Fourth Universal Definition of Myocardial Infarction (2018)

Cardiovascular disease in women with early-onset preeclampsia: a matched case-control study

OBJECTIVE

To compare the risk of cardiovascular disease and the occurrence of cardiovascular events in the mid-long term after delivery, between women with and without a history of early-onset preeclampsia.

METHODS

A prospective case-control study has been conducted in Hospital Universitario 12 de Octubre, Madrid. 50 women with early-onset preeclampsia (diagnosed < 34 + 0 weeks) who delivered between 2008 and 2017 and a matched group (by age, parity, pregestational body mass index and date of delivery) of 50 women with uncomplicated pregnancies were recruited. In them, a 1-day visit for cardiovascular assessment was performed 3-12 years after delivery, consisting of the completion of blood and urine tests including oxidative stress analysis, vascular ultrasound to assess subclinical atherosclerosis and 24-hour blood pressure monitoring. Furthermore, Framingham10 and Framingham30 scales of cardiovascular disease risk were applied. Univariate analysis was used for comparisons, and the Kaplan-Meier method was performed to estimate their survival time until the development of a cardiovascular disease event (chronic hypertension, renal disease, myocardial infarction, thromboembolism and cerebrovascular disease).

RESULTS

Patients were evaluated at a median of 7.5 years (interquartile range, 6.5-9) after delivery. Women with a history of early-onset preeclampsia vs controls showed significantly lower levels of hemoglobin (12.9 vs 13.7 g/dL), hematocrit (38.9 vs 40.8%), prothrombin activity (93.1 vs 99.8%), IgA (223.5 vs 279.9 mg/dL) and C3 factor (101.0 vs 110.5 mg/dL) and prolongated prothrombin time (12.4 vs 11.6 s). Early-onset preeclampsia cases showed worse blood pressure control, with higher percentages of over-limit systolic blood pressure (17.9 vs. 11.2%, p < 0.01) and diastolic blood pressure (28.1 vs. 18.7%, p < 0.01) readings in 24 h. There were no significant differences in the vascular ultrasound studies as well as in the estimated cardiovascular risk obtained with the Framingham scales. At the visit time, a cardiovascular event was present in 44% women with history of early-onset preeclampsia vs 10% in the control group (p < 0.01). The most common event was chronic hypertension, with a relative risk of 4.7 (95% confidence interval 1.7-13.0) for the early-onset preeclampsia group.

CONCLUSIONS

Women with a history of early-onset preeclampsia, compared to their matched controls, showed a greater risk of cardiovascular disease mainly at the expense of a 4.7-fold risk of developing chronic hypertension, with a median follow-up of 7.5 years after delivery.

Clinical utility of preoperative stress perfusion cardiac magnetic resonance for predicting cardiovascular events in patients undergoing major noncardiac surgery

BACKGROUND

Although guidelines recommend preoperative stress testing for patients with risk factors, the appropriate indications for stress perfusion cardiac magnetic resonance (CMR) have not been clearly defined. This study aimed to investigate the value of preoperative stress perfusion CMR in predicting major adverse cardiovascular events (MACE) in patients undergoing major noncardiac surgery.

METHODS

This study included 309 patients who underwent CMR within 180 days prior to major noncardiac surgery between 2010 and 2022. Patients were categorized based on the presence or absence of inducible myocardial ischemia. The primary outcome was MACE, defined as a composite of cardiovascular death, myocardial infarction, sustained ventricular arrhythmia, heart failure, or ischemic stroke occurring during the indexed hospitalization for surgery or within 30 days post-discharge.

RESULTS

The mean patient age was 72 years (51% male), and 21% demonstrated inducible myocardial ischemia. Total MACE occurred in 4.5% of patients and was significantly higher in the inducible ischemia group compared to those without ischemia (16.9% vs. 1.3%, p < 0.001). Cox regression analysis identified inducible ischemia as the strongest predictor of MACE (hazard ratio [HR] 10.72, 95% confidence interval [95% CI] 2.91-39.60, p < 0.001). Other predictors included left ventricular ejection fraction (HR 0.94, 95% CI 0.92-0.97, p < 0.001), the number of ischemic segments (HR 1.19, 95% CI 1.07-1.31, p = 0.001), the presence of late gadolinium enhancement (LGE) (HR 6.28, 95% CI 1.93-20.44, p = 0.002), and the number of LGE segments (HR 1.21, 95% CI 1.08-1.37, p = 0.002). The predictive performance of the Revised Cardiac Risk Index score significantly improved after the addition of inducible ischemia (C-statistic 0.61 vs. 0.77; net reclassification improvement 0.58, p < 0.001; integrative discrimination index 0.07, p < 0.001).

CONCLUSIONS

In this retrospective cohort study, inducible myocardial ischemia detected by stress perfusion CMR in patients undergoing major noncardiac surgery was associated with MACE during hospitalization or within 30 days post-discharge. Larger prospective or multicenter studies are required to validate these findings and ensure generalizability.

Prognostic value of coronary plaque composition in symptomatic patients with obstructive coronary artery disease

OBJECTIVES

To determine whether plaque composition analysis defined by cardiac CT can provide incremental prognostic value above coronary artery disease (CAD) burden markers in symptomatic patients with obstructive CAD.

MATERIALS AND METHODS

Between 2009 and 2019, a multicentric registry included all consecutive symptomatic patients with obstructive CAD (at least one ≥ 50% stenosis on CCTA) and was followed for major adverse cardiovascular (MACE) defined by cardiovascular death or nonfatal myocardial infarction. Each coronary segment was scored visually for both the degree of stenosis and composition of plaque, which were classified as non-calcified, mixed, or calcified. To assess the prognostic value of each CCTA findings, different multivariable Cox regression models were used: model 1: clinical (traditional risk factors); model 2: model 1 + CAD burden (number of proximal segments with stenosis ≥ 50% + number of vessels with obstructive CAD); and model 3: model 2 + plaques feature (number of segments with non-calcified plaque).

RESULTS

Of 2312 patients (mean age 70 ± 12 years, 46% men), 319 experienced a MACE (13.8%) (median follow-up: 6.7 years (5.9-9.1)). The number of proximal segments with ≥ 50% stenosis, the number of vessels with obstructive CAD, and the number of segments with non-calcified plaque were all independently associated with MACEs (all p < 0.001). The addition of plaque composition analysis (model 3) showed the best improvement in model discrimination and reclassification (C-statistic improvement = 0.03; net reclassification improvement = 28.6%; integrative discrimination index = 5.4%, all p < 0.001).

CONCLUSIONS

In this population, the analysis of coronary plaque composition had an incremental prognostic value to predict MACEs above a model combining traditional risk factors and CAD burden.

KEY POINTS

Question Several coronary computed tomography angiography (CCTA) studies have shown the potential interest of plaque composition analysis, which can be further evaluated. Findings In symptomatic patients with obstructive coronary artery disease (CAD), plaque composition analysis had an incremental prognostic value above a model combining traditional risk factors and CAD burden. Clinical relevance In symptomatic patients with obstructive CAD, plaque composition analysis using CCTA has a strong incremental prognostic value above a model combining traditional risk factors and CAD burden, thus translating into a more accurate long-term major adverse cardiovascular event prediction.

Utility of High-Sensitivity Cardiac Troponin Monitoring in Thoracic Surgery for Predicting Severe Postoperative Complications

OBJECTIVES

To evaluate the utility of high-sensitivity cardiac troponin (hs-cTn) monitoring in thoracic surgery to predict severe postoperative complications (sPOCs) according to the Clavien-Dindo classification.

DESIGN

Retrospective, observational cohort study.

SETTING

Tertiary-level hospital involving multiple departments.

PARTICIPANTS

A total of 220 patients who underwent lung resection surgery between November 2018 and October 2021, with preoperative and postoperative troponin measurements.

INTERVENTIONS

hs-cTnI levels (Abbott Alinity) were measured before surgery and within the first 24 hours postoperatively. Myocardial injury (MI) was defined as hs-cTnI greater than 26.2 ng/L postoperatively. In addition, the impact of a postoperative cTnI elevation greater than 20% or a preoperative value below 1.6 ng/L on the occurrence of sPOCs is analyzed. Postoperative complications were recorded for the first 30 days and classified using the Clavien-Dindo classification.

MAIN MEASUREMENTS AND RESULTS

Patients with sPOCs had higher pre- and postoperative hs-cTnI levels compared to those without complications. Patients with MI had a higher incidence of POCs than those without MI. Additionally, undetectable preoperative hs-cTnI levels were associated with better survival.

CONCLUSIONS

Perioperative troponin elevation is associated with worse short-term postoperative outcomes, including a higher incidence of sPOCs and prolonged hospital stays. Preoperative hs-cTnI levels correlate with preoperative morbidity (frailty) in patients.

Re-engineering the clinical approach to suspected cardiac chest pain assessment in the emergency department by expediting research evidence to practice using artificial intelligence. (RAPIDx AI)-a cluster randomized study design

BACKGROUND

Clinical work-up for suspected cardiac chest pain is resource intensive. Despite expectations, high-sensitivity cardiac troponin assays have not made decision making easier. The impact of recently validated rapid triage protocols including the 0-hour/1-hour hs-cTn protocols on care and outcomes may be limited by the heterogeneity in interpretation of troponin profiles by clinicians. We have developed machine learning (ML) models which digitally phenotype myocardial injury and infarction with a high predictive performance and provide accurate risk assessment among patients presenting to EDs with suspected cardiac symptoms. The use of these models may support clinical decision-making and allow the synthesis of an evidence base particularly in non-T1MI patients however prospective validation is required.

OBJECTIVE

We propose that integrating validated real-time artificial intelligence (AI) methods into clinical care may better support clinical decision-making and establish the foundation for a self-learning health system.

DESIGN

This prospective, multicenter, open-label, cluster-randomized clinical trial within blinded endpoint adjudication across 12 hospitals (n = 20,000) will randomize sites to the clinical decision-support tool or continue current standard of care. The clinical decision support tool will utilize ML models to provide objective patient-specific diagnostic probabilities (ie, likelihood for Type 1 myocardial infarction [MI] versus Type 2 MI/Acute Myocardial Injury versus Chronic Myocardial Injury etc.) and prognostic assessments. The primary outcome is the composite of cardiovascular mortality, new or recurrent MI and unplanned hospital re-admission at 12 months post index presentation.

SUMMARY

Supporting clinicians with a decision support tool that utilizes AI has the potential to provide better diagnostic and prognostic assessment thereby improving clinical efficiency and establish a self-learning health system continually improving risk assessment, quality and safety.

TRIAL REGISTRATION

ANZCTR, Registration Number: ACTRN12620001319965, https://www.anzctr.org.au/.

Dual-Prep registry: atherectomy devices and intravascUlAr lithotripsy for the PREParation of heavily calcified coronary lesions registry

Evaluation of calcified lesions by intravascular imaging has revealed that atherectomy devices have only limited impact. However, subsequent use of coronary intravascular lithotripsy (IVL) may increase treatment effectiveness without increasing risk of complications. This study was designed to evaluate the safety and effectiveness of IVL use after atherectomy in severely calcified coronary lesions as pre-treatment for drug-eluting stents (DES). The Dual-Prep registry is a multicenter, prospective registry of consecutive image-guided percutaneous coronary interventions (PCI). The primary effectiveness and safety endpoints were procedural success (residual stenosis < 50% by quantitative coronary angiography) without an in-hospital major adverse cardiac event (MACE) and 30-day freedom from MACE, respectively. Baseline vessel calcification score and final DES expansion were evaluated by optical coherence tomography (OCT). A total of 118 patients with 120 lesions were enrolled at 20 sites. The calcification score of lesions after atherectomy by core-lab assessment was 4.0 in all cases. Rotational atherectomy was applied prior to IVL in 83.9% cases with mean burr size of 1.57 ± 0.20 mm; IVL was subsequently successfully delivered in all cases (mean balloon diameter 3.02 ± 0.45 mm), followed by DES deployment (mean diameter 3.19 ± 0.51 mm, length of 36.3 ± 16.0 mm). The primary efficacy and safety endpoints were met in 98.3% and 98.3% of cases, respectively. A DES expansion index < 0.8 was seen in 42.2%, and an eccentricity index < 0.7 was not observed in any patient. In severely calcified lesions, image-guided atherectomy followed by IVL lesion preparation demonstrated high procedural success rates and satisfactory non-eccentric stent expansion. This approach may be considered for lesions where an 'IVL-first' strategy may not be feasible. jRCT1032230384 (Oct 7, 2023).

Influence of Macrotroponin on the 99th Percentile Threshold in 2 High-Sensitivity Cardiac Troponin Assays

BACKGROUND

Cardiac troponin (cTn) levels exceeding the 99th percentile upper reference limit and a rise/fall pattern are key for diagnosing myocardial injury and infarction. Macrotroponins, formed by patient anti-cTn antibodies targeting cTn, can cause persistently elevated cTn levels without ongoing myocardial injury. The frequency and impact of macrotroponin interference on cTn 99th percentiles are unclear. This study compares sex-specific 99th percentiles for 2 cTn assays, before and after excluding macrotroponin-positive samples, focusing on the top 10% of cTn levels.

METHODS

We examined 1058 plasma samples from healthy individuals previously used for Danish cTn 99th percentiles. Following International Federation of Clinical Chemistry and Laboratory Medicine educational recommendations, macrotroponin presence was assessed in the top 10% cTn samples using immunoglobulin G (IgG) depletion screening and a reference sucrose gradient, confirming macrotroponin when both methods concurred. Due to analytical dilution constraints, [the highest] 88 of 135 Siemens Atellica high-sensitivity cTnI (hs-cTnI) samples were analyzed with both methods. All 106 Roche hs-cTnT samples were negative using IgG depletion, and sucrose analysis was limited to the highest 70 samples.

RESULTS

Macrotroponin was found in 76% (67/88) of Siemens samples but in none of the Roche samples (0/70). Excluding macrotroponin-affected samples lowered the Siemens 99th percentiles from 117 ng/L to 22 ng/L in men and from 37 ng/L to 9 ng/L in women. The 99th/50th percentile ratio for Siemens decreased from 12- to 29-fold to 3- to 7-fold, approaching the Roche ratios.

CONCLUSIONS

Macrotroponin significantly influenced the Siemens Atellica hs-cTnI 99th percentiles, suggesting important clinical implications that warrant further prospective studies. The 99th/50th percentile ratio may help evaluate macrotroponin interference in troponin assays.

Cardiac cephalalgia-headache as an atypical presentation of ST-segment elevation myocardial infarction: a case report

BACKGROUND

Ischaemic heart disease commonly presents with chest pain and autonomic symptoms; however, atypical manifestations can occur. Cardiac cephalalgia is a rare presentation of acute coronary syndrome, characterised by a migraine-like headache triggered by myocardial ischaemia. Diagnosis requires a high index of suspicion.

CASE PRESENTATION

We describe a 47-year-old man with diabetes and a history of smoking who presented with an acute, severe frontotemporal headache accompanied by nausea and vomiting. Electrocardiography revealed ST-segment elevation in the inferior leads. Coronary angiography demonstrated multivessel coronary artery disease involving the right coronary artery and the left anterior descending artery. A subsequent measurement of serum troponin I confirmed myocardial injury. Both arteries were successfully stented, leading to clinical improvement and resolution of the headache.

CONCLUSIONS

This case highlights the importance of considering cardiac causes in patients presenting with severe headaches particularly in those with cardiovascular risk factors.

Optimisation of care among patients with diabetes mellitus and acute coronary syndrome through a specialised cardiodiabetes service-A registry study

AIMS

Diabetes mellitus remains a prevalent condition worldwide and a significant risk factor for atherosclerotic cardiovascular disease. Recent evidence suggests the use of glucose-lowering therapies with cardiovascular benefit in optimising the cardiometabolic profile of patients with type 2 diabetes mellitus. However, uptake remains low. This study was carried out to assess the impact of a novel cardiodiabetes service for the management of patients with diabetes mellitus presenting with acute coronary syndromes.

METHODS

A retrospective, observational, registry-based analysis was performed among patients presenting with an acute coronary syndrome and diabetes mellitus to a regional heart centre before and after the implementation of a cardiodiabetes service. Intergroup comparison was made for the proportion of patients having a valid glycated haemoglobin during admission, initiation of guideline-recommended glucose and lipid-lowering therapies.

RESULTS

At median follow-up of 29.7 months, a valid HbA1c measurement at baseline was lower in the pre-intervention compared to the post-intervention group (556/711 [78.2%] vs. 302/362 [83.4%], p = 0.043) while more patients in the post-intervention group were prescribed sodium-glucose co-transporter inhibitors (297/362 [82.0%] vs. 359/711 [50.5%]). All-cause mortality (5.2 vs. 12.3 [events/100 patient-years], relative ratio [RR] 0.42, 95% confidence interval [CI] 0.28-0.61, and p < 0.001), first events of acute kidney injury (AKI) (10.0 vs. 13.0, RR 0.77, CI 0.57-1.03, p = 0.090) and all events of AKI (16.6 vs. 22.1, RR 0.75, CI 0.60-0.94, p = 0.015) were significantly lower in the post-intervention group.

CONCLUSION

The introduction of a joint-speciality cardiodiabetes service improved the care and survival of patients with acute coronary syndrome and diabetes mellitus.

Balancing privacy and health integrity: A novel framework for ECG signal analysis in immersive environments

The widespread use of immersive technologies such as Virtual Reality, Mixed Reality, and Augmented Reality has led to the continuous collection and streaming of vast amounts of sensitive biometric data. Among the biometric signals collected, ECG (electrocardiogram) stands out given its critical role in healthcare, particularly for the diagnosis and management of cardiovascular diseases. Numerous studies have demonstrated that ECG contains traits to distinctively identify a person. As a result, the need for anonymization methods is becoming increasingly crucial to protect personal privacy while ensuring the integrity of health data for effective clinical utility. Although many anonymization methods have been proposed in the literature, there has been limited exploration into their ability to preserve data integrity while complying with stringent data protection regulations. More specifically, the utility of anonymized signal and the privacy level achieved often present a trade-off that has not been thoroughly addressed. This paper analyzes the trade-off between balancing privacy protection with the preservation of health data integrity in ECG signals focusing on memory-efficient anonymization techniques that are suitable for real-time or streaming applications and do not require heavy memory computation. Moreover, we introduce an analytical framework to evaluate the privacy preservation methods alongside health integrity, incorporating state-of-the-art disease and person identifiers. We also propose a novel metric that assists users in selecting an anonymization method based on their desired trade-off between health insights and privacy protection. The experimental results demonstrate the impact of the de-identification techniques on critical downstream tasks, such as Arrhythmia detection and Myocardial Infarction detection along with identification performance, while statistical analysis reveals the biometric nature of ECG signals. The findings highlight the limitations of using such anonymization methods and models, emphasizing the need for approaches that maintain the clinical relevance of ECG data in real-time and streaming applications, particularly in memory-constrained environments.

Age and sex differences in the efficacy of early invasive strategy for non-ST-elevation acute coronary syndrome: A comparative analysis in stable patients

Objective

Previous works have struggled to clearly define sex-specific outcomes based on initial management in NSTE-ACS patients. We examined if early revascularization (<24 h) versus conservative strategy impacts differently based on sex and age in stable NSTE-ACS patients upon hospital admission.

Methods

We identified 8905 patients with diagnosis of non-ST elevation acute coronary syndromes (NSTE-ACS) in the ISACS-TC database. Patients with cardiac arrest, hemodynamic instability, and serious ventricular arrhythmias were excluded. The final cohort consisted of 7589 patients. The characteristics between groups were adjusted using inverse probability of treatment weighting models. Primary outcome measure was all-cause 30-day mortality. Risk ratios (RRs) with their 95 % CIs were employed.

Results

Of the 7589 NSTE-ACS patients identified, 2450 (32.3 %) were women. The data show a notable reduction in mortality for the older women (aged 65 years and older) undergoing early invasive strategy compared to those receiving an initial conservative (3.0 % versus 5.1 %; RR: 0.57; 95 % CI: 0.32 - 0.99) Conversely, younger women did not exhibit a significant association between early invasive strategy and mortality reduction (2.0 % versus 0.9 %; RR: 2.27; 95 % CI: 0.73 - 7.04). For men, age stratification did not markedly alter the observed benefits of an early invasive strategy over a conservative approach in the overall population, with reduced death rates in both older (3.1 % versus 5.7 %; RR: 0.52; 95 % CI: 0.34 - 0.80) and younger age groups (0.8 % versus 1.7 %; RR: 0.46; 95 % CI: 0.22 - 0.94). These age and sex-specific mortality patterns did not significantly change within subgroups stratified by the presence of NSTEMI, or a GRACE risk score>140.

Conclusion

Early coronary revascularization is associated with improved 30-day survival in older men and women and younger men who present to hospital in stable conditions after NSTE-ACS. It does not confer a survival advantage in young women. Further studies are needed to more accurately risk-stratify young women to guide treatment strategies.

Registration

ClinicalTrials.gov: NCT01218776.

Prehospital antiplatelet therapy in patients with out-of-hospital cardiac arrest suspected of acute coronary syndrome

BACKGROUND

There are currently no specific guidelines for prehospital antiplatelet therapy in patients with out-of-hospital cardiac arrest (OHCA) associated with acute coronary syndrome (ACS). This study aims to evaluate the efficacy and safety of a prehospital antiplatelet loading dose in patients with OHCA suspected of ACS referred to a cardiac catheterization laboratory (cath lab).

METHODS

We included consecutive patients referred for coronary angiography within 24 h after OHCA from 2012 to 2024. Prehospital antiplatelet treatment was defined as prescribing aspirin alone and/or a P2Y12 inhibitor before admission to the cath lab. Outcomes included: all-cause death at 30 days, in-hospital major adverse cardiovascular events (MACE), defined as a composite of all-cause death, myocardial infarction, stent thrombosis, or stroke, and in-hospital major bleeding (BARC ≥ 3). An inverse probability weighting approach was used to compare outcomes between the two groups.

RESULTS

Of the 411 patients admitted to the cath lab within 24 h after OHCA, 217 (52.8%) received prehospital antiplatelet therapy, either aspirin alone (44.5%) or aspirin plus a P2Y12 inhibitor (8.3%). There was no difference in 30-day all-cause death between patients who received a prehospital treatment and those who did not (56.7%[50.0%;63.1%] vs 59.8%[52.8%;66.4%], p = 0.280). Rates of in-hospital MACE and major bleeding were not significantly different between the two strategies. Results appear to be consistent in subgroups of patients with ST-segment elevation or successfully resuscitated patients.

CONCLUSIONS

Prehospital antiplatelet therapy was safe, but showed no apparent improvement in survival or cardiovascular outcomes in patients with OHCA suspected of ACS.

Prognostic value of combining cardiac myosin-binding protein C and N-terminal pro-B-type natriuretic peptide in patients without acute coronary syndrome treated at medical cardiac intensive care units

We investigated the prognostic value of cardiac myosin-binding protein C (cMyC), a novel cardiospecific marker, both independently and in combination with N-terminal pro-B-type natriuretic peptide (NT-proBNP), for predicting 6-month all-cause mortality in patients without acute coronary syndrome (ACS) treated at medical (nonsurgical) cardiac intensive care units (CICUs). Admission levels of cMyC, high-sensitivity cardiac troponin T (hs-cTnT), and NT-proBNP were measured in 1032 consecutive patients (mean age; 70 years) without ACS hospitalized acutely in medical CICUs for the treatment of cardiovascular disease. Serum cMyC was closely correlated with hs-cTnT and moderately with NT-proBNP (r = 0.92 and r = 0.49, respectively, p < 0.0001). During the 6-month follow-up period after admission, there were 109 (10.6%) all-cause deaths, including 72 cardiovascular deaths. Both cMyC and NT-proBNP were independent predictors of 6-month all-cause mortality (all p < 0.05). Combining cMyC and NT-proBNP with a baseline model of established risk factors improved patient classification and discrimination beyond any single biomarker (all p < 0.05) or the baseline model alone (both p < 0.0001). Moreover, patients were divided into nine groups using cMyC and NT-proBNP tertiles, and the adjusted hazard ratio (95% confidence interval) for 6-month all-cause mortality in patients with both biomarkers in the highest vs. lowest tertile was 9.67 (2.65-35.2). When cMyC was replaced with hs-cTnT, similar results were observed for hs-cTnT. In addition, the C-indices for addition of cMyC or hs-cTnT to the baseline model were similar (0.798 vs. 0.800, p = 0.94). In conclusion, similar to hs-cTnT, cMyC at admission may be a potent, independent predictor of 6-month all-cause mortality in patients without ACS treated at medical CICUs, and their prognostic abilities may be comparable. Combining cMyC or hs-cTnT with NT-proBNP may substantially improve early risk stratification of this population.

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

Background

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

Methods

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

Results

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

Conclusions

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

Association between phenotypic age and in-hospital outcomes in patients with acute myocardial infarction: A retrospective observational study

Background

Phenotypic age (PhenoAge) has emerged as a superior predictor of age-related morbidity and mortality. This study aimed to assess the associations between PhenoAge and in-hospital outcomes in patients with acute myocardial infarction (AMI).

Methods

2896 AMI patients admitted to the First Affiliated Hospital of Xi'an Jiaotong University from 2019 to 2022 were analyzed in this retrospective study. PhenoAge was calculated by using the phenotypic age calculator, an equation for chronologic age and 9 clinical biomarkers, and Phenotypic Age Accelerate (PhenoAgeAccel) was measured using the residuals of regression PhenoAge on chronological age. Clinical outcomes were defined as in-hospital major adverse cardiovascular events (MACEs), including cardiogenic shock, malignant arrhythmia, acute heart failure, and mechanical complications.

Results

Overall, patients with high PhenoAge had a higher Gensini score and a higher likelihood of receiving supportive care, as well as worse clinical outcomes. The same results were observed in patients with positive PhenoAgeAccel. Moreover, PhenoAge and PhenoAgeAccel were significantly associated with in-hospital MACEs even after adjusting for multiple traditional risk factors. The area under the curve for PhenoAge was 0.714 (P < 0.001), which significantly outperformed chronologic age (AUC: 0.601, P < 0.001) and other cardiovascular risk factors. Re-examination of the ROC curves using different combinations of variables, PhenoAge was also able to significantly improve the predictive value of several models.

Conclusions

PhenoAge is significantly associated with clinical outcomes and reliably predicts in-hospital MACEs. Compared with chronological age, PhenoAge is a better complementary biomarker for predicting the risk of in-hospital adverse cardiovascular events in patients with AMI.

Changes in the Right Ventricular Diameters and Systolic Function After Successful Percutaneous Coronary Intervention in Patients With First Acute Myocardial Infarction

Background

Right ventricular (RV) diameters and systolic function are strong predictors of outcomes and major adverse cardiovascular events (MACEs) in acute myocardial infarction (AMI). This study evaluated RV parameters via echocardiography in AMI patients and assessed their changes 1 month after discharge.

Methods

A prospective observational study was conducted on 133 consecutive patients with their first AMI. RV diameters and systolic function were evaluated with echocardiography within 24 h after successful percutaneous coronary intervention (PCI) and again 1 month after discharge. MACEs were evaluated during hospitalization and at 1 month post discharge.

Results

Men accounted for 69.92% of the participants, with a mean age of 68 years. Reduced right ventricular free wall longitudinal strain (RVFWSL) and right ventricular four-chamber longitudinal strain (RV4CSL) were observed in 62.4% (mean -18.28±8.77%) and 83.34% (mean -14.78±6.94%) of patients, respectively. Right ventricular longitudinal strain (RVLS) was significantly lower in the ST-elevation myocardial infarction (STEMI) group and Killip III-IV patients. RV basal and mid diameters (RVD1, RVD2) were larger in right coronary artery (RCA) and left main artery (LM) lesions than in left anterior descending artery (LAD) and left circumflex artery (LCx) ones (P < 0.05). RVLS correlated significantly with body mass index (BMI), troponin I, and left ventricular ejection fraction (LVEF). After 1 month, RVFWSL and RV4CSL improved significantly, especially in patients without MACEs, Killip III-IV, and single-vessel lesions.

Conclusions

RV diameters varied with the culprit lesion and remained stable after 1 month. RVLS was significantly reduced in AMI, especially in STEMI and Killip III-IV, correlating with LVEF. After 1 month, RVLS improved faster, particularly in patients without MACEs, Killip III-IV, or single-vessel lesions.

Using eosinophil response to predict cardiovascular outcomes in patients with ST- elevation myocardial infarction who undergo primary percutaneous coronary intervention

Objective

Eosinophils have been implicated in mediating the inflammatory response after ST-elevation myocardial infarction (STEMI), but its role as a biomarker predicting major adverse cardiovascular events (MACE) remains unclear. We aimed to evaluate the predictive value of eosinophil response on 30-day and 1-year MACE post primary percutaneous coronary intervention (PCI) after STEMI.

Methods

Single centre retrospective cohort study of STEMI patients undergoing PCI. Eosinophil response was defined as the change in peripherally circulating eosinophils cell count at admission minus 48 h post primary PCI. Primary endpoints were 30-day and 1-year MACE. Receiver operating characteristic (ROC) curves were created to identify optimal cut-off predicting MACE. Multivariate logistic regression analyses were used to determine if the ROC cut-off was an independent predictor of MACE.

Results

Of the 366 patients in this study (median age 61 years [53.0-71.0]; 267 males [73 %]), 41 patients (11.2 %) and 78 patients (21.3 %) developed MACE at 30-days and 1-year. The optimal ROC curve cut-off predicting MACE was an eosinophil response of greater than -0.05 × 10^9/L (ΔEos > -0.05). It had a sensitivity, specificity, and positive and negative predictive value of 83, 39, 6 and 98 % for 30-day MACE, and 74, 39, 19 and 88 % for 1-year MACE. An ΔEos > -0.05 change was associated with a threefold higher likelihood of MACE at 30-days (OR 3.1, 95 % CI 1.04-9.07, p=0.042), but not 1-year.

Conclusion

An eosinophil response of -0.05 × 10^9L at 48 h following primary PCI post STEMI is highly sensitive at predicting 30-day MACE, and in its absence, holds a high negative predictive value.

Prospective randomized single-blind multicenter study to assess the safety and effectiveness of the SELUTION SLR 014 drug eluting balloon in the treatment of subjects with in-stent restenosis: Rationale and design

BACKGROUND

Repeat drug-eluting stenting is superior to balloon angioplasty for prevention of recurrent in-stent restenosis (ISR), but carries a potential disadvantage of multiple layers of stent. The safety and effectiveness of a sirolimus drug-eluting balloon as an alternative has not been assessed.

STUDY DESIGN AND METHODS

The SELUTION4ISR trial is a prospective, multicenter, single-blinded, randomized, controlled trial. A total of 418 subjects with bare metal or drug-eluting stent (DES) ISR with up to 2 previous stent procedures at the target lesion, lesion length <26 mm and reference diameter ≥2.0 mm - ≤4.5 mm will be randomized 1:1 to treatment with either the SELUTION SLR™ DEB (SLR DEB) or standard of care (SOC), which includes either repeat DES or balloon angioplasty without drug coating. A subset of subjects will undergo planned angiographic and optical coherence tomography follow-up. The primary endpoint will be target lesion failure, defined as cardiac death, target vessel myocardial infarction, or clinically-driven target lesion revascularization at 12 months follow-up. The study will sequentially assess noninferiority of the SLR DEB to SOC in the overall cohort, followed by noninferiority then superiority of the SLR DEB to DES in the cohort with only 1 previous stent at the target lesion.

TRIAL REGISTRATION

The trial is registered at Clinicaltrials.gov (NCT04280029).

CURRENT STATUS

The trial completed enrollment in July 2024.

CONCLUSION

The SELUTION4ISR study will evaluate the safety and effectiveness of SLR DEB in a prospective, randomized, international, multicenter trial for treatment of coronary ISR.

Highly sensitive and reproducible SERS substrate based on ordered multi-tipped Au nanostar arrays for the detection of myocardial infarction biomarker cardiac troponin I

Acute myocardial infarction (AMI) is a severe cardiovascular disease, for which early diagnosis is critical for reducing mortality and improving patient outcomes. Cardiac troponin I (cTnI) is widely recognized as the "gold standard" biomarker for AMI due to its high specificity and sensitivity. The concentration of cTnI correlates directly with different stages of AMI. Therefore, the accurate detection of cTnI concentration is of paramount importance. However, the low concentration of cTnI in biological fluids requires ultrasensitive detection methods. In this study, we developed a sandwiched surface enhanced Raman scattering (SERS)-based biosensor composed of SERS-immune substrate, target antigen, and SERS nanotags and realized sensitive and accurate detection of cTnI. The SERS-immune substrate features an ordered, multi-tipped monolayer of Au nanostars fabricated using a three-phase interfacial self-assembly method and 4-(2-hydroxyerhyl)piperazine-1-erhanesulfonic acid (HEPES) buffer modification. Compared to Au nanosphere SERS substrates, the Au nanostar SERS substrates exhibited about a 3-fold increase in Raman enhancement and demonstrated good uniformity and batch stability. This novel SERS detection platform, leveraging dual plasmonic enhancement from both the SERS-immune substrate and SERS nanotags, achieves detection of cTnI with a limit of detection (LOD) as low as 9.09 pg mL-1 and a relative standard deviation (RSD) as low as 11.24%. Thus, the Au nanostar SERS substrates developed in this study demonstrate significant potential for rapid and accurate detection of cTnI.

Development and validation of an in-hospital major adverse cardiovascular events risk model for young patients with acute coronary syndrome: a retrospective cohort study

Background

The incidence of acute coronary syndrome (ACS) among young individuals is increasing, making it a leading cause of mortality in this population. This study aimed to develop and validate a risk prediction model for in-hospital major adverse cardiovascular events (MACE) in young ACS patients.

Methods

A retrospective analysis was performed to predict in-hospital MACE. Patients were divided into a training set (n = 342) and a testing set (n = 171). Screening variables were optimized using least absolute shrinkage and selection operator (LASSO) regression and univariable logistic regression analysis. A predictive nomogram model was developed through multivariate logistic regression. The model's discrimination and calibration were assessed using the receiver operating characteristic (ROC) curve, calibration plots, and Hosmer-Lemeshow goodness-of-fit tests. Clinical utility was evaluated using decision curve analysis (DCA).

Results

White blood cell count, Killip classification, lymphocyte count, heart rate, triglycerides, and Gensini score were identified as significant predictors. The constructed nomogram demonstrated strong predictive performance. The area under the ROC curve (AUC) was 0.9242 (95% confidence interval [CI]: [0.8841-0.9643]) for the training set and 0.8346 (95% CI [0.742-0.9272]) for the testing set, with respective cut-off values of 0.107 and 0.119. Calibration was confirmed with Hosmer-Lemeshow statistics of 12.454 (p = 0.2558) in the training set and 7.16 (p = 0.7102) in the testing set. DCA showed threshold probabilities ranging from 0% to 100% in the training set and 0% to 90% in the testing set.

Conclusions

The proposed nomogram model demonstrated robust discrimination and calibration, offering a valuable tool for predicting the risk of in-hospital MACE in young ACS patients.

Safety and Efficacy of Cobalt Chromium Everolimus-Eluting Stents for Treatment of In-Stent Restenosis: An ILUMIEN IV Substudy

BACKGROUND

The optimal management strategy for in-stent restenosis (ISR) remains unclear. We aimed to determine the safety and efficacy of percutaneous coronary intervention with XIENCE cobalt chromium everolimus-eluting stents (EES) for treatment of ISR.

METHODS

In the ILUMIEN IV (Optical Coherence Tomography Guided Coronary Stent Implantation Compared to Angiography: A Multicenter Randomized Trial in Percutaneous Coronary Intervention) trial, the 1-year outcomes of all randomized patients with a single diffuse or multifocal single-layer ISR lesion treated with EES were compared with a performance goal. The primary end point was target lesion failure, the composite of cardiac death, target vessel-myocardial infarction, or ischemia-driven target lesion revascularization. Outcomes in patients with a single EES-treated ISR and non-ISR lesion were also compared.

RESULTS

From May 2018 through December 2020, 247 patients with a single ISR lesion were treated with EES. Target lesion failure at 1 year occurred in 18 patients (7.4% [upper 1-sided 97.5% CI, 11.5%]), which was lower than the predefined performance goal of 20% (P<0.001). Compared with non-ISR lesions treated with EES (n=2021), the postpercutaneous coronary intervention minimal stent area by optical coherence tomography was smaller in treated ISR lesions (5.0±1.8 mm2 versus 5.6±1.9 mm2; P<0.001), but minimum stent expansion was similar (78.8±18.0% versus 79.0±16.9%; P=0.87), as was 1-year target lesion failure (7.4% versus 4.7%; hazard ratio, 1.58 [95% CI, 0.95-2.61]; P=0.07).

CONCLUSIONS

XIENCE EES was safe and effective for treatment of single-layer ISR. Compared with non-ISR lesions, ISR lesions treated with EES had a smaller postpercutaneous coronary intervention minimal stent area although stent expansion and 1-year target lesion failure rates were not different.

REGISTRATION

URL: https://clinicaltrials.gov/; Unique identifier: NCT03507777.

Acute Left Anterior Descending Occlusion Myocardial Infarction Incidentally Found on Surveillance Computed Tomography

Advances in computed tomography (CT) scanner technology and faster image acquisition have enabled improved visualization of cardiac structures, even on routine noncardiac chest CT scans. Recognition of incidental cardiac findings is crucial as they may signal underlying pathology. A 60-year-old woman with metastatic gastroesophageal junction cancer underwent outpatient surveillance CT which revealed decreased density of the left ventricular myocardium at the mid and apical anterior walls and septum, concerning for myocardial ischemia or infarction. Although asymptomatic and without cardiac history, she had markedly elevated troponin levels and was found to have an acute occlusion in the mid-left anterior descending artery, successfully treated with percutaneous coronary intervention. This case highlights the value of recognizing incidental myocardial hypoperfusion on noncardiovascular CT imaging. The literature describes hypoattenuation as a marker of acute myocardial infarction, but its detection in asymptomatic patients raises diagnostic and management challenges.

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

BACKGROUND

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

METHODS AND RESULTS

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

CONCLUSION

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

A High-Sensitivity Troponin I Rapid Assay vs. a High-Sensitivity Troponin T Routine Assay in Acute Chest Pain Patients: A Prospective Monocentric Study

Background/Objective: The measurement of troponin is recommended for acute myocardial infarction (AMI) diagnosis. Yet, hs-cardiac troponin T (hs-cTnT) can be elevated due to non-cardiac conditions, such as skeletal muscle injury, chronic kidney disease (CKD) or pulmonary embolism. The aim of our study was to compare the diagnostic accuracy of a bedside rapid hs-cardiac troponin I (hs-cTnI) assay (Quidel TriageTrue®) with hs-cTnT measured in a routine laboratory (Roche Elecsys). Methods: This prospective monocentric study was conducted in an acute cardiac outpatient unit at a tertiary hospital. Hs-cTnI was measured via a point-of-care test from whole blood, while hs-cTnT was measured from plasma through the routine laboratory facility. Results: In 129 patients (65.1% male, 61.8 ± 15.6 years) with acute chest pain, results for hs-cTnI were available 14 ± 11 min after the first clinical presentation, which was 74 ± 54 min earlier than for hs-cTnT. Coronary angiography confirmed AMI in 17 patients (13.28%). The relative risk of AMI patients with elevated hs-cTnI results was 6.59 compared to 2.29 for hs-cTnT. Hs-cTnI exhibited an equivalent negative predictive value to hs-cTnT (99%) for AMI but had a comparatively higher positive predictive value (50.0 vs. 25.8%). In 39 patients with at least CKD stage 3a, median hs-cTnT was pathological (27.0 ng/L), in contrast with hs-cTnI (11.2 ng/L). Further, hs-cTnI was less likely elevated in patients with CKD and no AMI. Conclusions: The diagnostic value of hs-cTnI was comparable to that of hs-cTnT, and the blood sampling-to-result time was shorter than routine hs-cTnT.

Impact of Isolated Side Branch Lesions on Procedural Techniques and Outcomes of Bifurcation Percutaneous Coronary Intervention

BACKGROUND

There is limited information on the impact of the isolated side branch lesions (ISBL) on the procedural techniques and outcomes of bifurcation percutaneous coronary intervention (PCI).

AIMS

To examine the clinical, procedural and long-term outcomes of ISBL.

METHODS

We examined the clinical, angiographic characteristics, and procedural outcomes of 1719 bifurcation PCIs in 1501 patients between 2014 and 2023 from the PROGRESS-BIFURCATION registry. A propensity score matched (PSM) Cox proportional hazards model was used to assess long-term outcomes.

RESULTS

ISBL (Medina class 0,0,1) was present in 80 patients (5.3%). ISBL patients had similar baseline characteristics to the remaining patients, except for hypertension (90.0% vs. 79.2%, p = 0.020), prior PCI (66.3% vs. 44.5%, p < 0.001), and prior MI (50.6% vs. 35.2%, p = 0.006) that were more common in ISBL patients. ISBL had a median side branch diameter of 2.5 mm (interquartile range [IQR] 2.5-3.0), a median length of 10 mm (IQR 5-12), and a median side branch stenosis of 90% (IQR 80-95). The most common stenting strategies were side branch stenting (41.8%) and inverted provisional (25.5%). Technical and procedural success and in-hospital major adverse cardiovascular events (MACE) were similar in patients with and without ISBL. At 3-year follow-up, the incidence of MACE was higher in ISBL patients (36.3% vs. 26.4%, p = 0.043), driven by higher repeat target vessel PCI (26.8% vs. 12.0%; p = 0.003). On PSM adjusted Cox analysis, ISBL were independently associated with higher follow-up MACE (hazard ratio 1.58, 95% confidence intervals 1.13-2.20, p = 0.008).

CONCLUSIONS

PCI of ISBL was infrequent and was associated with similar technical and procedural success with non-ISBL but higher long-term MACE driven by higher TVR.

Association Between Cardiometabolic Multimorbidity and 15-year Mortality in the Asia Cohort Consortium

BACKGROUND

Studies on the association between multimorbidity and mortality in large populations have mainly been conducted in European and North American populations. This study aimed to identify the association between cardiometabolic multimorbidity and all-cause and cardiovascular disease (CVD) mortality in the Asia Cohort Consortium.

METHODS

In this prospective cohort study, pooled analysis was performed to evaluate the association between cardiometabolic diseases (hypertension, diabetes, ischemic heart disease, and stroke), multimorbidity, and all-cause and CVD mortality, including premature mortality, among participants from 11 Asian cohort studies. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox hazard regression.

RESULTS

A total of 483,532 participants were followed for a median of 14.3 years. Compared with participants without any disease, those with stroke and diabetes had higher age- and sex-adjusted HRs for all-cause mortality (HR 3.9; 95% CI, 3.28-4.56). Moreover, the age- and sex-adjusted HRs for CVD mortality were highest in participants with stroke, ischemic heart disease, and diabetes (HR 10.6; 95% CI, 6.16-18.25). These patterns remained consistent after additional adjustments for smoking status and body mass index. The risk of premature mortality followed similar trends but was more pronounced.

CONCLUSION

These findings highlight the differential impacts of individual cardiometabolic diseases and their combinations on mortality risks. Stroke and diabetes were associated with the highest risks for all-cause and cardiovascular mortality, underscoring the need for targeted prevention and personalized management strategies tailored to these high-risk conditions in Asian populations.

Global Sociodemographic Disparities in Ischemic Heart Disease Mortality According to Sex, 1980 to 2021

BACKGROUND

Mortality due to ischemic heart disease (IHD) has declined in countries with high socioeconomic development. Whether these declines extend to other settings, and whether socioeconomic development influences IHD mortality among men and women differently, is unknown.

METHODS

We obtained annual data on sex-specific IHD mortality rates for countries/territories in the GBD study (Global Burden of Disease) from 1980 to 2021. The sociodemographic index (SI), a measure of socioeconomic development, was retrieved for each country/territory. Age-adjusted IHD mortality rates were modeled as a smooth function of sex, year, and SI.

RESULTS

From 1980 to 2021, IHD mortality rates did not decrease in low SI settings for men or women. In contrast, mortality rates relative to 1980 declined by >25% in average SI settings (age-adjusted mortality per 100 000, 153-107 for women and 218-161 for men) and >50% in high SI settings (age-adjusted mortality per 100 000, 162-69 for women and 258-114 for men). Comparing the 20th versus 80th percentile of SI in 2021 (corresponding to lower versus higher socioeconomic development), mortality rates were 81% higher for men and 111% higher for women living in socioeconomically deprived settings (P for difference by sex: 0.01), although absolute differences were larger in men. The association of low SI with higher IHD mortality was especially pronounced for mortality attributable to environmental/occupational risk factors (eg, particulate matter air pollution, lead exposure, and extremes of temperature), with mortality rates being 174% higher among women and 199% higher among men.

CONCLUSIONS

Across the past 4 decades, low socioeconomic development was associated with no improvement in IHD mortality rates for men or women, in contrast to the large reductions observed in settings with high socioeconomic development. In contemporary settings, socioeconomic deprivation is associated with larger relative excess mortality in women and larger absolute excess mortality in men.

Possible Misdiagnosis of Myocardial Infarction Using Regulatory-Approved and Close-to-Bioequivalent Upper Limits of Normal for Cardiac Troponin

BACKGROUND

Possible misdiagnosis of acute myocardial infarction (AMI) may occur due to inappropriate upper limit of normal (ULN) for cardiac troponin and has the potential to harm patients. In this observational international multicenter study, we aimed to assess to what extent the novel hs-cTn-assays are affected.

METHODS

A total of 6646 patients presenting with suspected AMI to the emergency department were enrolled. All level pairs (n=18 732) of 4 widely used high-sensitivity cardiac troponin T/I (hs-cTnT/I) assays using (1) the regulatory-approved uniform and sex-specific clinical ULN and (2) mathematically derived close-to-bioequivalent ULNs were assessed. The primary outcome was the quantification of the incidence of inconsistencies in the diagnosis of AMI. Inconsistency was defined as hs-cTnT/I concentration above the recommended ULN in one but not the other assay: for example, hs-cTnT-Elecsys+/hs-cTnI-Architect- or hs-cTnT-Elecsys-/hs-cTnI-Architect+.

RESULTS

AMI was the adjudicated diagnosis in 1422 patients (21.4%). When the regulatory-approved uniform ULN was used, the rate of inconsistent AMI diagnoses was 17.6% (Elecsys/Architect), 18.8% (Elecsys/Centaur), 14.2% (Elecsys/Access), 4.9% (Architect/Centaur), 8.3% (Architect/Access), and 7.4% (Access/Centaur), respectively. Overall, diagnostic mismatches were not decreased, but in fact increased using regulatory-approved sex-specific ULNs. In women as compared with men, they were 23.8% versus 17.6% (Elecsys/Architect), 30.1% versus 19.1% (Elecsys/Centaur), 23.2% versus 15% (Elecsys/Access), 7.2% versus 4.5% (Architect/Centaur), 8.3% versus 8.7% (Architect/Access) and 7.8% versus 8.2% (Access/Centaur), respectively. Using close-to-bioequivalent ULNs reduced inconsistencies by 15% to 20% (P<0.001). Findings were confirmed in a sensitivity analysis among all level pairs with final diagnosis of AMI (mismatches in 7.3%-20.5%).

CONCLUSIONS

Current regulatory-approved uniform and sex-specific ULNs for hs-cTnT/I result in discordances in binary assay results, possibly impacting the diagnosis of AMI. A regulatory process that defines bioequivalent ULNs could reduce inconsistencies significantly.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT00470587.

Stent-Edge Hinge Movement in a Calcified Lesion Is Associated With Increased Prevalence of a Calcified Nodule at Follow-Up

BACKGROUND

Coronary stenting alters vessel dynamics, displacing hinge movement closer to stent edges. We aimed to investigate whether calcified nodules (CNs) are more frequent at stent edges associated with calcium.

METHODS

In vessels with previously implanted stents evaluated by optical coherence tomography, 4 different calcified lesions were studied: stent-edge calcified lesions with or without a CN, and unstented native calcified lesions with or without a CN.

RESULTS

In 801 patients, 989 stent-edge calcified lesions and 354 unstented native calcified lesions were identified. Stent-edge calcified lesions exhibited a higher prevalence of CNs versus native calcified lesions (15.7% versus 5.1%; P<0.001) and were observed in locations (mid left anterior descending artery, mid left circumflex, or branches) where no unstented native vessel CNs were seen. Stent-edge (versus native vessel) location (odds ratio [OR], 4.58 [95% CI, 2.23-9.43]) predicted the presence of a CN. Correspondingly, greater angiographic (systole-diastole) ∆angle at the stent edge or unstented lesion (per 10°, OR, 2.27 [95% CI, 1.43-3.60]) and greater calcium burden: calcium length (per 10 mm, OR, 4.04 [95% CI, 2.36-6.92]), maximum calcium arc (per 90°, OR, 1.65 [95% CI, 1.25-2.17]), and maximum calcium thickness (per 0.1 mm, OR, 1.25 [95% CI, 1.15-1.36]) were associated with the presence of a CN. Stent-edge CNs were associated with a higher rate of stent-edge calcified lesion-related major adverse cardiac events (a composite of cardiac death, target vessel-related myocardial infarction, clinically driven target lesion revascularization, or definite/probable stent thrombosis) compared with stent edges without a CN (15.9% versus 6.5%; P=0.01), mainly driven by target lesion revascularization.

CONCLUSIONS

Stent-edge calcium may predispose to the development of a CN. Stent-edge CNs were associated with a higher major adverse cardiac events rate than stent edges without a CN, whether treated or untreated.

Age-specific prognosis of acute and steady minor elevations in cardiac troponin among non-acute myocardial infarction inpatients: a large real-world cohort study

BACKGROUND

The upper reference limit of normal (ULN) of cardiac troponin (cTn) for older adults can be higher than for young adults, while the same ULN is used for both older and young adults in the current clinical practice.

METHODS

In this multicentre longitudinal cohort study, non-acute myocardial infarction (non-AMI) inpatients with at least two cTn concentrations hospitalised between 2013 and 2022 in the Tianjin Health and Medical Data Platform were included. Multivariable Cox proportional hazards and landmark regression models were used to estimate the risk of in-hospital, 30-day and 1-year mortality in different cTn groups (normal, stable minor elevation (1-2×ULN with variation ≤20%), acute minor elevation (1-2×ULN with variation >20%) and apparent elevation (>2×ULN)).

RESULTS

A total of 57 117 patients (mean age, 69.6 (13.6) years; 25 037 (43.8%) female) were included. Even minor elevation in cTn was associated with higher mortality risk. Compared with the normal cTn group, the adjusted HRs of in-hospital mortality for patients with steady minor elevation, acute minor elevation and >2× ULN in cTn were 1.70 (95% CI 1.25 to 2.33), 1.92 (95% CI 1.59 to 2.32) and 4.03 (95% CI 3.50 to 4.65), respectively. Similar trends were found for all-cause 30-day and 30-day to 1-year mortality. Among older adults, compared with the steady minor elevation group, patients with acute minor elevation in cTn had higher 30-day mortality risk (HR 1.30, 95% CI 1.02 to 1.65) but similar 30-day to 1-year mortality risk (HR 0.95, 95% CI 0.82 to 1.10), while among non-older adults, differences in short-term and 1-year mortality risks between the two groups were not statistically significant (p>0.05).

CONCLUSIONS

In non-AMI inpatients, including older adults, any stable or acute elevation in cTn, even minor, warrants attention. Further studies are needed to assess whether these patients can benefit from more aggressive treatment approaches.

Detection and Location of Myocardial Infarction Using Electrocardiogram: Validation by Cardiovascular Magnetic Resonance Imaging

BACKGROUND

In the assessment of ischemic heart disease, cardiac magnetic resonance (CMR) is considered the gold standard for detecting and locating myocardial infarction (MI), but electrocardiogram (ECG) is less expensive and more widely available. Recognition of MI on ECG outside the acute phase is challenging; Q waves are absent in a significant proportion of patients and may reduce or disappear over time. Although ECG is widely used in the initial assessment of previous infarction, studies to validate ECG using CMR as a reference in the context of chronic coronary disease are limited.

OBJECTIVES

To evaluate the diagnostic performance of ECG in detecting and locating CMR-defined MI.

METHODS

This study included 352 individuals who underwent CMR and ECG, 241 patients with previous MI confirmed by CMR and 111 controls with normal CMR. Their ECG tracings were analyzed by 2 observers, who were blinded to the CMR, for detection and location of MI following to the Fourth Brazilian Society of Cardiology Guidelines on the Analysis and Issuance of Electrocardiographic Reports. The significance level adopted was 5% (p < 0.05).

RESULTS

ECG showed good performance for detecting previous MI, with sensitivity of 69.3% (64.5% to 74.1%), specificity of 99.1% (98.1% to 100%), and accuracy of 78.7% (74.4% to 83.0%). However, in locating MI in accordance with CMR, its accuracy was unsatisfactory.

CONCLUSIONS

When compared to CMR, ECG was shown to be a method with good accuracy for detecting previous MI, but not for defining its location.

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.

Risk of premature cardiovascular disease and all-cause mortality in young adults, association with risk factor prevalence early in life

BACKGROUND

With the increase in risk factors and the emergence of unhealthy lifestyles in young adults, we need to pay more attention to the cardiovascular health of this group. This study aimed to assess the association of the degree of joint risk factor control with premature cardiovascular disease (CVD) and all-cause mortality in young people.

METHODS

Kailuan Study is a prospective cohort study based on a community population, which began in June 2006, and followed up every two years. A sample of 16,519 eligible participants in the Kailuan cohort was recruited in this current study and 15,948 was included in the final analysis, with an average age of 32.34 ± 5.19 years, and a male proportion of 74.76%. Based on the control status of the risk factors, participants were divided into three groups: well-controlled group (≥ 7 risk factors controlled), moderately controlled group (5-6 risk factors controlled), and poorly controlled group (≤ 4 risk factors controlled). Multivariate Cox proportional hazard model was used to analyse the relationship between the joint control of risk factors and onset of CVD and all-cause mortality.

RESULTS

During a mean follow-up period of 14.78 ± 1.33 years, we identified 285 incident CVD cases and a total of 274 deaths from all causes. Compared to the well-controlled group, the moderately controlled group and poorly controlled group exhibited progressively higher risks of CVD and all-cause mortality. The adjusted hazard ratios (HRs) for CVD in the moderately controlled group and poorly controlled group were 2.24 (95% confidence interval [CI]: 1.66-3.02) and 3.09 (95% CI: 2.04-4.68), respectively. The adjusted HRs for all-cause mortality in these two groups were 1.53 (1.15-2.04) and 2.65 (1.79-3.92), respectively.

CONCLUSIONS

We observed an inverse relationship between the degree of risk factor control and the risk of CVD and all-cause mortality in young adults, emphasizing the importance of actively controlling more risk factors in early life.

Exposure to polyethylene terephthalate micro(nano)plastics exacerbates inflammation and fibrosis after myocardial infarction by reprogramming the gut and lung microbiota and metabolome

Micro(nano)plastics (MNPs), a ubiquitous environmental pollutant, have received increasing attention for their impacts on human health. We conducted an in-depth study on the role of polyethylene terephthalate (PET) MNPs in myocardial infarction (MI). Blood from the coronary circulation of MI patients was collected to detect microplastics (MPs). Peripheral monocytes (PBMCs) and AC16 cells were used to assess inflammation, cell proliferation and apoptosis after PET nanoplastics (NPs) stimulation. The mouse MI model was established after PET NPs respiratory or oral exposure. The results showed that various types of MPs, including high levels of PET MPs, were detected in the coronary circulation. PET NPs promoted inflammatory factors secretion by PBMCs, inhibited AC16 cell proliferation and promoted hypoxia-induced AC16 cell apoptosis. PET NPs exacerbated post-MI inflammation and fibrosis through activating the NLRP3 inflammasome pathway. Through macrogenetic sequencing and metabolomics analyses, we observed that PET NPs reprogrammed the intestinal and lung microbiota and metabolome in MI mice, leading to chronic inflammation. In conclusion, PET MPs were widely present in the coronary circulation of MI patients. PET MNPs can activate the NLRP3 inflammasome pathway to exacerbate post-MI ventricular remodelling, which may be related to the reprogramming of the gut and lung microbiota and metabolome.

Psychological distress and myocardial infarction (MI): A cross-sectional and longitudinal UK population-based study

OBJECTIVE

The objective of the present research is to establish the cross-sectional and longitudinal associations between dimensions of psychological distress (i.e., social dysfunction and anhedonia, depression and anxiety, and loss of confidence) and the risk of clinically diagnosed myocardial infarction (MI).

METHODS

We analyzed valid data from 12931 participants from Wave 1 (collected from 2009 to 2010) and who continued to participate until Wave 10 (collected from 2019 to 2020, N = 5117) of the Understanding Society: the UK Household Longitudinal Study using a confirmatory factor analysis (CFA) and binary logistic regressions.

RESULTS

There were three factors including social dysfunction and anhedonia, depression and anxiety, and loss of confidence within the GHQ-12. Social dysfunction and anhedonia continued to show significant positive associations with the chance of past clinical MI diagnosis (OR = 1.24, 95% CI [1.13, 1.35], p < .001) and the risk of developing MI over the 10-year period (OR = 1.23, 95% CI [1.01, 1.49], p < .05). In addition, age showed a significant positive association with the risk of developing MI over time (OR = 1.04, 95% CI [1.01, 1.06], p < .01). Sex maintained a significant negative association (OR = 0.30, 95% CI [0.21, 0.44], p < .001). Hypertension status demonstrated a strong positive association over time (OR = 1.52, 95% CI [1.08, 2.15], p < .05).

CONCLUSION

Intervention and prevention programs may be required for individuals with high social dysfunction and anhedonia levels to reduce the prevalence of MI and the risk of developing MI over time.

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.

Cardiac biomarkers N-terminal fragment of the prohormone B-type natriuretic peptide and cardiac troponin I for characterization of the cardiac disease phenotype of the English Bull Terrier

The N-terminal fragment of prohormone B-type natriuretic peptide (NT-proBNP) and cardiac troponin I (cTnI) contribute information regarding cardiac load and function and myocardial injury, respectively, to the clinical work-up of dogs with heart disease. The English bull terrier (BT) has a predisposition to a complex cardiac phenotype. This prospective case-control study aimed to further characterize this phenotype through cardiac biomarker evaluation. Fifteen healthy BT (group 1) and 50 BT with various heart disease presentations (groups 2-4) were included. The main presentations were MVD (45 dogs) and MS (13 dogs). 16/50 dogs had echocardiographic evidence of cardiac remodeling: 7 with either increased left atrial (LA) or left ventricular (LV) volumes (group 3) and 9 with increased LA and LV volumes (group 4). Cardiac biomarkers were not significantly different between dogs with disease subtypes MVD or MS versus dogs with other disease presentations. When evaluated in relation to remodeling, median NT-proBNP and cTnI in group 4 (1004 pmol/L, 0.09 ng/mL) were significantly higher than in group 1 (257 pmol/L, 0.02 ng/mL), group 2 (300 pmol/L, 0.026 ng/mL) and group 3 (250 pmol/L, 0.02 ng/mL). There was significant discriminatory ability for both biomarkers between group 4 and groups 1, 2 or 3. Furthermore, cTnI significantly differentiated dogs with any degree of remodeling (groups 3 + 4) from those without (groups 1 + 2). The cardiac disease phenotype of the BT is not associated with a unique cardiac biomarker profile. Rather, biomarker levels are similar to those reported in other breeds with valvular heart disease.

Prognostic Value of Non-Traditional Lipid Indices for In-Hospital Mortality in Patients with Acute Coronary Syndromes

Background and Objectives: Acute coronary syndrome (ACS) is a life-threatening cardiovascular condition with high mortality rates, necessitating accurate and early risk assessment to optimize patient outcomes. While traditional lipid markers, such as low-density lipoprotein-cholesterol (LDL-C) and high-density lipoprotein-cholesterol (HDL-C), are widely used, non-traditional lipid indices, including the lipoprotein combined index (LCI), atherogenic index of plasma (AIP), atherogenic index (AI), Castelli risk indices (CRI-I, CRI-II), and atherogenic combined index (ACI) may offer additional prognostic insights by reflecting the underlying atherogenic and inflammatory processes. This study aimed to assess the prognostic value of these non-traditional lipid indices, along with traditional lipid and biochemical markers, for in-hospital mortality in ACS patients. Materials and Methods: This retrospective observational study analyzed data from ACS patients admitted to the coronary care unit (CCU) between January 2019 and September 2024. A cohort of 920 patients was divided into survivor (n = 823, 89.46%) and non-survivor (n = 97, 10.54%) groups based on in-hospital mortality outcomes. Demographic, hematological, biochemical, and lipid profile data, including traditional and non-traditional lipid indices, were collected. Separate logistic regression models were developed for each index, adjusting for demographic and clinical variables in order to assess the independent predictive power of each non-traditional lipid index. Results: Significant differences were observed between survivor and non-survivor groups in terms of age, c-reactive protein (CRP), white blood cell count (WBC), hemoglobin (HGB), and creatinine levels (all p-values < 0.05). While traditional lipid markers, such as LDL-C and HDL-C, showed limited predictive value, non-traditional lipid indices demonstrated stronger associations. The highest Exp (Beta) values were observed for the CRI-II, AI, and CRI-I. An ROC analysis further confirmed that the CRI-II, AI, and CRI-I had the highest AUC values, with pairwise comparisons underscoring the CRI-II's superior accuracy. These findings suggest that non-traditional lipid indices predict atherogenic risk better than traditional markers alone. Conclusions: Non-traditional lipid indices, particularly the CRI-I and II, AI, LCI, ACI, and AIP, were found to be significantly associated with in-hospital mortality in ACS patients. These indices may provide additional prognostic value beyond traditional lipid parameters; however, further prospective studies are needed to confirm their clinical utility. These results underscore the importance of integrating non-traditional lipid indices into routine risk assessments to improve mortality predictions and inform targeted interventions in high-risk ACS patients.

Epicardial Adipose Tissue and Heterogeneity Parameters Combined with Inflammatory Cells to Predict the Value of Heart Failure with Preserved Ejection Fraction Patients Post Myocardial Infarction

BACKGROUND AND PURPOSE

Epicardial adipose tissue (EAT) comprises three distinct lipid components, each exerting differential effects on cardiovascular diseases. During disease progression, dynamic alterations in lipid composition and spatial distribution contribute to the inherent heterogeneity of EAT. The excessive activation of inflammatory cells may contribute to chronic inflammation, promoting atherosclerosis and cardiac diseases. However, the role of EAT in patients with myocardial infarction (MI) who develop heart failure with preserved ejection fraction (HFpEF) remains unclear. This study aims to quantify the overall and perivascular volumes of EAT using cardiac magnetic resonance (CMR) imaging and assess its heterogeneity, exploring the predictive value of EAT heterogeneity and different EAT volumes combined with inflammatory cells for the occurrence of HFpEF in MI patients with normal left ventricular ejection fraction (LVEF).

METHODS

This retrospective cohort study enrolled patients diagnosed with MI with preserved LVEF via clinical assessment and CMR at the Second Affiliated Hospital of Kunming Medical University between January 2015 and July 2023. Patients who did not undergo percutaneous coronary intervention (PCI) were followed, with the incidence of HFpEF serving as the primary endpoint. The cohort was stratified into two groups: those without HFpEF and those who developed HFpEF.Cardiac structure, function, EAT volume, and infarct volume parameters were obtained using the CMR post-processing software CVI-42, while EAT heterogeneity parameters entropy were derived using Python software. Independent sample t-tests, non-parametric tests, and chi-square tests were employed to analyze the differences in clinical baseline data and CMR metrics between the two groups. Spearman's rank correlation was utilized to analyze the associations between EAT parameters and inflammatory cells, inflammatory markers, and diastolic dysfunction indicators. Furthermore, we conducted univariate and multivariate Cox regression analyses to determine the predictive value of each parameter for the development of HFpEF in MI patients. Time-dependent ROC curves were generated to evaluate the efficacy of each parameter in predicting HFpEF, the AIC values of each parameter and the final model were calculated to evaluate the predictive performance. The optimal cut-off values were identified using time-dependent ROC curves in R software, and Kaplan-Meier event-survival curves were plotted to illustrate the event-free rates based on these optimal thresholds.The median follow-up time was calculated using the reverse Kaplan-Meier method.

RESULTS

A total of 203 MI patients with normal LVEF were included, with 74 in the HFpEF group and 129 in the non-HFpEF group. No significant differences were observed between the two groups regarding age, sex, and infarct volume; however, significant statistical differences were noted in BMI, diabetes, renal failure, leukocytes, neutrophils, monocytes, total EAT, EAT entropy, left ventricular EAT (LV EAT), left atrial end-systolic volume (LAESV), triglycerides, NHR, MHR and LACI(Left atrioventricular coupling index) (P < 0.05). Both overall and local EAT volumes showed a positive correlation with leukocytes and monocytes,as well as with the inflammatory markers MHR and SIRI. Furthermore, EAT volume exhibited a positive correlation with the LACI, a marker of diastolic dysfunction. Univariate and multivariate Cox regression analyses indicated that BMI, diabetes, monocyte, LV EAT, and EAT entropy are independent risk factors for HFpEF. And the AIC value of the multivariate regression model was the smallest.Further time-dependent ROC analysis revealed that the maximum AUC for BMI was 0.67, while the AUC for LV EAT was 0.63, and EAT entropy was 0.60, the maximum AUC for monocyte was 0.70, and the combined prediction of LV EAT and EAT entropy had a maximum AUC of 0.70. After a median follow-up of 34 months, Kaplan-Meier survival curves demonstrated that LV EAT greater than 21.23 mL was associated with the occurrence of HFpEF, whereas EAT entropy was not.

CONCLUSIONS

In patients with chronic MI, normal LVEF, and no prior PCI, the occurrence of HFpEF is not correlated with infarct volume; however, BMI, diabetes, monocyte, LV EAT, and EAT entropy are independent risk factors for HFpEF with significant predictive value, with the highest predictive efficacy observed monocyte and when combining EAT entropy and LV EAT. Additionally, both overall and local EAT volumes exhibit a moderate positive correlation with leukocytes,monocytes and inflammatory markers, and were also positively correlated with diastolic dysfunction. This suggests that, in clinical practice, beyond traditional indicators, there should be an increased focus on EAT heterogeneity and perivascular EAT in MI patients with normal LVEF who have not undergone PCI to to reduce the incidence of HFpEF.

Point-of-care troponin tests to rule out acute myocardial infarction in the prehospital environment: a protocol for a systematic review and meta-analysis

BACKGROUND

Chest pain is a major cause of emergency ambulance calls, often linked to acute myocardial infarction (AMI), a critical condition requiring immediate hospitalisation. Current diagnostic methods, such as history taking and ECG, have limitations, especially for non-ST-elevation myocardial infarction. High-sensitivity cardiac troponin (cTn) assays are more diagnostically sensitive, but the downside is that it needs hospital-based testing, which can delay diagnosis and the necessary treatment protocol. Point-of-care cTn testing, on the other hand, is much faster and done nearer to the patient; hence, it may fundamentally change the prehospital care pathway in terms of diagnostic accuracy, clinical utility and related safety.

OBJECTIVE

To present a protocol for a systematic review and meta-analysis that will assess the diagnostic accuracy, clinical utility and safety of point of care (POC) troponin tests, with or without clinical decision aids, for ruling out AMI in adults presenting with cardiac chest pain to emergency ambulance services in prehospital settings.

METHODS

This protocol follows BMJ guidelines and adheres to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2015 reporting standards. It is registered with PROSPERO (ID: CRD42024533117). A comprehensive search strategy will identify relevant studies in MEDLINE, EMBASE and CINAHL, focusing on literature from 2000 onwards. Eligibility criteria include adults with chest pain suspected of AMI, excluding those with ST-elevation myocardial infarction. The primary target is type 1 AMI, with secondary outcomes including major adverse cardiac events at 30 days. Risk of bias assessment will be performed using tools such as Quality Assessment of Diagnostic Accuracy Studies version 2, Risk of Bias 2, and Risk of Bias in Non-randomised Studies of Interventions, while the quality of the economic evaluations will be appraised using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Data items extracted will include patient demographics, test characteristics and outcomes. Where possible, meta-analyses will be conducted by fitting hierarchical models for diagnostic accuracy and random effects models for clinical and cost-effectiveness estimates. Subgroup analyses are proposed to quantify the effect of variables such as gender, ethnicity and type of troponin assay on the estimated parameters.

ETHICS AND DISSEMINATION

Ethical approval is not required. The results will be published in a peer-reviewed journal and presented at international conferences.

PROSPERO REGISTRATION NUMBER

This protocol is registered with PROSPERO, the International Prospective Register of Systematic Reviews, under the ID CRD42024533117. Any future amendments will be updated in the PROSPERO record.

Randomized comparison of the combined Sirolimus eluting and endothelial progenitor cell combo Stent vs. biolimus eluting absorbable polymer coated biomatrix alpha stent in patients undergoing percutaneous coronary intervention: Rationale and study design of the Scandinavian Organization for randomized trials with clinical outcome (SORT OUT) XI trial

RATIONALE

The biodegradable polymer Biomatrix Alpha stent contains biolimus A9 drug which is a sirolimus derivative increased in lipophicity. The biodegradable polymer sirolimus eluting Combo stent is a dual-therapy sirolimus-eluting and CD34+ antibody coated stent capturing endothelial progenitor cells (EPCs).

HYPOTHESIS

The main hypothesis of the SORT OUT XI trial was that the biodegradable polymer biolimus A9 Biomatrix Alpha stent is noninferior to the biodegradable polymer sirolimus eluting Combo stent in an all-comers population with coronary artery disease undergoing percutaneous coronary intervention (PCI).

METHODS

The SORT OUT XI study was a randomized, multicenter, single blinded, all-comer, 2-arm, noninferiority trial comparing the biodegradable polymer biolimus A9 Biomatrix Alpha stent to the biodegradable polymer sirolimus eluting Combo stent in 3 Danish University Hospitals in Western Denmark. The composite primary endpoint was target lesion failure (TLF) within 12 months. TLF was defined as composite of cardiac death, myocardial infarction not related to other than index lesion or target lesion revascularization. Clinically driven event detection was used and no planned follow up was performed. With a sample size of 1,564 patients in each treatment arm, a 2-group large-sample normal approximation test of proportions with a 1-sided 5% significance level had a 90% power to detect noninferiority with a predetermined noninferiority margin of 2.1%.

RESULTS

The trial ran from August 14, 2019 to March 19, 2023. A total of 3141 patients were enrolled and randomized 1:1 to Combo stent (n = 1,573) and Biomatrix Alpha stent (n = 1,568).

CONCLUSION

The SORT OUT XI trial will assess if the biolimus A9 eluting Biomatrix Alpha stent is noninferior to the dual-therapy Combo stent with respect to target lesion failure.

CLINICALTRIALS

GOV: NCT03952273.

Comparison of the efficacy of primary percutaneous coronary intervention in super-old and old aged patients in an advanced aging society

BACKGROUND

Current guidelines strongly recommend the application of primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction; however, information on its efficacy in super-old patients aged >90 years is inadequate. We compared the efficacy of primary PCI and its clinical outcomes in super-old patients with those of old patients in a super-aging society.

METHODS

Shimane Acute Coronary Syndrome (ACS) Registry was a multicenter retrospective cohort study. Consecutive patients with ACS who visited all PCI centers in Shimane Prefecture between January and December 2020 were enrolled. Patients were classified into four age categories: non-old (<65 years), pre-old (65-<75 years), old (75-<90 years), and super-old (≥90 years). Primary endpoints were major adverse cardiovascular events (MACE), including all-cause death, recurrent ACS, any stroke, and hospitalization for worsening heart failure.

RESULTS

In total, 454 patients were enrolled: 99 non-old, 124 pre-old, 181 old, and 50 super-old. The application rate of primary PCI decreased with increased age, with 89 % in old age and 78 % in super-old age (p = 0.042). In-hospital mortality rate was significantly higher in super-old age than in old age (22 % vs. 8 %, p = 0.010), particularly in shock cases (67 % vs. 31 %, p = 0.040); no difference was observed between the two groups in non-shock cases (8 % vs. 4 %, p = 0.259) or in cases that received primary PCI (10 % vs. 6 %, p = 0.232). Landmark analysis revealed that MACE after 30th day did not differ between super-old and old age groups.

CONCLUSIONS

In the advanced aging society of Shimane Prefecture, more than half of patients with ACS were aged ≥75 years, with super-old patients aged ≥90 years accounting for 11 % of all patients. In-hospital mortality rate among super-old age patients was lower among those who underwent primary PCI. The prognosis for super-old age patients who were discharged alive was similar to that of old age patients.

MIO: An ontology for annotating and integrating medical knowledge in myocardial infarction to enhance clinical decision making

As biotechnology and computer science continue to advance, there's a growing amount of biomedical data worldwide. However, standardizing and consolidating these data remains challenging, making analysis and comprehension more difficult. To enhance research on complex diseases like myocardial infarction (MI), an ontology is necessary to ensure consistent data labeling and knowledge representation. This will facilitate data management and the application of artificial intelligence techniques in this field, ultimately advancing precision medicine research for MI. This study introduced the MI Ontology (MIO), which was developed using Stanford's seven-step method and Protégé. MIO aims to support precision medicine research on MI by effectively modeling and representing MI-related concepts and relationships. The validation of the MIO model involved employing Ontology Web Language (OWL) reasoners and comparing it with other disease-specific ontologies. MIO is an ontology model comprising of 3090 classes, 14 object attributes, 3494 individuals, 9415 synonyms and 49263 axioms, which encompass knowledge related to MI such as anatomical entities, clinical findings, drugs, genes, influencing factors, pathogenesis, patients-related concepts, procedures, and disease types. Furthermore, MIO has passed logical consistency validation and exhibits a broader conceptual scope and deeper knowledge structure than other disease-specific ontologies. Additionally, clinical use scenarios for MIO were developed to help address specific clinical problems. This study constructed the first comprehensive disease-specific ontology in cardiovascular diseases, named MIO, to promote precision medicine research on MI. MIO integrates and standardizes medical data, addressing complexity and standardization challenges. This promotes the use of big data analysis, explainable AI, and deep phenotype research in precision medicine. Future efforts will focus on enhancing and expanding MIO's applicability and scalability for superior services in this field.

Safety and clinical implications of coronary spasm provocation testing in patients presenting with myocardial infarction with no overt culprit lesion

BACKGROUND

Acetylcholine (ACh) provocation testing is a critical diagnostic tool for identifying coronary artery spasms in patients presenting with angina pectoris or myocardial infarction (MI) who do not exhibit obstructive coronary artery disease. Despite its utility, the use of ACh testing is limited due to concerns regarding potential life-threatening complications and a historical underrepresentation of MI populations in clinical research.

METHODS

This registry-based study analyzed 1063 patients with 115 presenting with MI and 948 without (non-MI), who underwent ACh spasm provocation testing. The primary safety endpoints include arrhythmic and other acute complications. The primary clinical endpoint was the incidence of major adverse cardiac events (MACE). The median follow-up was 2.4 years.

RESULTS

The ACh testing showed low incidences of major cardiovascular complications with no incidences of procedure-related death. Additionally, rates of fatal ventricular arrhythmia, cardiogenic shock, and procedure-related myocardial infarction showed no significant differences between the MI and non-MI patient groups. There was no significant difference in MACE between MI and non-MI groups stratified based on the ACh test responses. Multivariable analysis revealed that ST-segment elevation and diabetes mellitus were associated with a higher rate of MACE in MI patients with positive ACh tests (adjusted hazard ratio 10.98 [95 % CI: 1.14-106.07] and 8.80 [1.14-68.11], respectively).

CONCLUSIONS

The present study suggests that ACh provocation testing is safe for patients with MI, validating its expanded use in clinical settings. ST-segment elevation may serve as a prognostic marker for stratifying risk and optimizing management in patients evaluated for coronary artery spasm.

Risk of Myocardial Infarction in Patients With Aortic Stenosis: Insights From the VALVENOR Registry

BACKGROUND

A close interaction between aortic stenosis (AS) and coronary artery disease has been suggested. However, the risk of myocardial infarction (MI) in patients with AS is poorly described outside the context of aortic valve replacement.

OBJECTIVES

The purpose of this study was to assess the incidence, correlates, and impact on outcomes of MI occurrence in patients with different degrees of AS severity.

METHODS

Between 2016 and 2017, the multicenter prospective VALVENOR registry enrolled 2,830 outpatients with native valvular AS (peak aortic jet velocity [Vmax] ≥2.5 m/s). AS was defined as mild (Vmax 2.5-2.9), moderate (Vmax 3-3.9), or severe (Vmax ≥4). MI was defined using the fourth universal definition (type 2 MI were not considered).

RESULTS

The mean age was 76.0 years, 54% of the patients were men, and 18.3% had experienced prior coronary event (PCE). At 5 years, the cumulative incidence of MI (death as competing event) was only 2.5% (n = 72, one-third of ST-segment elevation MI). PCE and angina symptoms were associated with an increased risk, whereas female gender was associated with a decreased risk. By contrast, AS severity was not associated with the risk of MI. Subsequent mortality was high and at 52.8% during follow-up (median 648 days after MI occurrence). Incident MI was a powerful predictor of mortality (HR: 2.00, P < 0.001 after adjustment).

CONCLUSIONS

In patients with AS, the risk of MI is relatively low especially in patients without PCE and without angina. No association between the risk of MI and AS severity was observed. Although rare, incident MI is strongly associated with subsequent mortality.

Comparison of long-term prognoses of percutaneous coronary intervention via distal transradial and conventional transradial access for acute coronary syndrome

BACKGROUND

Distal transradial access (dTRA) has recently emerged as a new vascular access alternative for coronary angiography (CAG) and/or percutaneous coronary intervention (PCI). However, published data on long-term mortality and major adverse cardiac events after PCI via dTRA are inconclusive. The aim of this study was to compare the long-term prognoses of PCI via dTRA and conventional transradial access (cTRA) for acute coronary syndrome (ACS) after 1-3 years of follow-up.

METHODS

Patients who were diagnosed with ACS and underwent PCI between January 1, 2020 and December 31, 2021, were retrospectively enrolled. The patients were divided into two groups at a 1:1 ratio, subjected to propensity score matching (PSM), and then followed for 1-3 years after PCI. Cox proportional hazards regression was used to evaluate the relationship between the two access sites and clinical outcomes.

RESULTS

Among the 550 patients in the dTRA and cTRA groups, 11 (4.0%) and 19 (6.9%) died during the observation period, respectively. dTRA and cTRA had similar risks of all-cause mortality [hazard ratio (HR) = 0.688; 95% CI = 0.323-1.463; P = 0.331] and major adverse cardiac events (MACEs, HR = 0.806, 95% CI = 0.515-1.263; P = 0.347) after PCI. The risk of cardiovascular mortality (HR = 0.330, 95% CI = 0.107-1.105; P = 0.053), TLR-MACEs (HR = 0.587, 95% CI = 0.339-1.109; P = 0.058), and unplanned revascularization (HR = 0.860, 95% CI = 0.483-1.529; P = 0.606) were not significantly different between the two groups.

CONCLUSIONS

PCI via dTRA has the same long-term prognoses as PCI via cTRA in ACS patients, and the compression time and bleeding rate are lower than those in patients undergoing PCI via cTRA.

Pantera Lux Drug-Coated Balloon for the Treatment of Coronary Artery Lesions in Routine Practice

Background/Objectives: We sought to confirm the performance and safety of the Pantera Lux paclitaxel-coated balloon (pDCB) when used as per the instructions for use at a single high-volume center. Methods: In this retrospective analysis, 386 consecutive patients were categorized into three groups: the treatment of drug-eluting stent in-stent restenosis (DES-ISR) lesions (n = 191), bare-metal stent in-stent restenosis (BMS-ISR) lesions (n = 127), and de novo lesions (n = 68). The primary endpoint at 12 months was target-lesion revascularization (TLR). Secondary endpoints were device success, target-vessel myocardial infarction (TV-MI), and cardiac death. Results: The baseline characteristics were balanced between the groups, with a median age of 71.3 years, 25% being female, 32% being diabetic. The majority presented with chronic coronary syndrome (82.9%). Type C lesions were more often observed in the DES-IRS group as compared with the BMS-IRS and de novo groups (15.6% vs. 7.9% vs. 7.4%, p < 0.001). Cutting balloons were more often used in the DES-IRS group (41.0% vs. 19.7% vs. 1.5%, p < 0.001). The residual stenosis rate was 7.6% vs. 3.3% vs. 7.3% (p = 0.002). The TLR at 12 months was 8.9% vs. 2.4% vs. 1.5% (p = 0.013). Device success was achieved in 98.8% vs. 98.5% vs. 100% of cases (p = 0.8). TV-MI occurred in 3.2% vs. 0.8% vs. 1.5% (p = 0.5) and cardiac death in 2.6% vs. 0.0% vs. 2.9% (p = 0.13) in DES-IRS vs. BMS-IRS vs. de novo lesions. Conclusions: In this single-center observation, we confirmed the safety and efficacy of the Pantera Lux paclitaxel-coated balloon for the treatment of DES-IRS, BMS-IRS, and de novo lesions with low TLR rates at 12 months.

Independent prognostic significance of myocardial flow reserve over coronary artery calcium, myocardial perfusion, and clinical variables in patients without known coronary artery disease, according to diabetes status

OBJECTIVE

To explore differences in prevalence and prognosis associated with reduced myocardial flow reserve (MFR) in patients without known coronary artery disease (CAD) based on diabetes status.

METHODS

Of 2639 patients without known CAD who underwent rubidium positron emission tomography myocardial perfusion imaging (MPI), 818 patients (31%) had diabetes. Reduced MFR was defined as MFR <2.0. Coronary artery calcium (CAC) score was categorized as 0, 1-99, 100-399, and ≥400. Ischemic total perfusion deficit (TPD) was categorized as <1%, 1-<5%, and ≥5%. Outcome variables were all-cause death (ACD) and non-fatal myocardial infarction (MI).

RESULTS

During the median follow-up of 4.1 years, 574 (21.8%) ACD/MI occurred (204 [25.1%] diabetic patients, 370 [20.3%] nondiabetic patients). In multivariable Cox analysis, reduced MFR was associated with increased ACD/MI in patients with diabetes (per .1 decrease: HR: 1.04, 95% CI: 1.02-1.06, P < .001) and patients without diabetes (per .1 decrease: HR: 1.03, 95% CI: 1.02-1.04, P < .001). No interaction existed between diabetes and MFR for ACD/MI risk regardless of CAC or ischemic burden (all P > .05). Adding MFR to the risk prediction model of clinical, conventional MPI findings, and CAC improved the discrimination for clinical outcomes in both groups (DM: .003, non-DM: <.001, respectively).

CONCLUSION

Reduced MFR was more common in patients with diabetes and an important independent prognostic marker over CAC and clinical variables. The association between MFR and ACD/MI risk did not differ between patients with and without diabetes who had no prior CAD, regardless of CAC and ischemic burden.