Application of the SYNTAX score in interventional cardiology: A systematic review and meta-analysis

Neoadjuvant therapy bridging percutaneous coronary intervention (PCI) and video-assisted thoracoscopic (VATS) lobectomy: a retrospective study

Background

Currently, there is no unified standard for the treatment of coronary artery disease (CAD) in non-small cell lung cancer (NSCLC), and the treatments have their own advantages and disadvantages. Thus, this study aimed to analyze the safety and feasibility of neoadjuvant therapy during the dual antiplatelet therapy (DAPT) period before surgery in patients with NSCLC coexisting with CAD after percutaneous coronary intervention (PCI) treatment.

Methods

We retrospectively included 13 patients with T2aN0M0 (stage IB) NSCLC who also had concomitant CAD. After PCI treatment, neoadjuvant targeted or immunotherapy was administered based on the type of lung cancer, and the effects on treatment and impact on surgery were observed.

Results

The objective response rate (ORR) after neoadjuvant treatment in 13 patients was 53.8% [95% confidence interval (CI): 25.1-80.8%], and the disease control rate (DCR) reached 100%. Ten patients (76.9%) experienced adverse events (AEs) ≤ grade 2. All patients underwent standard VATS lobectomy with lymph node dissection. One case (7.7%) required conversion to open thoracotomy, and all cases achieved R0 resection. The median operative time was 150 [interquartile range (IQR) 125-250] minutes, median intraoperative blood loss was 180 (IQR 150-235) mL, median postoperative drainage tube placement time was 4 (IQR 3-5) days, median total drainage volume was 1,310 (IQR 780-1,705) mL, and the median postoperative hospitalization was 7 (IQR 7-8) days. One patient (7.7%) experienced rapid atrial fibrillation. No deaths occurred. Postoperative pathological evaluation in three cases achieved major pathological response (MPR) (23.1%, 95% CI: 5-53.8%), with two cases achieving pathological complete response (pCR) (15.4%, 95% CI: 1.9-45.4%).

Conclusions

The study presents initial evidence suggesting for the safety and feasibility of performing PCI treatment followed by neoadjuvant therapy during the DAPT period for patients with T2aN0M0 (IB) stage NSCLC coexisting with CAD. This approach presents a potential treatment option to control the disease while eliminating concerns about tumor progression and metastasis.

The relationship between triglyceride/high-density lipoprotein cholesterol ratio and the severity of coronary artery disease in patients presenting with acute coronary syndrome

BACKGROUND

The SYNTAX score is a score that grades the severity and complexity of coronary lesions. In this study, we aimed to investigate the relationship between triglyceride/high-density lipoprotein cholesterol (triglyceride/HDL-C) ratio and SYNTAX scores in patients presenting with non-ST elevation myocardial infarction (NSTEMI).

METHODS

This prospective study included 258 patients who presented at our center with STEMI, and underwent coronary angiography (CAG). The triglyceride/HDL-C ratio was calculated, and the relationship of this ratio with the SYNTAX score was determined with univariate and multivariate linear regression analyses.

RESULTS

The patients were separated into two groups according to the triglyceride/HDL-C ratios as low (<3.88) and high (≥3.88). The SYNTAX scores of the group with a high triglyceride/HDL-C score were determined to be significantly high ( P  < 0.001). When the SYNTAX scores were separated into two groups as low (≤22) and high (>23), a statistically significant correlation was determined between a high SYNTAX score and a high triglyceride/HDL-C ratio ( P  < 0.001). Logistic regression analysis was performed for the SYNTAX score, and the BMI value [odds ratio (OR) = 0.91, 95% confidence interval (CI): 0.85-0.98] and the triglyceride/HDL-C ratio (OR = 6.86, 95% CI: 3.45-13.65) alone were determined to be independent determinants of the SYNTAX score.

CONCLUSION

The most important result obtained from this study was that the triglyceride/HDL-C ratio, which is an index that has recently started to be frequently used, was a marker of greater coronary anatomic complexity (SYNTAX score >22), independently of other parameters in patients who presented with NSTEMI and underwent CAG.

Redox Status and Telomere-Telomerase System Biomarkers in Patients with Acute Myocardial Infarction Using a Principal Component Analysis: Is There a Link?

In the present study, we examined redox status parameters in arterial and venous blood samples, its potential to predict the prognosis of acute myocardial infarction (AMI) patients assessed through its impact on the comprehensive grading SYNTAX score, and its clinical accuracy. Potential connections between common blood biomarkers, biomarkers of redox status, leukocyte telomere length, and telomerase enzyme activity in the acute myocardial infarction burden were assessed using principal component analysis (PCA). This study included 92 patients with acute myocardial infarction. Significantly higher levels of advanced oxidation protein products (AOPP), superoxide anion (O2•-), ischemia-modified albumin (IMA), and significantly lower levels of total oxidant status (TOS) and total protein sulfhydryl (SH-) groups were found in arterial blood than in the peripheral venous blood samples, while biomarkers of the telomere-telomerase system did not show statistical significance in the two compared sample types (p = 0.834 and p = 0.419). To better understand the effect of the examined biomarkers in the AMI patients on SYNTAX score, those biomarkers were grouped using PCA, which merged them into the four the most contributing factors. The "cholesterol-protein factor" and "oxidative-telomere factor" were independent predictors of higher SYNTAX score (OR = 0.338, p = 0.008 and OR = 0.427, p = 0.035, respectively), while the ability to discriminate STEMI from non-STEMI patients had only the "oxidative-telomere factor" (AUC = 0.860, p = 0.008). The results show that traditional cardiovascular risk factors, i.e., high total cholesterol together with high total serum proteins and haemoglobin, are associated with severe disease progression in much the same way as a combination of redox biomarkers (pro-oxidant-antioxidant balance, total antioxidant status, IMA) and telomere length.

Correlation of RETINAL Artery Diameter with Coronary Artery Disease: The RETINA CAD Pilot Study-Are the Eyes the Windows to the Heart?

INTRODUCTION

This study aimed to determine whether there was any correlation between coronary artery disease (CAD) and retinal artery diameter at an academic tertiary medical center in Trinidad and Tobago.

METHODS

This prospective study evaluated patients (n = 77) with recent invasive coronary angiography (CAG) and the Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score who subsequently underwent optical coherence tomography-angiography (OCT-A) at the Eric Williams Medical Sciences Complex (EWMSC) from January 2021 to March 2021. Routine medical history and cardiovascular medications were also recorded. Spearman's rank correlation coefficient and Mann-Whitney U-tests were used to compare correlations and medians between groups.

RESULTS

The average patient age was 57.8 years old, with the majority being male [n = 55 (71.4%)] and of South Asian ethnicity [n = 53 (68.8%)]. Retinal artery diameter was negatively correlated with the SYNTAX score (-0.332 for the right eye, p = 0.003 and -0.237 for the left eye, p = 0.038). A statistically significant relationship was also demonstrated in females and diabetic patients. There were no serious adverse events (SAEs).

CONCLUSION

A significantly negative correlation was observed between retinal artery diameter and SYNTAX score. This study alludes to the practical use of optical coherence tomography-angiography (OCT-A) as a noninvasive diagnostic modality for patients with cardiovascular disease (CVD). Further large-scale, multicentric studies are required to confirm these exploratory findings.

TRIAL REGISTRATION NUMBER

NCT04233619.

A bibliometric analysis of acute myocardial infarction in women from 2000 to 2022

Background

Plenty of publications had been written in the last several decades on acute myocardial infarction (AMI) in women. However, there are few bibliometric analyses in such field. In order to solve this problem, we attempted to examine the knowledge structure and development of research about AMI in women based on analysis of related publications.

Method

The Web of Science Core Collection was used to extract all publications regarding AMI in women, ranging from January 2000 to August 2022. Bibliometric analysis was performed using VOSviewer, Cite Space, and an online bibliometric analysis platform.

Results

A total of 14,853 publications related to AMI in women were identified from 2000 to 2022. Over the past 20 years, the United States had published the most articles in international research and participated in international cooperation the most frequently. The primary research institutions were Harvard University and University of Toronto. Circulation was the most cited journal and had an incontrovertible academic impact. 67,848 authors were identified, among which Harlan M Krumholz had the most significant number of articles and Thygesen K was co-cited most often. And the most common keywords included risk factors, disease, prognosis, mortality, criteria and algorithm.

Conclusion

The research hotspots and trends of AMI in women were identified and explored using bibliometric and visual methods. Researches about AMI in women are flourishing. Criteria and algorithms might be the focus of research in the near future, which deserved great attentions.

Artificial intelligence in cardiovascular prevention: new ways will open new doors

Prevention and effective treatment of cardiovascular disease are progressive issues that grow in tandem with the average age of the world population. Over recent decades, the potential role of artificial intelligence in cardiovascular medicine has been increasingly recognized because of the incredible amount of real-world data (RWD) regarding patient health status and healthcare delivery that can be collated from a variety of sources wherein patient information is routinely collected, including patient registries, clinical case reports, reimbursement claims and billing reports, medical devices, and electronic health records. Like any other (health) data, RWD can be analysed in accordance with high-quality research methods, and its analysis can deliver valuable patient-centric insights complementing the information obtained from conventional clinical trials. Artificial intelligence application on RWD has the potential to detect a patient's health trajectory leading to personalized medicine and tailored treatment. This article reviews the benefits of artificial intelligence in cardiovascular prevention and management, focusing on diagnostic and therapeutic improvements without neglecting the limitations of this new scientific approach.

Prediction of microvascular obstruction by coronary artery angiography score after acute ST-segment elevation myocardial infarction: a single-center retrospective observational study

Background

Some coronary artery angiography (CAG) scores are associated with the no-reflow phenomenon after percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI). However, quality evidence regarding the association between the CAG scores and microvascular injury is still needed. Our study aimed to validate the ability of the CAG scores in predicting microvascular obstruction (MVO) detected by cardiac magnetic resonance (CMR) imaging.

Methods

From October 2020 to October 2021, 141 consecutive patients with acute STEMI who underwent primary PCI and CMR were retrospectively reviewed. CMR imaging was performed between 3 and 7 days after PCI. The patients were divided into MVO and non-MVO group based on the CMR results. Three CAG scores (SYNTAX score, SYNTAX II score and Gensini score) were used to assess the severity of coronary artery atherosclerotic burden.

Results

A total of 122 patients were included (mean age 60.6 ± 12.8 years). MVO occurred in 51 patients (41.8%). Patients with MVO had higher SYNTAX scores, SYNTAX II scores and Gensini scores than those without MVO (all p < 0.001). The Gensini score (r = 0.567, p < 0.001) showed the strongest correlation with infarction size than SYNTAX score (r = 0.521, p < 0.001) and SYNTAX II score (r = 0.509, p < 0.001). The areas under the receiver operator characteristic curves of SYNTAX score, SYNTAX II score and Gensini score for predicting MVO patients were 0.726, 0.774 and 0.807. In multivariable regression analysis, peak troponin I (odd ratio [OR] = 1.236, p = 0.001) and SYNTAX II score (OR = 11.636, p = 0.010) were identified as independent predictors of MVO.

Conclusions

In patients with acute STEMI undergoing primary PCI treatment, the peak troponin I and SYNTAX II score may be an independent predictor of MVO.

Correlation between frontal QRS‐T angle, Tp‐e interval, and Tp‐e/ QT ratio to coronary artery severity assessed with SYNTAX score in stable coronary artery disease patients

Background

Methods

Results

Conclusions

Analysis of Risk Factors of Coronary Heart Disease and Its Correlation with Inflammatory Factors in Patients with Type 2 Diabetes Mellitus

In this paper, we propose a new method to analyze the risk factors of coronary heart disease (CHD) and their correlation with inflammatory factors in patients with type 2 diabetes mellitus (T2DM). To verify and implement this idea, we have selected a total of 165 patients with T2DM treated in our hospital from March 2019 to October 2021 that were divided into CHD group (n = 72) and non-CHD group (n = 93) according to the results of coronary angiography. Patients with CHD were divided into three groups according to SYNTAX score: low-risk group, medium-risk group, and high-risk group. The clinical data of all patients were collected. Univariate and multivariate analyses were used to screen the risk factors of CHD in patients with T2DM. The related inflammatory factors such as C-reactive protein (CRP), interleukin-6 (IL-6), and water-soluble CD40 ligand (sCD40L) were detected in all patients. Pearson's linear correlation analysis was used to analyze the correlation between the expression levels of CRP, IL-6, and sCD40L and CHD in patients with T2DM. The receiver working curve (ROC) was used to evaluate the efficacy of IL-6, CRP, and sCD40L in predicting high risk of CHD in patients with T2DM. Multivariate analysis showed that age and course of T2DM, FFA, UA, and Hcy were risk factors for CHD in patients with T2DM. The serum levels of IL-6, CRP, and sCD40L in patients with CHD were significantly higher than those in patients without CHD. According to SYNTAX score, 72 patients with CHD were divided into low-risk group (n = 36), medium-risk group (n = 26), and high-risk group (n = 10). Compared with the low-risk group, the expression levels of serum IL-6 CRP and sCD40L in the middle-risk group and high-risk group were significantly higher than those in the low-risk group. The expression levels of IL-6 CRP and sCD40L in the high-risk group were also significantly higher than those in the medium-risk group. There is a positive correlation between syntactic score and IL-6 expression in patients with T2DM complicated with coronary heart disease (r = 0.778, P < 0.001), with the expression of CRP (r = 0.756, P < 0.001) and with the expression of sCD40L (r = 0.748, P < 0.001). Advanced age, long course of T2DM, elevated levels of FFA, UA, and Hcy are all risk factors of CHD in patients with type 2 diabetes. T2DM patients with the above risk factors should be vigilant and pay attention to monitoring the related indexes of coronary heart disease to avoid the occurrence of serious cardiovascular disease. CRP, IL-6, and sCD40L are involved in the progression of CHD in patients with T2DM. The more severe CHD is, the higher the expression of IL-6, CRP, and sCD40L in serum.

Clinical Nomogram to Predict Major Adverse Cardiac Events in Acute Myocardial Infarction Patients within 1 Year of Percutaneous Coronary Intervention

The purpose of this study was to summarize the clinical characteristics and risk factors of major adverse cardiovascular events (MACEs) in patients who had had acute myocardial infarction (AMI) within 1 year of percutaneous coronary intervention (PCI). A total of 421 AMI patients who were treated with PCI and experienced MACEs within 1 year of their admission were included in this retrospective study. In addition, patients were matched for age, sex, and presentation with 561 patients after AMI who had not had MACEs. The clinical characteristics and risk factors for MACEs within 1 year in AMI patients were investigated, to develop a nomogram for MACEs based on univariate and multivariate analyses. The C statistic was used to assess the discriminative performance of the nomogram. In addition, calibration curve and decision curve analyses were conducted to validate the calibration performance and utility, respectively, of the nomogram. After univariate and multivariate analyses, a nomogram was constructed based on age (odds ratio (OR): 1.030; 95% confidence interval (CI): 1.014–1.047), diabetes mellitus (OR: 1.667; 95% CI: 1.151–2.415), low-density lipoprotein cholesterol (OR: 1.332; 95% CI: 1.134–1.565), uric acid (OR: 1.003; 95% CI: 1.001–1.005), lipoprotein (a) (OR: 1.003; 95% CI: 1.002–1.003), left ventricular ejection fraction (OR: 0.929; 95% CI: 0.905–0.954), Syntax score (OR: 1.075; 95% CI: 1.053–1.097), and hypersensitive troponin T (OR: 1.002; 95% CI: 1.002–1.003). The C statistic was 0.814. The calibration curve showed good concordance of the nomogram, while decision curve analysis demonstrated satisfactory positive net benefits. We developed a convenient, practical, and effective prediction model for predicting MACEs in AMI patients within 1 year of PCI. To ensure generalizability, this model requires external validation.

Blood lead level in Chinese adults with and without coronary artery disease

BACKGROUND

The Trial to Assess Chelation Therapy study found that edetate disodium (disodium ethylenediaminetetraacetic acid) chelation therapy significantly reduced the incidence of cardiac events in stable post-myocardial infarction patients, and a body of epidemiological data has shown that accumulation of biologically active metals, such as lead and cadmium, is an important risk factor for cardiovascular disease. However, limited studies have focused on the relationship between angiographically diagnosed coronary artery disease (CAD) and lead exposure. This study compared blood lead level (BLL) in Chinese patients with and without CAD.

METHODS

In this prospective, observational study, 450 consecutive patients admitted to Beijing Anzhen Hospital with suspected CAD from November 1, 2018, to January 30, 2019, were enrolled. All patients underwent coronary angiography, and an experienced heart team calculated the SYNTAX scores (SXscore) for all available coronary angiograms. BLLs were determined with atomic absorption spectrophotometry and compared between patients with angiographically diagnosed CAD and those without CAD.

RESULTS

In total, 343 (76%) patients had CAD, of whom 42% had low (0-22), 22% had intermediate (23-32), and 36% had high (≥ 33) SXscore. BLLs were 36.8 ± 16.95 μg/L in patients with CAD and 31.2 ± 15.75 μg/L in those without CAD (P = 0.003). When BLLs were categorized into three groups (low, middle, high), CAD prevalence increased with increasing BLLs (P < 0.05). In the multivariate regression model, BLLs were associated with CAD (odds ratio (OR): 1.023, 95% confidence interval (CI): 1.008-1.039; P = 0.0017). OR in the high versus low BLL group was 2.36 (95% CI: 1.29-4.42,P = 0.003). Furthermore, BLLs were independently associated with intermediate and high SXscore (adjusted OR: 1.050, 95% CI: 1.036-1.066; P < 0.0001).

CONCLUSION

BLLs were significantly associated with angiographically diagnosed CAD. Furthermore, BLLs showed excellent predictive value for SXscore, especially for complex coronary artery lesions.

Application of Artificial Intelligence in Acute Coronary Syndrome: A Brief Literature Review

Artificial intelligence (AI) is defined as a set of algorithms and intelligence to try to imitate human intelligence. Machine learning is one of them, and deep learning is one of those machine learning techniques. The application of AI in healthcare systems including hospitals and clinics has many possible advantages and future prospects. Applications of AI in cardiovascular medicine are machine learning techniques for diagnostic procedures including imaging modalities and biomarkers and predictive analytics for personalized therapies and improved outcomes. In cardiovascular medicine, AI-based systems have found new applications in risk prediction for cardiovascular diseases, in cardiovascular imaging, in predicting outcomes after revascularization procedures, and in newer drug targets. AI such as machine learning has partially resolved and provided possible solutions to unmet requirements in interventional cardiology. Predicting economically vital endpoints, predictive models with a wide range of health factors including comorbidities, socioeconomic factors, and angiographic factors comprising of the size of stents, the volume of contrast agent which was infused during angiography, stent malposition, and so on have been possible owing to machine learning and AI. Nowadays, machine learning techniques might possibly help in the identification of patients at risk, with higher morbidity and mortality following acute coronary syndrome (ACS). AI through machine learning has shown several potential benefits in patients with ACS. From diagnosis to treatment effects to predicting adverse events and mortality in patients with ACS, machine learning should find an essential place in clinical medicine and in interventional cardiology for the treatment and management of patients with ACS. This paper is a review of the literature which will focus on the application of AI in ACS.

Predictive value of CHADS2 and CHA2DS2-VASc scores for coronary artery lesions and in-hospital prognosis of patients with acute ST-segment elevation myocardial infarction

Objective

To evaluate the predictive value of CHADS₂ and CHA₂DS₂-VASc scores for coronary artery lesions and in-hospital prognosis of patients with acute ST-segment elevation myocardial infarction (STEMI).

Methods

A total of 524 patients who were diagnosed with STEMI from January 2016 to August 2017 were retrospectively reviewed. The correlation between CHADS₂ and CHA₂DS₂-VASc scores with the patients’ clinical data, number of coronary lesions, Gensini scores, the target vessel and hospitalization time and in-hospital adverse events (AEs) was analyzed.

Results

The number of coronary lesions in STEMI patients was mainly single and double lesions. The CHADS₂ and CHA₂DS₂-VASc scores were not meaningful for predicting the number of coronary lesions. However, for left main coronary artery lesion, CHADS₂ score was significantly increased when the number increased (P < 0.05), but CHA₂DS₂-VASc score showed no statistical difference (P > 0.05). The incidence of target lesions in STMEI patients was mainly left anterior descending coronary artery (LAD) and right coronary artery (RCA). The two scores were not meaningful for predicting target lesions (P > 0.05). For the severity of coronary lesions, there was positive correlation between CHADS₂ score with Gensini score (P < 0.05), but no exact correlation between CHA₂DS₂-VASc score and Gensini score (P > 0.05). The stratifications of CHADS₂ score and CHA₂DS₂-VASc score were significantly associated with hospitalization time and adverse events during hospitalization (P < 0.05). The high score group had longer hospitalization time and more AEs during hospitalization than the low score group and the middle group statistically (P < 0.05).

Conclusion

CHADS₂ score had a certain value to predict the severity of coronary lesion and the presence of left main coronary artery in STEMI. The CHA₂DS₂-VASc score had no predictive ability to do it. There was no significant value in predicting the number of coronary lesions and the location of the target lesions in STEMI patients. However, both scores had the predictive ability for patient hospitalization and AEs during hospitalization.

The association between the fibrinogen-to-albumin ratio and coronary artery disease severity in patients with stable coronary artery disease

OBJECTIVE

Fibrinogen-to-albumin ratio (FAR) is an inexpensive and easily measurable novel inflammatory index that has been found to be associated with atherosclerosis. In this study, we aimed to investigate the association between the FAR and coronary artery disease (CAD) severity in patients with stable CAD.

METHODS

In total, 356 consecutive patients with CAD were classified into three groups, those with a low Synergy between percutaneous coronary intervention and the Taxus and Cardiac Surgery Study (SYNTAX) score (≤22), those with an intermediate SYNTAX score (23≥ SYNTAX score ≤32) and those with a high SYNTAX score (>32).

RESULTS

We determined that there were significant differences in the mean age (P < 0.001), male gender (P = 0.008), serum fibrinogen (P = 0.03), low-density lipoprotein cholesterol (P < 0.001) and FAR (P < 0.001) among the SYNTAX score groups. A strong positive correlation was detected between FAR and SYNTAX score (r = 0.899; P < 0.001), and the cutoff level of FAR for high SYNTAX score was 82 (sensitivity of 82%, specificity of 88.3% and an area under the curve of 0.826).

CONCLUSION

The novel inflammatory index, FAR, is significantly associated with the severity of CAD in patients with stable CAD.

The Relationship Between Type D Personality and the Complexity of Coronary Artery Disease

PURPOSE

The relationship between personality traits and cardiovascular disease has gathered sustained interest over the last years, type -D personality (TDP) being significantly associated with coronary artery disease (CAD). However, data regarding the connection between the TDP and the severity of CAD disease is scarce. The aim of our study was to assess the relationship between TDP and the complexity of CAD, and to compare it with other sociodemographic and clinical features.

PATIENTS AND METHODS

We conducted a cross-sectional case-control clinical-based study on 221 consecutive hospitalized patients with chest pain (60 ± 10.2 years; 131 men), referred for coronary angiography.

RESULTS

TDP was identified in 42 (19%) patients, using the DS 14 scale. Symptomatology profile was evaluated using the SCL-90 scale. Syntax score was greater in the subgroup of patients with TDP in comparison to non-TDP subgroup (26.21±12.03 vs 15.49±8.89, respectively, p<0.001), and most of SCL-90 symptom dimensions have significantly higher levels in the subgroup of TDP with CAD patients (all p < 0.05). Smoking (β=0.132, p=0.037), dyslipidemia (β=0.149, p=0.013), Diabetes Mellitus (β=232, p<0.001), NA dimension of TDP (β=0.255, p<0.001) and SI (β=0.279, p<0.001) dimension of TDP have a significant contribution to the complexity of CAD assessed by Syntax score.

CONCLUSION

TDP was associated with a more complex CAD assessed by Syntax score, and may represent a dynamic interface between the biological and psychological vulnerabilities and the symptoms of CAD.

Cardiac mortality benefit of direct admission to percutaneous coronary intervention-capable hospital in acute myocardial infarction: Community registry-based study

Appropriate risk stratification and timely revascularization of acute myocardial infarction (AMI) are available in percutaneous coronary intervention (PCI) - capable hospitals (PCHs). This study evaluated whether direct admission vs inter-hospital transfer influences cardiac mortality in patients with AMI. This study was conducted in the PCH where the patients were able to arrive within an hour. The inclusion criteria were AMI with a symptom onset time within 24 hours and having undergone PCI within 24 hours after admission. The cumulative incidence of cardiac death after percutaneous coronary intervention was evaluated in the direct admission versus inter-hospital transfer groups. Among the 3178 patients, 2165 (68.1%) were admitted via inter-hospital transfer. Patients with ST-segment elevation myocardial infarction (STEMI) in the direct admission group had a reduced symptom onset-to-balloon time (121 minutes, P < .001). With a median period of 28.4 (interquartile range, 12.0-45.6) months, the cumulative incidence of 2-year cardiac death was lower in the direct admission group (NSTEMI, 9.0% vs 11.0%, P = .136; STEMI, 9.7% vs 13.7%, P = .040; AMI, 9.3% vs 12.3%, P = .014, respectively). After the adjustment for clinical variables, inter-hospital transfer was the determinant of cardiac death (hazard ratio, 1.59; 95% confidence interval, 1.08-2.33; P = .016). Direct PCH admission should be recommended for patients with suspected AMI and could be a target for reducing cardiac mortality.

Effect of Treatment Regimen on Long-Term Mortality of Geriatric Patients Diagnosed With Stable Coronary Artery Disease

Background Increased life expectancy across the world has resulted in an increase in the proportion of the elderly population who are lost to heart diseases. Advanced age and comorbidities are believed to change the response to treatments. In this study, we aimed to investigate the effects of surgical and medical treatments on the mortality of stable coronary diseases. Methods A total of 150 geriatric patients who underwent coronary angiography (CAG) were followed up in our cardiology clinic. Patients who decided to undergo coronary artery bypass graft (CABG) surgery after CAG and were willing to undergo the operation were assigned to group 1, whereas those who were unwilling to undergo the operation were not eligible for percutaneous coronary intervention and were followed up medically, and were assigned to group 2. Keeping the primary goal as mortality rates, both the groups were compared using medical records for three years after the treatment. Results After three years, the overall mortality rate included six patients (16%) in the CABG group versus 63 patients (55%) in the medical therapy group (p < 0.001). The CABG therapy was found to be significantly and independently associated with first- and third-year mortality (risk ratio: 0.064, 95% confidence interval: 0.009-0.467, p = 0.007; risk ratio: 0.305, 95% confidence interval: 0.151-0.615, p < 0.001, respectively). Kaplan-Meier analysis for first- and third-year all-cause mortality rates led to significant results and curves between the groups. Conclusion Our study revealed that compared to CABG surgery in the treatment of coronary artery disease in geriatric patients, medical treatment is associated with poor outcomes in terms of mortality in long-term follow-up.

The Association between Serum Heme Oxygenase-1 Levels and Coronary SYNTAX Score

AIM

The relationship between heme oxygenase-1 (HO-1) levels and atherosclerosis was investigated in multiple studies. The aim of this study was to establish the relationship between HO-1 levels and coronary SYNergy between percutaneous coronary intervention with TAXus and Cardiac Surgery (SYNTAX) score in patients with stable coronary artery disease (CAD).

METHODS

Patients who had been planned to undergo invasive coronary angiography due to a suspected CAD, between the dates of September and December 2019, were included in the study. Serum HO-1 levels were measured from peripheral venous blood. The SYNTAX score was calculated using standard coronary angiography images. Regression analysis was performed to establish the relationship between HO-1 levels and the SYNTAX score.

RESULTS

In total, 137 patients were included. The median age was 63 years (IQR: 15), and most of the patients were male (75.2%). The median HO-1 level was 1.44 (IQR: 0.88) ng/mL, and the median SYNTAX score was 6 (IQR: 13). Regression analysis showed that HO-1 is the single most important variable associated with the SYNTAX score (HO-1 levels from 1.01 to 1.87 ng/mL, OR: 6.77, 95% confidence interval 5.18-8.36, p < 0.0001).

CONCLUSION

In this study, serum HO-1 levels were significantly associated with the coronary SYNTAX score.

Fibrinolysis Therapy Combined with Deferred PCI versus Primary Angioplasty for STEMI Patients During the COVID-19 Pandemic: Preliminary Results from a Single Center

Introduction

The efficacy of fibrinolysis therapy with deferred percutaneous coronary angioplasty (FPCI) versus primary angioplasty (PPCI) during the coronavirus disease 2019 (COVID-19) pandemic is unclear when medical quarantine is needed.

Patients and Methods

Acute ST segment elevation myocardial infarction (STEMI) patients underwent PPCI after finishing the screening protocol from January 23, 2020 to June 10, 2020 while FPCI was applied when COVID-19-confirmed cases reoccurred in Beijing near our hospital from June 11, 2020 to July 20, 2020. The door-to-balloon time (DTB) or door-to-needle time (DTN) as well as in-hospital adverse clinical outcomes were compared between the two groups. A propensity score-matched (PSM) analysis was performed to diminish the potential influence of confounding factors on the clinical outcomes.

Results

A total of 126 STEMI patients underwent PPCI after finishing the screening protocol and 17 patients received FPCI before PSM. Patients who received FPCI were younger than patients who underwent PPCI (50.8±14.0 versus 64.1±14.2 years, p=0.001), and chronic kidney disease (CKD) was less common in FPCI patients than in patients who underwent PPCI (0% versus 24.6%, p=0.024). The DTN was significantly shorter than DTB (25.8±4.2 versus 61.1±10.7, p=0.000) before PSM. The DTN was significantly shorter than DTB (26.9±4.2 versus 64.9±23.6, p=0.000); however, the incidence rate of in-hospital ischemia and bleeding adverse clinical outcomes were comparable between the two groups after PSM.

Conclusion

Fibrinolysis therapy combined with deferred PCI can reduce the ischemia time and has a similar in-hospital adverse clinical outcome rate compared with patients who underwent primary PCI during the COVID-19 pandemic.

Platelet microvesicles are associated with the severity of coronary artery disease: comparison between peripheral and coronary circulation

Microvesicles (MVs) have recently emerged as markers of thrombosis. Furthermore, there is an unexplained residual thrombotic risk is observed in patients with acute coronary syndrome (ACS) and/or stable coronary artery disease (CAD), despite treatment. We measured platelet (PMVs) and erythrocyte (ErMVs) in patients with ACS and stable CAD, both in the peripheral and coronary circulation. We studied consecutive eligible patients during a coronary angiography. Blood samples were collected from the stem of the left coronary artery and femoral artery. PMVs were significantly increased in CAD patients compared to controls. ACS patients had also increased PMVs in coronary and peripheral circulation, compared to controls. Furthermore, ACS patients exhibited increased PMVs in coronary compared to peripheral circulation. Lastly, coronary PMVs were associated with the severity of CAD based on the SYNTAX score. No significant differences were observed in the levels of ErMVs among groups. Therefore, PMVs emerge as novel markers of thrombosis in CAD, further augmenting the vicious cycle of inflammation and thrombosis during ACS. Importantly, coronary PMVs may reflect the severity of CAD in this population.

Atherogenic Index of Plasma Is an Independent Risk Factor for Coronary Artery Disease and a Higher SYNTAX Score

We aimed to identify the best diagnostic cutoff value of the atherogenic index of plasma (AIP) for coronary artery disease (CAD) and its correlation with the SYNTAX score (SS). From January 2016 to December 2019, 2253 patients with CAD and 1347 non-CAD patients with complete data were included in the study. Coronary angiography was performed using the Judkins technique, and the SS was calculated using network software. There were differences in age, body mass index, total cholesterol, triglyceride, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol levels, and AIP between groups (all P < .01). Multivariate logistic regression analysis showed that AIP was an independent risk factor for CAD and a high SS (SS ≥ 23) with adjusted odds ratios of 2.248 (95% CI: 1.666-3.032, P < .01) and 1.623 (95% CI: 1.118-2.358, P < .01) per standard deviation increase. Receiver operating characteristic curve analysis revealed that the best diagnostic cutoff value of AIP for the prediction of CAD and SS ≥ 23 was 2.035 and 2.23, the specificity was 61.8% and 65.7%, the sensitivity was 76.4% and 54.9%, the Youden index was 0.382 and 0.206, and the area under the curve was 0.733 (95% CI: 0.717-0.750, P < .01) and 0.653 (95% CI: 0.630-0.676, P < .01). Atherogenic index of plasma, as a biomarker, may assist in the prevention of CAD in the Chinese population.

Serum visfatin level is associated with complexity of coronary artery disease in patients with stable angina pectoris

BACKGROUND

Visfatin is an adipokine that plays a role in the inflammatory process of atherosclerosis. This study aimed to investigate whether adipokine is associated with the extent of stable coronary artery disease (CAD).

METHODS

The study population included 110 patients who underwent elective coronary angiography (CAG) due to stable angina pectoris. The severity of CAD was assessed by the 'Synergy Between Percutaneous Coronary Intervention With TAXUS and Cardiac Surgery (SYNTAX)' score. We evaluated patients in two groups: group 1 with a SYNTAX score <22 (low) and group 2 with a SYNTAX score ⩾22 (intermediate to high).

RESULTS

Serum visfatin (8.6 ± 4.2 ng/ml versus 13.4 ± 5.2 ng/ml, p < 0.001) and serum C-reactive protein (CRP) levels [0.46 (0.25-0.77) mg/dl versus 0.71 (0.32-1.10) mg/dl, p < 0.001] were lower in group 1. A positive significant correlation was found between serum visfatin level and SYNTAX score (r = 0.559, p < 0.001). In a multivariate logistic regression analysis, visfatin [odds ratio (OR) 1.22, 95% confidence interval (CI) 1.10-1.36; p < 0.001], CRP (OR 6.22, 95% CI 1.70-22.7; p = 0.006), and diabetes mellitus (OR 3.83, 95% CI 1.10-13.2; p = 0.034) were found to be independent predictors of SYNTAX score.

CONCLUSIONS

Serum visfatin level was positively correlated with CAD severity in patients with high SYNTAX score. Serum visfatin level can be a useful biomarker for predicting high SYNTAX scores in patients with angina pectoris undergoing CAG.

Usefulness of white blood cell count to mean platelet volume ratio in the prediction of SYNTAX score in patients with non-ST elevation myocardial infarction

Objective:

White blood cell (WBC) count to mean platelet volume (MPV) ratio (WMR) is associated with major adverse cardiovascular events in patients with non-ST elevation acute coronary syndrome (NSTEMI). We aimed to compare WMR between NSTEMI patients and matched-controls and to evaluate its predictive value on SYNTAX score.

Methods:

Total 175 patients with NSTEMI and 160 age and co-morbidity matched subjects were recruited in our study. WMR was compared between the patient and control groups. The patient group was further subdivided into 3 tertiles according to SYNTAX scores as follows: low SYNTAX score tertile (score ≤22, 141 patients); intermediate SYNTAX score tertile (score between 23 and 32, 20 patients); and, high SYNTAX score tertile (score ≥33, 14 patients). WMR was further assessed among the tertiles.

Results:

WMR was significantly greater in the patient group compared to the control group (p<0,001). WMR among low, intermediate and high score tertiles were calculated to be 890±26, 1090±042 and 1500±65, respectively (p <0,001). In receiver operating characteristics (ROC) analysis, WMR >960 predicted a SYNTAX score ≥23 with 80.6% sensitivity and 67.6% specificity (AUC: 0.756; 95% CI: 0.685 - 0.818; p <0.0001) and a WMR >1360 predicted a SYNTAX score ≥33 with 71.4% sensitivity and 93% specificity (AUC: 0.840; 95%CI: 0.777 - 0.892; p <0.0001).

Conclusions:

WMR value was significantly elevated in NSTEMI patients, compared to controls. Higher WMR was associated with greater SYNTAX score in patients with NSTEMI. WMR may be used to predict severity of the CAD and to implement risk stratification in patients with NSTEMI.

Clinical outcome comparison of percutaneous coronary intervention and bypass surgery in diabetic patients with coronary artery disease: a meta-analysis of randomized controlled trials and observational studies

BACKGROUND

The optimal revascularization technique in diabetic patients with complex coronary artery disease (CAD), including left main CAD and multivessel coronary disease (MVD), remains controversial. The current study aimed to compare adverse clinical endpoints of coronary artery bypass graft (CABG) and percutaneous coronary intervention (PCI) in patients with diabetes mellitus (DM).

METHODS

Relevant studies were found from MEDLINE, OVID, Science Direct, Embase and the Cochrane Central database from January 2010 to April 2019. Risk ratio (RR) with 95% confidence interval (CI) was used to express the pooled effect on discontinuous variables. Outcomes evaluated were all-cause mortality, major adverse cardiac/cerebrovascular events (MACCE), cardiac death, myocardial infarction, stroke, and repeat revascularization.

RESULTS

Sixteen studies were included (18,224 patients). PCI was associated with the increase risk for MACCE (RR 1.59, 95% CI 1.38-1.85), cardiac death (RR 1.76, 95% CI 1.11-2.80), MI (RR 1.98, 95% CI 1.53-2.57), repeat revascularization (RR 2.61, 95% CI 2.08-3.29). The risks for all-cause mortality (RR 1.23, 95% CI 1.00-1.52) and stroke (RR 0.71, 95% CI 0.48-1.03) were similar between two strategies. Stratified analysis based on studies design and duration of follow-up showed largely similar findings with the overall analyses, except for a significant increased risk of all-cause mortality (RR 1.32, 95% CI 1.04-1.67) in long-term group, and CABG was associated with a higher stroke rate compared to PCI, which are results that were found in RCTs (RR 0.47, 95% CI 0.28-0.79) and mid-term groups (RR 0.39, 95% CI 0.23-0.66).

CONCLUSIONS

CABG was superior to PCI for diabetic patients with complex CAD (including left main CAD and/or MVD), but might be associated with a higher risk of stroke mid-term follow-up.Number of Protocol registration PROSPERO CRD 42019138505.

Use of the SYNTAX Score II to predict mortality in interventional cardiology: A systematic review and meta-analysis

BACKGROUND

As the SYNTAX Score has limitations, it should be replaced by another better angiographic tool. By comparing mortality that was observed following percutaneous coronary intervention (PCI) in patients who were allotted a low versus a high score, we aimed to systematically investigate mortality prediction using the SYNTAX Score II in Interventional Cardiology.

METHODS

Electronic databases were searched for relevant publications using the terms "SYNTAX Score II and percutaneous coronary intervention." The main outcome was all-cause mortality. This analysis was carried out by the RevMan 5.3 software [risk ratios (RRs) and 95% confidence intervals (95% CIs) were calculated].

RESULTS

A total number of 9443 participants were enrolled for this analysis. As different studies reported different range of SYNTAX Score II, we further classified these scores range into 4 different groups: 17 < SS > 17, 20 < SS > 20, 22 < SS > 22, and 26 < SS > 26 appropriately. Results of this analysis showed that the risk of mortality in patients with a high SYNTAX Score II (SS > 17) was significantly higher (RR: 2.65, 95% CI: 1.05-6.73; P = .04) than patients with a low SYNTAX Score II (SS < 17). Even when participants with a low SYNTAX Score II (SS < 20) were compared with patients who were assigned to a higher SYNTAX Score II (SS > 20), a significantly higher risk of mortality was associated with a high SYNTAX Score II (RR: 3.73, 95% CI: 1.99 - 6.96; P = .0001).

CONCLUSION

Following PCI, the risk of mortality was higher in those patients with a high SYNTAX Score II. The SYNTAX Score II might be considered as an important tool to predict mortality in Interventional Cardiology. Future research should further explore the benefits of this tool.

Choosing between ticagrelor and clopidogrel following percutaneous coronary intervention: A systematic review and Meta-Analysis (2007-2017)

BACKGROUND

Limitations have been observed with the use of clopidogrel following percutaneous coronary intervention (PCI) indicating the urgent need of a more potent anti-platelet agent. We aimed to compare the efficacy and safety of ticagrelor versus clopidogrel following PCI.

METHODS

Online databases were searched for relevant studies (published between the years 2007 and 2017) comparing ticagrelor versus clopidogrel following coronary stenting. Primary outcomes assessed efficacy whereas secondary outcomes assessed safety. Odds ratios (OR) with 95% confidence intervals (CIs) based on a random effect model were calculated and the analysis was carried out by the RevMan 5.3 software.

RESULTS

A total number of 25,632 patients with acute coronary syndrome (ACS) [12,992 patients with ST segment elevation myocardial infarction (STEMI) and 14,215 patients with non-ST segment elevation myocardial infarction (NSTEMI)] were included in this analysis, of whom 23,714 patients were revascularized by PCI. Results of this analysis did not show any significant difference in all-cause mortality, major adverse cardiac events (MACEs), myocardial infarction, stroke and stent thrombosis observed between ticagrelor and clopidogrel with (OR: 0.83, 95% CI: 0.67-1.03; P = .09), (OR: 0.64, 95% CI: 0.41-1.01; P = .06), (OR: 0.77, 95% CI: 0.57-1.03; P = .08), (OR: 0.85, 95% CI: 0.57-1.26; P = .42) and (OR: 0.70, 95% CI: 0.47-1.05; P =.09).However, ticagrelor was associated with a significantly higher minor and major bleeding with (OR: 1.57, 95% CI: 1.30-1.89; P = .00001) and (OR: 1.52, 95% CI: 1.01-2.29; P = 0.04) respectively. Dyspnea was also significantly higher in the ticagrelor group (OR: 2.64, 95% CI: 1.87-3.72; P = .00001).

CONCLUSION

Ticagrelor and clopidogrel were comparable in terms of efficacy in these patients with ACS. However, the safety outcomes of ticagrelor should further be investigated.

Reassessing Coronary Artery Bypass Surgery Versus Percutaneous Coronary Intervention in Patients with Type 2 Diabetes Mellitus: A Brief Updated Analytical Report (2015-2017)

INTRODUCTION

In this analysis, we aimed to systematically compare percutaneous coronary intervention (PCI) versus coronary artery bypass surgery (CABG) in terms of adverse outcomes utilizing data from a recent (2015-2017) population of patients with type 2 diabetes mellitus (T2DM).

METHODS

An electronic search of recent studies (2015-2017) was carried out using 'diabetes mellitus,' 'coronary artery bypass surgery,' and 'percutaneous coronary intervention' as the main search terms. Uncomplicated T2DM patients with stable coronary artery disease (CAD), left main CAD, and multi-vessel disease were included. RevMan software (version 5.3) was used to calculate odds ratios (OR) and 95% confidence intervals (CIs).

RESULTS

Among a total of 13,114 T2DM patients, CABG and PCI patients did not differ significantly in their rates of mortality (OR 0.90, 95% CI 0.61-1.31; P = 0.57) and cardiac death (OR 1.00, 95% CI 0.78-1.30; P = 0.98). However, rates of major adverse events, repeat revascularization, and myocardial infarction were significantly higher in the PCI group. Stroke rates did not significantly differ between the two groups.

CONCLUSION

Mortality (1-5 years) did not significantly differ between the CABG and PCI patients with T2DM. However, rates of other major adverse events were significantly higher in the PCI patients, suggesting that CABG is more advantageous than PCI in patients with T2DM.

Early (≤ 30 Days), Late (31-360 Days) and Very Late (> 360 Days) Stent Thrombosis in Patients with Insulin-Treated versus Non-Insulin-Treated Type 2 Diabetes Mellitus: A Meta-Analysis

INTRODUCTION

At this time in 2018, with type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD) still on the rise, the post-percutaneous coronary interventional (PCI) outcomes observed in patients with diabetes mellitus who are on insulin therapy (ITDM) and those who do not require insulin (NITDM) are still controversial and require further investigation. Considering this idea to be of particular interest to the readers, as well as being an important issue in interventional cardiology, we aimed to systematically assess early (≤ 30 days), late (31-360 days) and very late (> 360 days) stent thrombosis in patients with ITDM and NITDM following drug-eluting stent (DES) implantation.

METHODS

Well-known online databases (the Cochrane, EMBASE and MEDLINE databases and http://www.ClinicalTrials.gov ) were searched for relevant English publications based on ITDM and NITDM and stent thrombosis following PCI using specific terms. Early stent thrombosis, late stent thrombosis and very late stent thrombosis were the clinical outcomes. The main analysis was carried out using the latest version of the RevMan software (version 5.3) whereby odds ratios (OR), and 95% confidence intervals (CI) were generated.

RESULTS

A total of 8524 participants with T2DM (2273 participants were on insulin therapy and 6251 participants were not) were included. Results of this analysis showed early stent thrombosis to be significantly higher in patients with ITDM (OR 1.81, 95% CI 1.04-3.15; P = 0.04), whereas late and very late stent thromboses were not significantly different following PCI with DES in diabetic patients with versus without insulin therapy (OR 1.44, 95% CI 0.73-2.84, P = 0.30 and OR 0.80, 95% CI 0.33-1.92, P = 0.62, respectively). Late stent thromboses associated exclusively with everolimus-eluting stents (EES) and paclitaxel-eluting stents (PES) were not significantly different in patients with ITDM and NITDM.

CONCLUSION

Following PCI with DES, early stent thrombosis was significantly higher in patients with ITDM. However, late and very late stent thromboses were not significantly different in patients with type 2 diabetes mellitus who were treated with or without insulin. Comparison with individual DES was not sufficiently powerful to reach a conclusion.