients with IHCA was significantly worse.

Developing a Computational Phenotype of the Fourth Universal Definition of Myocardial Infarction for Inpatients

Background: The fourth universal definition of myocardial infarction (MI) introduced the differentiation of acute myocardial injury from MI. In this study, we developed a computational phenotype for distinct identification of acute myocardial injury and MI within electronic medical records (EMRs). Methods: Two cohorts were used from a Calgary-wide EMR system: a chart review of 3042 randomly selected inpatients from Dec 2014 to Jun 2015; and 11,685 episodes of care that included cardiac catheterization from Jan 2013 to Apr 2017. Electrocardiogram (ECG) reports were processed using natural language processing and combined with high-sensitivity troponin lab results to classify patients as having an acute myocardial injury, MI, or neither. Results: For patients with an MI diagnosis, only 64.0% (65.7%) in the catheterized cohorts (chart review cohort) had two troponin measurements within 6 h of each other. For patients with two troponin measurements within 6 h; of those with an MI diagnosis, our phenotype classified 25.2% (31.3%) with an acute myocardial injury and 62.2% (55.2%) with an MI in the catheterized cohort (chart review cohort); and of those without an MI diagnosis, our phenotype classified 12.9% (12.4%) with an acute myocardial injury and 10.0% (13.1%) with an MI in the catheterized cohort (chart review cohort). Conclusions: Patients with two troponin measurements within 6 h, identified by our phenotype as having either an acute myocardial injury or MI, will at least meet the diagnostic criteria for an acute myocardial injury (barring lab errors) and indicate many previously uncaptured cases. Myocardial infarctions are harder to be certain of because ECG report findings might be superseded by evidence not included in our phenotype, or due to errors with the natural language processing.

High altitude pulmonary oedema: Mimicker of acute coronary syndrome

High altitude pulmonary oedema (HAPO) is a common emergency seen at high altitude. It can be associated with electrocardiogram (ECG) changes due to pulmonary arterial hypertension in the form of ST elevation and T wave inversion in the right precordial leads, which mimic acute coronary syndrome. These changes can lead to confusion in diagnosis and management. ECG changes resolve over a period of time when the patients are de-inducted to low land. So appropriate history and clinical examination, followed by monitoring of patients with cardiac enzymes and ECG, can prevent misdiagnosis and thereafter management.

Posttraumatic Stress Disorder and the Risk of Heart Failure Hospitalizations Among Individuals With Coronary Artery Disease

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with maladaptive dysregulation of stress response systems, which could lead to an increased risk of heart failure. We investigated whether PTSD was independently associated with first and recurrent heart failure hospitalizations in the setting of coronary artery disease.

METHODS

Individuals with stable coronary artery disease and without heart failure at baseline were enrolled in 2 parallel prospective cohort studies in metropolitan Atlanta, GA. Participants underwent a structured clinical interview to assess their lifetime history of PTSD. Current PTSD symptoms were assessed using the PTSD symptom checklist. Participants were followed up for a median time of 4.9 years. The primary end point was first or recurrent hospitalization for heart failure. Secondary end points included cardiovascular death and nonfatal myocardial infarction with and without hospitalization for heart failure. Survival analysis for repeated events was used to assess the association of PTSD with adverse events.

RESULTS

We studied 736 individuals with a mean age of 60±10 years; 36% were Black, and 35% were women. In total, 69 (9.4%) patients met the criteria for PTSD. Having a PTSD diagnosis was associated with the primary end point of first or recurrent heart failure hospitalizations, with a hazard ratio of 4.4 (95% CI, 2.6-7.3). The results were minimally attenuated after adjusting for demographic and clinical factors (hazard ratio, 3.7 [95% CI, 2.1-6.3]). Similarly, a 10-point increase in the PTSD symptom checklist score was associated with a 30% (95% CI, 10%-50%) increase in heart failure hospitalizations. PTSD was not associated with an end point of cardiovascular death or nonfatal myocardial infarction, which excluded hospitalizations due to heart failure.

CONCLUSIONS

Among patients with coronary artery disease, PTSD is associated with incident and recurrent heart failure hospitalizations. Future research is needed to investigate whether PTSD management can reduce the risk of heart failure.

Diagnostic value of a point-of-care cardiac troponin-I assay (i-STAT®) for clinical application in canine and feline cardiology

INTRODUCTION/OBJECTIVES

This study was performed to evaluate the diagnostic value and net benefits, including cost-effectiveness, of a point-of-care analyser (i-STAT®) for measurement of cardiac troponin I (cTnI) in dogs and cats.

ANIMALS, MATERIALS AND METHODS

Hundred and twenty dogs and 120 cats presented with signs of cardiac disease and suspected myocardial insult on cardiac assessment. This was a validation study expressed as agreement between the i-STAT® analyser and two common commercial reference methods (IMMULITE® 2000 and ACCESS® hsTnI).

RESULTS

The comparison between methods showed a negative bias between the i-STAT® and the two commercial cTnI assays. The bias was more evident when the i-STAT® values were compared to the traditional cTnI assay (IMMULITE® 2000), with a calculated difference of -1.14 ng/mL (dogs) and -0.96 ng/mL (cats). However, the bias was distinctly lower when the i-STAT® measurements were compared to the high-sensitivity cTnI assay (ACCESS®), namely -0.3 ng/mL in dogs and -0.17 in cats.

DISCUSSION

The i-STAT® method can reliably detect normal, low and elevated cTnI values, which is fundamental to differentiate pets with and without myocardial damage and, with the rapid availability of results, this confirms the clinical utility of the i-STAT® method.

CONCLUSIONS

cardiac troponin I concentrations measured with the i-STAT® have good comparability with those obtained with both commercial assays for low and elevated cTnI values. However, results should be cautiously interpreted for high cTnI values, especially if a strict cut-off value is adopted for diagnostic or prognostic purposes in critical clinical conditions, such as myocarditis or acute myocardial ischaemia.

Elevated carbohydrate antigen 125 (CA125) is associated with incident heart failure and mortality in acute coronary syndrome

AIMS

Carbohydrate antigen 125 (CA125), a mucin produced by serosal cells in response to mechanical and inflammatory stimuli, has emerged as an important biomarker to guide risk stratification in heart failure (HF). The prognostic value of CA125 in acute coronary syndrome (ACS) patients is less explored.

METHODS

In a cohort of 524 ACS patients (73% males, mean age 67 ± 12 years), we assessed the associations between CA125 and the risk for HF and death during a median follow-up period of 27.3 months for incident HF and 39.5 months for mortality. Plasma CA125 was measured within 24 h after admission in the entire cohort and after 6 weeks in a subgroup of 115 elderly patients (>75 years of age). We also assessed the relationships between baseline CA125 and echocardiographic parameters of cardiac structure and function at 1 year post-ACS in this subgroup.

RESULTS

Baseline CA125 was associated with incident HF in the entire cohort in a Cox proportional hazards model adjusted for age, sex, cardiovascular (CV) risk factors (diabetes, smoking, hypertension, previous HF, previous ACS and previous stroke), renal function and revascularization {hazard ratio [HR] 1.46 [95% confidence interval (CI) 1.10-1.93] per 1-standard deviation [SD] CA125 increase; P = 0.009}. In the detailed follow-up subgroup, elevated baseline CA125 predicted subsequent deterioration of left ventricular (LV) ejection fraction (LVEF), defined as a >5% absolute LVEF decrease in patients with LVEF ≥ 50% at discharge [odds ratio (OR) 3.31 (95% CI 1.15-9.54) per 1-SD baseline CA125 increase; P = 0.027]. We also found significant correlations between high baseline CA125 and larger LV volumes (LV end-diastolic volume index, Spearman's r = 0.329, P < 0.001; LV end-systolic volume index, r = 0.391, P < 0.001) and left atrial volume index (r = 0.320, P < 0.001) at 1 year post-ACS, indicative of adverse cardiac remodelling. Elevated baseline and follow-up CA125 were associated with increased mortality, independently of age and sex [HR 1.37 (95% CI 1.09-1.71), P = 0.006, per 1-SD baseline CA125; HR 1.98 (95% CI 1.06-3.67), P = 0.031, per increasing 6 week CA125 tertile]. The relationship between 6 week CA125 and incident mortality remained significant in the fully adjusted model [HR 2.23 (95% CI 1.15-4.35) per increasing CA125 tertile; P = 0.018].

CONCLUSIONS

We report independent associations between elevated CA125, LV dysfunction, cardiac remodelling, incident HF and mortality post-ACS. Our results warrant further evaluation of CA125 as a potential biomarker for risk stratification and management of ACS patients, both at the time of the acute coronary event and during follow-up.

Association of normal body mass index and weight loss with long-term major cardiovascular events after PCI for myocardial infarction

Objectives: To investigate whether normal body mass index (BMI) shortly after percutaneous coronary intervention (PCI) for myocardial infarction is associated with increased risk of long-term major cardiovascular events (MACE), and to explore potential clinical determinants of long-term weight loss (WL) after PCI. Methods: Single-center cohort study with 5-year follow-up of patients treated with PCI for myocardial infarction between 2016 and 2018. Categorical WL was defined as > 0 kg body weight reduction from baseline to end of follow-up. Results: Of 236 patients (24% women), mean age was 64.9 ± 10.2 years and mean BMI within 4 days after PCI was 27.1 ± 4.3 kg/m2. Seventy-five patients (32%) had at least one MACE, equally distributed between those with normal weight (31%), overweight (32%), and obesity (31%). Patients with overweight or obesity had a lower crude mortality rate than their normal weight counterparts (7.4% vs 16.4%, p = 0.049), but the relative hazard of death did not differ from those with normal weight, HR 0.50, 95% CI 0.22-1.15. Patients with either a long-term WL (n = 112) or no WL (n = 95) had a comparable incidence of non-fatal MACE (27% vs 22%, p = 0.518). The proportion of patients reporting unintentional weight loss was significantly higher in the normal weight group (82%) compared with those with overweight (41%) or obesity (28%), p < 0.001. Conclusion: Our results did not confirm any association between normal BMI after PCI and long-term MACE. However, patients with normal BMI at baseline had a higher incidence of unintentional WL than those with elevated BMI. Trial registration: Current research information system in Norway (CRISTIN): ID 542528.

Effect of high sensitivity C-reactive protein on uric acid-related cardiometabolic risk in patients with coronary artery disease-a large multicenter prospective study

Although serum uric acid (SUA) is a risk factor for cardiometabolic outcome, but it remains unclear which patients with coronary artery disease (CAD) benefit the most from SUA lowering therapy (ULT). The association of SUA level, systemic inflammation and cardiometabolic risk is still unclear. The current study is aimed to examine whether SUA-associated cardiometabolic risk is modulated by systemic inflammation in CAD patients. A total of 16,598 CAD patients with baseline high-sensitivity C-Reactive Protein (hsCRP) and SUA available were included. Baseline and follow-up data were collected. The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE), including death, myocardial infarction and stroke. In patients with hsCRP ≥ 2 mg/L, increasing quintiles of SUA were significantly associated with increased rates of 2-year MACCE (adjusted p < 0.001 for trend, p = 0.037 for interaction). Each unit increase in SUA levels was associated with a 11.3% increased risk of MACCE (adjusted p < 0.001, p = 0.002 for interaction). However, in patients with hsCRP < 2 mg/L, increasing quintiles of SUA were not associated with increased MACCE (adjusted p = 0.120). Elevated SUA levels are related to MACCE when hsCRP levels are 2 mg/L or more but not less than 2 mg/L. This finding suggests a potential benefit of combined ULT and anti-inflammation therapy in patients with hyperuricemia and greater systemic inflammation.

A Meta-Analysis of Timing of Complete Revascularization in Patients with ST-Elevation Myocardial Infarction

Background: Recent randomized clinical trials (RCTs) of STEMI patients with multi-vessel disease (MVD) reported potential superiority of immediate (ICR) vs. staged complete revascularization (SCR). Inherently, the risk of procedural MI is less likely to be detected in ICR patients, and this may have influenced the results. Recently published meta-analyses encompassed observational studies without including STEMI data from the BioVasc trial. The aim of this meta-analysis was to perform an updated comparison of the two strategies in STEMI patients with MVD. Methods: Electronic databases were searched from their inception till August 2024 to identify RCTs assessing CR timing in STEMI patients with MVD. Only studies with an endpoint involving major adverse cardiovascular events (MACE) were included. Results: Six RCTs totaling 2023 patients were included in the analysis. The median time to staged PCI was 19 days. The incidence of MACE (as defined by each study's protocol) was comparable between the two strategies [RR 0.86, 95% CI (0.58 to 1.27)]. There was also no difference in the risk of non-procedural MI [RR 0.91, 95% CI (0.49-1.67)], death [RR 1.47, 95% CI (0.89-2.44)] and cardiovascular death [RR 1.53, 95% CI (0.79-2.98)]. There was a significant 40% reduction in unplanned revascularization in patients undergoing ICR versus SCR [RR 0.60 (0.40 to 0.89), p = 0.01]. Conclusions: ICR reduced the risk of unplanned revascularization compared to SCR but had a comparable effect on MACE, death, cardiovascular death and non-procedural MI. Both strategies are safe in managing patients with acute MI and MVD.

Evaluation of Estimated Glucose Disposal Rate with Neutrophil-to-Lymphocyte Ratio Integrated for Prognosticating Adverse Cardiovascular and Cerebrovascular Events and Risk Stratification Among Acute Coronary Syndrome with Type 2 Diabetes Mellitus Following Percutaneous Coronary Intervention

Objective

This research aimed to address the critical need for effective prognostic tools in patients with acute coronary syndrome (ACS) and type 2 diabetes mellitus (T2DM) undergoing percutaneous coronary intervention (PCI) by exploring the potential significance of integrating estimated glucose disposal rate (eGDR) and neutrophil-to-lymphocyte ratio (NLR).

Methods

Major adverse cardiovascular and cerebrovascular events (MACCE) were the primary endpoint. Log rank test was conducted to compare the Kaplan-Meier curves across the overall follow-up period, and multivariate Cox regression was used to investigate the association between the eGDR/NLR and MACCE.

Results

One hundred fifty-four patients (9.5%) experienced MACCE including 15 cardiac deaths, 97 nonfatal MI, 120 TVR, and 10 strokes. Patients were distributed into low and high eGDR/NLR groups (lower eGDR [eGDR-L] group, higher eGDR [eGDR-H] group, lower NLR [NLR-L] group, and higher NLR [NLR-H] group) based on the median value of eGDR and NLR, further divided into four groups: eGDR-L + NLR-L, eGDR-H + NLR-L, eGDR-L + NLR-H, and eGDR-H + NLR-H. eGDR-L + NLR-H group exhibited significantly higher risks of MACCE (17.4%), compared to another three groups. An independent correlation between eGDR/NLR and MACCE was demonstrated by Cox regression analysis, establishing if the eGDR and NLR was treated as a continuous or categorical variable. Compared to eGDR-H + NLR-L group, patients in eGDR-L + NLR-H group had the uppermost MACCE risk (HR: 5.201; 95% CI 2.764-7.786; P < 0.001). A linear relationship between eGDR/ NLR and MACCE was showed by restricted cubic spline curves. Incorporating the eGDR and NLR toward the baseline risk model developed the precision of forecasting MACCE (baseline risk model-AUC: 0.611 vs baseline risk model + eGDR + NLR-AUC: 0.695, P < 0.001).

Conclusion

Combining eGDR with NLR can be utilized to forecast long-term MACCE and substantially improve the accuracy of risk stratification in ACS patients with T2DM following PCI.

Cardiac Troponin to Adjudicate Subclinical Heart Failure in Diabetic Patients and a Murine Model of Metabolic Syndrome

BACKGROUND

Cardiovascular disease, kidney health, and metabolic disease (CKM) syndrome is associated with significant morbidity and mortality, particularly from congestive heart failure (CHF). Guidelines recommend measurement of cardiac troponin (cTn) to identify subclinical heart failure (HF) in diabetics/CKM. However, appropriate thresholds and the impact from routine screening have not been elucidated.

METHODS

cTnI was assessed using the Abbott high sensitivity (hs)-cTnI assay in outpatients with physician-ordered hemoglobin A1c (Hb A1c) and associated with cardiac comorbidities/diagnoses, demographics, and estimated glomerular filtration rate (eGFR). Risk thresholds used in CKM staging guidelines of >10 and >12 ng/L for females and males, respectively, were used. Multivariate logistic regression was applied. hs-cTnI was assessed in a high-fat-diet induced murine model of obesity and diabetes.

RESULTS

Of 1304 patients, 8.0% females and 15.7% males had cTnI concentrations above the risk thresholds. Thirty-one (4.2%) females and 23 (4.1%) males had cTnI above the sex-specific 99% upper reference limit. A correlation between hs-cTnI and Hb A1c (R = 0.2) and eGFR (R = -0.5) was observed. hs-cTnI concentrations increased stepwise based on A1C of <5.7% (median = 1.5, IQR:1.3-1.8), 5.7%-6.4% (2.1, 2.0-2.4), 6.5%-8.0% (2.8, 2.5-3.2), and >8% (2.8, 2.2-4.3). Male sex (P < 0.001), eGFR (P < 0.001), and CHF (P = 0.004) predicted elevated hs-cTnI. Obese and diabetic mice had increased hs-cTnI (7.3 ng/L, 4.2-10.4) relative to chow-fed mice (2.6 ng/L, 1.3-3.8).

CONCLUSION

A high proportion of outpatients with diabetes meet criteria for subclinical HF using hs-cTnI measurements. Glucose control is independently associated with elevated cTnI, a finding replicated in a murine model of metabolic syndrome.

Left Atrial Strain for Prediction of Left Ventricular Reverse Remodeling After ST-segment Elevation Myocardial Infarction by Cardiac Magnetic Resonance Feature Tracking

PURPOSE

The study aimed to investigate the potential utility of left atrial (LA) strain by using cardiac magnetic resonance feature-tracking (CMR-FT) to predict left ventricular reverse remodeling (LVRR) following ST-segment elevation myocardial infarction (STEMI).

MATERIALS AND METHODS

Patients with a first STEMI treated by primary percutaneous coronary intervention were consecutively enrolled in the prospective study and underwent CMR scans at 5 days and 4 months. LA global longitudinal strain (reservoir strain [εs], conduit strain [εe], booster strain [εa]) and corresponding strain rate were assessed by CMR-FT using cine images. LVRR was defined as a reduction in the LV end-systolic volume index of >10% from baseline to follow-up. Logistic regression analyses were performed to determine the predictors of LVRR.

RESULTS

Of 90 patients analyzed, patients with LVRR (n=35, 39%) showed higher values of LA strain and strain rate and less extensive infarct size (IS) compared with patients without LVRR (n=55, 61%) at initial and second CMR. The LVRR group demonstrated significant improvements in LV and LA cardiac function over time, especially the obvious increase in LA strain and strain rate. In multivariate logistic regression analyses, εs and εe, together with IS, were independent predictors of LVRR. The combination of εs and IS could optimally predict the LVRR with the highest area under the curve of 0.743.

CONCLUSIONS

Post-STEMI patients with LVRR presented better recovery from cardiac function and LA deformation compared with patients without LVRR. Assessment of εs and εe by using CMR-FT after STEMI enabled prediction of LVRR.

Smoking and Type 1 Versus Type 2 Myocardial Infarction Among People With HIV in the United States: Results from the Center for AIDS Research Network Integrated Clinical Systems Cohort

ABSTRACT

Smoking is a myocardial infarction (MI) risk factor among people with HIV (PWH). Questions persist regarding the role of smoking behaviors and measurements (e.g., intensity, duration) on MI risk. We used Cox proportional hazards regression to compare the association of smoking parameterization with incidents of type 1 and type 2 MI and whether smoking intensity or duration improves MI risk prediction among PWH. Among 11,637 PWH, 37% reported currently smoking, and there were 346 MIs. Current smoking was associated with type 1 (84% increased risk) but not type 2 MI in adjusted analyses. The type 1 MI model with pack years had the best goodness of fit compared with other smoking parameterizations. Ever or never parameterization and smoking diagnosis data had significantly poorer model fit. These results highlight the importance of differentiating MI types and performing patient-based smoking assessments to improve HIV care and research rather than relying on smoking status from diagnoses.

Chronic total occlusion percutaneous coronary intervention of anomalous coronary arteries: insights from the PROGRESS CTO registry

BACKGROUND

There is limited information about the frequency and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in anomalous coronary arteries (ACA).

METHODS

We examined the clinical and angiographic characteristics and procedural outcomes of CTO PCI in ACA among 14,173 patients who underwent 14,470 CTO PCIs at 46 US and non-US centers between 2012 and 2023.

RESULTS

Of 14,470 CTO PCIs, 36 (0.24%) were CTO PCIs in an ACA. ACA patients had similar baseline characteristics as those without an ACA. The type of ACA in which the CTO lesion was found were as follows: anomalous origin of the right coronary artery (ARCA) (17, 48.5%), anomalous origin of left circumflex coronary artery (9, 25.7%), left anterior descending artery and left circumflex artery with separate origins (4, 11.4%), anomalous origin of the left anterior descending artery (2, 5.7%), dual left anterior descending artery (2, 5.7%) and woven coronary artery 1 (2.8%). The Japan CTO score was similar between both groups (2.17 ± 1.32 vs 2.38 ± 1.26, p = 0.30). The target CTO in ACA patients was more likely to have moderate/severe tortuosity (44% vs 28%, p = 0.035), required more often use of retrograde approach (27% vs 12%, p = 0.028), and was associated with longer procedure (142.5 min vs 112.00 min [74.0, 164.0], p = 0.028) and fluoroscopy (56 min [40, 79 ml] vs 42 min [25, 67], p = 0.014) time and higher contrast volume (260 ml [190, 450] vs 200 ml [150, 300], p = 0.004) but had similar procedural (91.4% vs 85.6%, p = 0.46) and technical (91.4% vs 87.0%, p = 0.59) success. No major adverse cardiac events (MACE) were seen in ACA patients (0% [0] vs 1.9% [281] in non-ACA patients, p = 1.00). Two coronary perforations were reported in ACA CTO PCI (p = 0.7 vs. non-ACA CTO PCI).

CONCLUSIONS

CTO PCI of ACA comprise 0.24% of all CTO PCIs performed in the PROGRESS CTO registry and was associated with higher procedural complexity but similar technical and procedural success rates and similar MACE compared with non-ACA CTO PCI.

Mortality, perioperative complications and surgical timelines in hip fracture patients: Comparison of the Spanish with the non-Spanish Cohort of the HIP ATTACK-1 trial

BACKGROUND

Hip fractures carry a substantial risk of complications and death. This study aimed to report the 90-day incidence of mortality, major perioperative complications and in-hospital timelines after a hip fracture in the Spanish HIP ATTACK-1 trial cohort, comparing with the non-Spanish cohort.

METHODS

Prospective cohort study of Spanish patients nested in the HIP ATTACK-1 trial. The HIP ATTACK-1 was an international, randomized, controlled trial (17 countries, 69 hospitals, 7 in Spain, highest recruiting country). Patients were randomized to either accelerated surgery (goal of surgery within 6 h of diagnosis) or standard care. Participants were ≥45 years of age who presented with a low-energy hip fracture requiring surgery.

RESULTS

Among 534 patients in the Spanish cohort, 69 (12.9 %) patients died at 90 days follow-up, compared to 225 (9.2 %) in the non-Spanish cohort (p = 0.009), mostly due to higher nonvascular related mortality. A composite of major postoperative complication occurred in 126 patients (23.6 %). The most common perioperative complications were myocardial injury (189 patients, 35.4 %), infection with no sepsis (86 patients, 16.1 %) and perioperative delirium (84 patients, 15.7 %); all these complication rates in Spain were significantly higher than the non-Spanish patients (29.2 % p = 0.005; 11.9 % p = 0.008 and 9.2 % p < 0.0001, respectively). Spanish cohort patients were older and had more comorbidities than the non-Spanish cohort, evidencing their greater frailty at baseline. Among Spanish patients, the median time from hip fracture diagnosis to surgery was 30.0 h (IQR 21.1-53.9) in the standard-care group, with 68.8 % of patients receiving surgery within 48 h of diagnosis. This median time was lower in the non-Spanish cohort (22.8 h, IQR 9.5-37.0), where 82.1 % of patients were operated within 48 h.

CONCLUSIONS

In the HIP ATTACK-1 trial, 1 in 8 patients died 90 days after a hip fracture in Spain. The most common complication after a hip fracture was myocardial injury, followed by infection and delirium. Spanish patients had worse outcomes than non-Spanish patients. Research needs to focus on new interventions such as accelerated surgery and perioperative troponin measurement with the appropriate investment of resources, to prevent and identify early these complications with a goal of improving mortality for this high-risk population.

LEVEL OF EVIDENCE

II.

Total Arterial Multivessel Minimally Invasive Coronary Artery Bypass Surgery: 5-Year Outcomes

BACKGROUND

Total arterial revascularization is associated with superior outcomes to conventional coronary artery bypass graft (CABG) surgery performed with the left internal thoracic artery (ITA) and veins. It is often performed with bilateral ITAs that increase risk of sternal wound infection. Minimally invasive multivessel CABG through a left anterior minithoracotomy eliminates sternal wound complications. However, being performed only in a few specialized centers, there is a paucity in follow-up outcome data. We, therefore, describe our 5-year single-center experience with such operations.

METHODS

Between 2015 and 2021, 186 patients underwent elective, total arterial minimally invasive CABG in our institution. Patient data were prospectively collected in the institutional database and retrospectively analyzed. Primary end points were in-hospital mortality and 5-year survival. The secondary end points included freedom from major adverse cerebrovascular and cardiac events.

RESULTS

Patients were a mean age of 66 ± 9 years, and 23 (12%) were women. The mean number of bypass grafts performed was 2.4 ± 0.5 (range, 2-4 grafts). Bilateral ITAs were used in 163 patients (88%) and left ITA and radial arteries in 22 (12%). The mean procedure time was 277 ± 58 minutes. There was 1 hospital death. Perioperative myocardial infarction, repeat thoracotomy, and conversion to sternotomy was observed in 6 (3%), 12 (6.5%), and 2 patients (1.1%), respectively. The mean 5-year survival was 93.3% ± 2.2%, and freedom from major adverse cardiac and cerebrovascular events was 83.8% ± 4.1%.

CONCLUSIONS

Total arterial minimally invasive CABG is a feasible surgical approach yielding excellent short- and midterm results when performed in selected patients in specialized high-volume cardiac centers.

Cardiac Troponin Levels in Patients with Chronic Kidney Disease: "Markers of High Risk or Just Noise''?

Kidney disease is linked to the development of cardiovascular disorders, further increasing morbidity and mortality in this high-risk population. Thus, early detection of myocardial damage is imperative in order to prevent devastating cardiovascular complications within this patient group. Over the years, cardiac biomarkers have been identified and are now widely used in everyday clinical practice. More specifically, available data suggest that cardiac troponin and its regulatory subunits (TnT, TnI, and TnC) reflect the injury and necrosis of myocardial tissue. While cTnC is identical in cardiac and skeletal muscle, TnT and TnI constitute cardiac-specific forms of troponin, and, as such, they have been established by international societies as biomarkers of cardiac damage and diagnostic indicators for acute myocardial infarction. Elevations in the levels of both cardiac troponins (cTnT and cTnI) have been also reported in asymptomatic patients suffering from chronic kidney disease. Therefore, if abnormal, they often generate confusion among clinicians regarding the interpretation and clinical significance of their numerical values in emergency settings. The aim of this review is to explore the reasons behind elevated troponin levels in patients with chronic kidney disease and identify when these elevated levels of biomarkers indicate the need for urgent intervention, considering the high cardiovascular risk in this patient group.

A novel GWAS locus influences microvascular response to mental stress and predicts adverse cardiovascular events

Excessive peripheral microvascular constriction during acute psychological stress reflects similar changes in coronary blood flow and is a predictor of adverse cardiovascular outcomes. Among individuals with coronary artery disease (CAD), we sought to determine if genetic factors contribute to the degree of microvascular constriction during mental stress. A total of 580 stable CAD individuals from two prospective cohort studies underwent mental stress testing. Digital pulse wave amplitude was continuously measured and the stress/rest (sPAT) ratio of pulse wave amplitude was calculated. Race stratified genome-wide association studies (GWAS) of sPAT-ratio were conducted using linear regression of additive genetic models. A trans-ethnic meta-analysis integrated the four sets of GWAS results. Participants were followed for the outcome of recurrent cardiovascular events (myocardial infarction, heart failure, revascularization, and CV death) for a median of 5 years. We used Wei-Lin-Weissfeld (WLW) model to assess the association between sPAT-ratio with recurrent events. Mean age was 63 ± 9. We identified three SNPs in linkage disequilibrium, closely related to chr7:111,666,943 T > C (rs6466396) that were associated with sPAT-ratio (p = 6.68E-09). Participants homozygous for the T allele had 80% higher risk of incident adverse events (HR 1.8, 95% CI, 1.4-2.2). Also, participants with a lower sPAT-ratio (< median) had a higher adverse event rate, hazard ratio (HR) = 1.3, [95%confidence interval (CI), 1.1-1.6]. However, adjustment for the genotypes did not substantially alter the impact of sPAT ratio on adverse outcome rate. In conclusion, we have identified a genetic basis for stress-induced vasomotion. The 3 linked variants modulate vasoconstriction during mental stress may have a prognostic importance.

A Prospective, Randomized Trial of Bioresorbable Polymer Drug-Eluting Stents versus Fully Bioresorbable Scaffolds in Patients Undergoing Coronary Stenting

Background: The performance of an everolimus-eluting bioresorbable scaffold (BRS) was inferior to an everolimus-eluting metallic drug-eluting stent (DES) with permanent polymer, mainly due the mechanical features of BRS technology. The performance of BRS as compared to metallic DES with bioresorbable polymers remains unstudied. Methods: This prospective, randomized, multicenter, clinical trial enrolled patients who underwent coronary stenting for de novo coronary lesions. Patients were randomly assigned to bioresorbable polymer everolimus-eluting stents (BP-EES) or everolimus-eluting BRS. The primary endpoint was percentage diameter stenosis (in-device) at 6- to 8-month angiographic surveillance. The main secondary endpoint was the device-oriented composite endpoint (DOCE) of cardiac death/target vessel-myocardial infarction/target lesion revascularization assessed after 12 months and 5 years. Results: The trial was prematurely terminated after the enrollment of 117 of 230 patients (BP-EES, n = 60; BRS, n = 57) due to safety issues associated with BRS technology. The primary endpoint of in-device diameter stenosis at angiographic surveillance was 12.5 ± 7.7% with BP-EES versus 19.3 ± 16.5% with BRS (p = 0.01). The DOCE occurred in 5.0% in the BP-EES group versus 12.3% of patients in the BRS group (hazard ratio [HR] 2.48, 95% confidence interval [CI] 0.64-9.58, p = 0.19) after 12 months and in 11.7% in the BP-EES group versus 26.4% of patients in the BRS group (HR 2.38, 95% CI 0.97-5.84, p = 0.06) after 5 years. Conclusions: BP-EES showed superior mid-term angiographic performance compared with BRS. Clinical event rates did not differ significantly between the groups up to 5 years of follow-up. These results should be interpreted with caution in view of the premature discontinuation of the study.

Diagnosing Myocardial Injury in an Acute Chest Pain Cohort; Long-Term Prognostic Implications of Cardiac Troponin T and I

BACKGROUND

There are limited data regarding the utility of follow-up cardiac troponin (cTn) measurements after admission for acute chest pain and how long-term stability of myocardial injury and prognostic value differ when using cardiac troponin T (cTnT) or I (cTnI).

METHODS

We measured high-sensitivity (hs)-cTnT (Roche Diagnostics) and hs-cTnI (Siemens Healthineers) during hospitalization for acute chest pain and after 3 months. Acute myocardial injury was defined as concentrations > sex-specific upper reference limit (URL) during hospitalization and ≤URL at 3-months. Chronic myocardial injury (CMI) was defined as concentrations > URL at both time points. Patients were followed from the 3-month sampling point for a median of 1586 (IQR 1161-1786) days for a primary composite endpoint of all-cause mortality, myocardial infarction (MI), revascularization, and heart failure, and a secondary endpoint of all-cause mortality.

RESULTS

Among 754 patients, 33.8% (hs-cTnT) and 19.2% (hs-cTnI) had myocardial injury during hospitalization. The rate of CMI was 5 times higher by hs-cTnT (20%) assay than hs-cTnI (4%), while acute myocardial injury was equally common; 14% (hs-cTnT) and 15% (hs-cTnI), respectively (6% and 5% when excluding index non-ST-elevation MI (NSTEMI). For hs-cTnT, peak index concentration, 3-month concentration and classification of CMI predicted the primary endpoint; hazard ratios (HRs) 1.38 (95% CI 1.20-1.58), 2.34 (1.70-3.20), and 2.31 (1.30-4.12), respectively. For hs-cTnI, peak index concentration predicted the primary endpoint; HR 1.14 (1.03-1.25). This association was nonsignificant after excluding index NSTEMI.

CONCLUSIONS

Acute myocardial injury is equally frequent, whereas CMI is more prevalent using hs-cTnT assay than hs-cTnI. Measuring hs-cTnT 3 months after an acute chest pain episode could assist in further long-term risk assessment. ClinicalTrials.gov Registration Number: NCT02620202.