2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Effectiveness of smartphone-assisted cardiac rehabilitation: a systematic review and meta-analysis

PURPOSE

To explore the effectiveness of smartphone-assisted home cardiac rehabilitation and whether it can be used as a remote detection method to promote home cardiac rehabilitation.

METHODS

Four databases were searched to collect randomized controlled trials (RCTs) about smartphone-assisted cardiac rehabilitation. The Cochrane risk-of-bias tool was used to assess the methodological quality of the included studies. Two independent investigators performed the literature screening, information extraction, and risk of bias assessment. Any disagreements were resolved by a third investigator. Meta-analysis and systematic review were performed. Sensitivity analysis and subgroup analysis were carried out to explore the sources of heterogeneity.

RESULTS

A total of 14 RCTs involving 1962 patients were included. Meta-analysis showed that compared with conventional cardiac rehabilitation/usual care, smartphone-assisted cardiac rehabilitation significantly improved VO2peak in patients with cardiovascular disease (WMD= 1.32, 95%CI:0.82 to 1.81, p > 0.05) and enhanced their treatment compliance (RR = 1.62, 95%CI:1.21 to 2.17, p > 0.05). There were no significant differences in six-minute walk distance (WMD = 12.88, 95%CI:-0.82 to 26.57, p > 0.05), body mass index (BMI) (WMD=-0.14, 95%CI:-0.34 to 0.06, p > 0.05), life quality, psychological status, and other cardiovascular risks.

CONCLUSION

Smartphone-assisted cardiac rehabilitation showed significant improvement in exercise capacity and treatment compliance in patients with cardiac rehabilitation but did not improve BMI, quality of life, psychological status, or reduce other cardiovascular risks. Smartphone-based cardiac rehabilitation is increasingly used as a remote detection method for cardiac rehabilitation in middle-income countries, which provides new insights into home cardiac rehabilitation.

The management of non-culprit vessel(s) in patients with unstable angina/non-ST elevation myocardial infarction and chronic kidney dysfunction

BACKGROUND AND AIMS

The clinical effects of multivessel interventions in patients with unstable angina/non-ST-segment elevation myocardial infarction (UA/NSTEMI), multivessel disease (MVD) and chronic kidney disease (CKD) remain uncertain. This study aimed to investigate the safety and effectiveness of intervention in non-culprit lession(s) among this cohort.

METHODS

We consecutively included patients diagnosed with UA/NSTEMI, MVD and CKD between January 2008 and December 2018 at our centre. After successful percutaneous coronary intervention (PCI), we compared 48-month overall mortality between those undergoing multivessel PCI (MV-PCI) through a single-procedure or staged-procedure approach and culprit vessel-only PCI (CV-PCI) after 1:1 propensity score matching. We conducted stratified analyses and tests for interaction to investigate the modifying effects of critical covariates. Additionally, we recorded the incidence of contrast-induced nephropathy (CIN) to assess the perioperative safety of the two treatment strategies.

RESULTS

Of the 749 eligible patients, 271 pairs were successfully matched. Those undergoing MV-PCI had reduced all-cause mortality (hazard ratio (HR): 0.67, 95% confidence interval (CI): 0.48-0.67). Subgroup analysis showed that those with advanced CKD (estimated glomerular filtration rate (eGFR) ≤ 30 mL/min/1.73 m2 ) could not benefit from MV-PCI (P = 0.250), and the survival advantage also tended to diminish in diabetes (P interaction < 0.01; HR = 0.95, 95% CI = 0.65-1.45). Although the staged-procedure approach (N = 157) failed to bring additional survival benefits compared to single-procedure MV-PCI (N = 290) (P = 0.460), it showed a tendency to decrease the death risk. CIN risks in MV-PCI and CV-PCI groups were not significantly different (risk ratio = 1.60, 95% CI = 0.94-2.73).

CONCLUSION

Among patients with UA/NSTEMI and non-diabetic CKD and an eGFR > 30 mL/min/1.73 m2 , MV-PCI was associated with a reduced risk of long-term death but did not increase the incidence of CIN during the management of MVD compared to CV-PCI. And staged procedures might be a preferable option over single-procedure MV-PCI.

A risk model for the early diagnosis of acute myocardial infarction in patients with chronic kidney disease

Introduction

Acute myocardial infarction (AMI) remains a critical disease, characterized by a high fatality rate in several countries. In clinical practice, the incidence of AMI is increased in patients with chronic kidney disease (CKD). However, the early diagnosis of AMI in the above group of patients is still poor.

Methods

In the present study, a total of 829 patients with CKD, defined by an estimated glomerular filtration rate (eGFR) of <60 ml/min/1.73 m2 or 60-90 ml/min/1.73 m2 for patients with mildly reduced kidney function, who attended the Sichuan Provincial People's Hospital (SPPH) between January 2018 and November 2022 were enrolled. All patients underwent coronary angiography due to the presence of typical or atypical symptoms of AMI. Patients were divided into the following two groups: The training cohort, including 255 participants with AMI and 242 without AMI; and the testing cohort, including 165 and 167 subjects with and without AMI, respectively. Furthermore, a forward stepwise regression model and a multivariable logistic regression model, named SPPH-AMI-model, were constructed to select significant predictors and assist the diagnosis of AMI in patients with CKD, respectively.

Results

The following factors were evaluated in the model: Smoking status, high sensitivity cardiac troponin I, serum creatinine and uric acid levels, history of percutaneous coronary intervention and electrocardiogram. Additionally, the area under the curve (AUC) of the receiver operating characteristic curve were determined in the risk model in the training set [AUC, 0.78; 95% confidence interval (CI), 0.74-0.82] vs. the testing set (AUC, 0.74; 95% CI, 0.69-0.79) vs. the combined set (AUC, 0.76; 95% CI, 0.73-0.80). Finally, the sensitivity and specificity rates were 71.12 and 71.21%, respectively, the percentage of cases correctly classified was 71.14%, while positive and negative predictive values of 71.63 and 70.70%, respectively, were also recorded.

Discussion

The results of the current study suggested that the SPPH-AMI-model could be currently considered as the only risk scoring system for the early diagnosis of AMI in patients with CKD. This method could help clinicians and emergency physicians to quickly and accurately diagnose AMI in patients with CKD to promote the immediate and effective treatment of these patients.

Clinical outcomes of serum potassium in patients with percutaneous coronary intervention: insights from a large single-center registry

Background

Serum potassium homeostasis plays an important role in myocardial electrical stability, but the impact of altered serum potassium levels on the major adverse cardiovascular and cerebral events (MACCE) in patients with percutaneous coronary intervention (PCI) has not been evaluated.

Aim

To evaluate the association between serum potassium level and the risk of MACCE in PCI patients.

Materials and methods

This retrospective study involved 8,263 in-patients from a single-center registry who were successfully treated with PCI between January 2003 and December 2020. Clinical data were collected for 24 h after admission. Data were analyzed from June 2003 to December 2021. The primary outcome was MACCE, defined as a composite of all-cause death, myocardial infarction, revascularization, stroke, and heart failure-related hospitalization.

Results

The median [interquartile range (IQR)] follow-up for all patients was 4.0 (2.1, 5.8) years, and 1,632 patients (19.7%) were diagnosed with MACCE. High serum potassium levels were associated with a 20% increased risk of MACCE (hazard ratio [HR]: 1.20, 95% confidence interval [CI]: 1.05-1.38, P = 0.008) and 72% increased risk of all-cause death (HR: 1.72, 95% CI: 1.39-2.14, P < 0.001). Multivariate Cox analysis showed that the risk of MACCE was higher in patients at the highest quartile of serum potassium (Q4 vs. Q1: adjusted HR: 1.18, 95% CI: 1.02-1.35, P = 0.026). Moreover, a higher serum potassium level was always associated with a higher risk of all-cause death (Q4 vs. Q1: adjusted HR: 1.50, 95% CI: 1.17-1.91, P = 0.001). A U-shaped relationship between serum potassium levels, MACCE, and all-cause death was derived in patients undergoing PCI. Serum potassium levels, maintained within the range of 3.8-4.0 mmol/L before PCI, exhibited the lowest risk of associated MACCE and all-cause death.

Conclusion

Our results demonstrate that the serum potassium level could be associated with higher risks of MACCE and all-cause death in PCI patients. In particular, serum potassium levels maintained at 3.8-4.0 mmol/L before PCI could lower the risk of MACCE and all-cause death.

Effect of Dan-Lou tablets on coronary heart disease revealed by microarray analysis integrated with molecular mechanism studies

Dan-Lou tablets (DLT) effectively treat coronary heart disease (CHD). However, its pharmacological mechanism in CHD treatment requires further investigation. This study aimed to elucidate the underlying pharmacological mechanisms of DLT in the treatment of CHD through clinical trials, microarray research, bioinformatics analysis, and molecular mechanism research. In this study, DLT improved coagulation function, endothelial injury, and levels of lipids, metalloproteases, adhesion molecules, inflammatory mediators, and homocysteine. The results of molecular biology research demonstrated that DLT can increase the gene and protein expressions of meningioma expressed antigen 5 (MGEA5) and mouse doubleminute 2 (MDM2) and inhibited the gene and protein expressions of signal transcription and transcription activator 5 B (STAT5B), tropomyosin-1 (TPM1), and aromatic hydrocarbon receptor nuclear transpose (ARNT). The results indicate that DLT reduced the extent of vascular endothelial damage in CHD rats by reducing the expressions of STAT5B, TPM1, and MDM2; inhibiting the inflammatory reaction; and increasing the expressions of ARNT and MGEA5.

Prognostic modelling of clinical outcomes after first-time acute coronary syndrome in New Zealand

OBJECTIVE

The Multi-Ethnic New Zealand Study of Acute Coronary Syndromes (MENZACS) was established to investigate the drivers of secondary events after first-time acute coronary syndrome (ACS), including addressing inequitable outcomes by ethnicity. Herein, the first clinical outcomes and prognostic modelling approach are reported.

METHODS

First, in 28 176 New Zealanders with first-time ACS from a national registry, a clinical summary score for predicting 1-year death/cardiovascular readmission was created using Cox regression of 20 clinical variables. This score was then calculated in the 2015 participant MENZACS study to represent clinical risk. In MENZACS, Cox regression was used to assess N-terminal pro-B-type natriuretic peptide (NT-proBNP) as a prognostic marker for death/cardiovascular readmission in four models, adjusting for (1) age and sex; (2) age, sex, ethnicity; (3) clinical summary score; (4) clinical summary score and ethnicity.

RESULTS

Of the 2015 MENZACS participants (mean age 61 years, 79% male, 73% European, 14% Māori, 5% Pacific people), 2003 were alive at discharge. Of the 2003, 416 (20.8%) experienced all-cause death/cardiovascular readmission over a median of 3.5 years. In a simple model, age, male sex, Māori ethnicity and NT-proBNP levels were significant predictors of outcome. After adjustment for the clinical summary score, which includes age and sex, NT-proBNP and ethnicity were no longer statistically significant: log₂(NT-proBNP) hazard ratio (HR) 1.03, 95% confidence interval (95% CI) 0.98 to 1.08, p=0.305; Māori ethnicity HR 1.26, 95% CI 0.97 to 1.62, p=0.084.

CONCLUSIONS

In 2015 patients with first-time ACS, recurrent events were common (20.8%). Increasing NT-proBNP levels and Māori ethnicity were predictors of death/cardiovascular readmission, but not after adjustment for the 20 clinical risk factors represented by the clinical summary score.

TRIAL REGISTRATION NUMBER

ACTRN12615000676516.

Effectiveness and safety of Tiaogan formula in the treatment of coronary heart disease: A protocol for systematic review and meta-analysis

BACKGROUND

The morbidity and mortality of coronary heart disease (CHD) has remained high, which greatly increases people's economic burden. Several studies have showed that Tiaogan formula (TGF), as a kind of Chinese herbal medicine, was of benefit to relieving angina pectoris symptoms and improving the quality of life for CHD patients. However, the intensity of evidence has been poor, limiting the further clinical application of TGF to CHD. This systematic review and meta-analysis will assess the effectiveness and safety of studies of TGF in CHD patients.

METHODS

A systematic search for literature up to December 2022 will be conducted in following public electronic databases: PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure, Chinese Scientific Journals Database Database, and Wanfang Database. Inclusion criteria are randomized controlled trials of Tiaogan formula in the treatment of coronary heart disease. The primary outcome measures will be mortality, acute cardiovascular events, total efficacy rate, and improvement of angina symptoms. The secondary outcome measures will be electrocardiogram, levels of blood lipid, and adverse events. RevMan 5.4 software Cochrane Collaboration (London, United Kingdom) will be applied for data synthesis, sensitivity analysis, subgroup analysis, and risk of bias assessment. A funnel plot will be developed to evaluate reporting bias and Egger tests will be used to assess funnel plot symmetries. We will use the Grading of Recommendations Assessment, Development and Evaluation system to assess the quality of evidence.

RESULTS

This study will provide a systematic review of Tiaogan formula in the treatment of CHD.

CONCLUSION

This study will provide a high-quality synthesis of the effects and safety of Tiaogan formula in the treatment of CHD patients.

Elevated Levels of Serum Alkaline Phosphatase are Associated with Increased Risk of Cardiovascular Disease: A Prospective Cohort Study

AIM

We aimed to investigate the associations of serum alkaline phosphatase (ALP) levels with incident cardiovascular disease (CVD), coronary heart disease (CHD), and stroke, as well as their subtypes, among men and women in a prospective cohort study.

METHODS

A total of 11,408 men and 14,981 women were included to evaluate the associations between ALP levels and incident CVD. Participants were divided into four groups according to the quartiles of serum ALP levels in men and women separately. Cox proportional hazard models were used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

During an average follow-up of 7.3 years, 7,015 incident CVDs (5,561 CHDs and 1,454 strokes) were documented. After adjustments for age, body mass index, smoking status, drinking status, diabetes, hyperlipidemia, hypertension, physical activity, aspirin usage, anticoagulants usage, menopausal status (women only), family history of CVD, estimated glomerular filtration rate, white blood cell counts, and admission batch and comparing the lowest quartile of ALP, the adjusted HRs (95% CIs) of participants in the highest quartile were 1.22 (1.11-1.34) for CVD, 1.14 (1.02-1.28) for CHD, 1.43 (1.18-1.73) for stroke, 1.31 (1.09-1.57) for acute coronary syndrome (ACS), 1.37 (1.11-1.70) for ischemic stroke, and 1.75 (1.10-2.79) for hemorrhagic stroke in men and 1.12 (1.01-1.23) for CVD, 1.10 (0.99-1.23) for CHD, 1.18 (0.92-1.51) for stroke, 1.23 (1.03-1.47) for ACS, 1.10 (0.83-1.45) for ischemic stroke, and 1.54 (0.90-2.65) for hemorrhagic stroke in women. The ALP-CVD associations remained significant even within the normal ranges of ALP levels (40-150 U/L). Moreover, linear dose-response relationships were found between ALP levels and incident CVD.

CONCLUSIONS

Higher ALP levels, even within the normal range, were significantly associated with increased risks of CVD, in a dose-dependent manner. These findings suggested that regular monitoring of ALP levels may help in improving the early identification of the population at higher CVD risk.

Early ACEI/ARB use and in-hospital outcomes of acute myocardial infarction patients with systolic blood pressure <100 mmHg and undergoing percutaneous coronary intervention: Findings from the CCC-ACS project

Background

Few studies have evaluated whether acute myocardial infarction (AMI) patients with relatively low blood pressure benefit from early ACEI/ARB use in the era of percutaneous coronary intervention (PCI).

Objectives

This study evaluated the associations of ACEI/ARB use within 24 h of admission with in-hospital outcomes among AMI patients with SBP < 100 mmHg and undergoing PCI.

Methods

This study was based on the Improving Care for Cardiovascular Disease in China-ACS project, a collaborative registry and quality improvement project of the American Heart Association and the Chinese Society of Cardiology. Between November 2014 and December 2019, a total of 94,623 patients with AMI were enrolled. Of them, 4,478 AMI patients with SBP < 100 mmHg and undergoing PCI but without clinically diagnosed cardiogenic shock at admission were included. Multivariable logistic regression and propensity score-matching analysis were used to evaluate the association between early ACEI/ARB use and in-hospital major adverse cardiac events (MACEs), a combination of all-cause death, cardiogenic shock, and cardiac arrest.

Results

Of AMI patients, 24.41% (n = 1,093) were prescribed ACEIs/ARBs within 24 h of admission. Patients with early ACEI/ARB use had a significantly lower rate of MACEs than those without ACEI/ARB use (1.67% vs. 3.66%, p = 0.001). In the logistic regression analysis, early ACEI/ARB use was associated with a 45% lower risk of MACEs (odds ratio: 0.55, 95% CI: 0.33-0.93; p = 0.027). Further propensity score-matching analysis still showed that patients with early ACEI/ARB use had a lower rate of MACEs (1.96% vs. 3.93%, p = 0.009).

Conclusion

This study found that among AMI patients with an admission SBP < 100 mmHg undergoing PCI, early ACEI/ARB use was associated with better in-hospital outcomes. Additional studies of the early use of ACEIs/ARBs in AMI patients with relatively low blood pressure are warranted.

Associations of Baseline and Changes in Leukocyte Counts with Incident Cardiovascular Events: The Dongfeng-Tongji Cohort Study

AIM

The aim of the present study was to investigate the associations of baseline and longitudinal changes in leukocyte counts with incident cardiovascular disease (CVD).

METHODS

We conducted a prospective study to investigate the associations of baseline and 5-year changes in leukocyte counts with incident CVD and its subtypes in middle-aged and elderly Chinese. We estimated the hazard ratios (HRs) and 95% confidence intervals (CIs) for CVD using the Cox proportional-hazards models.

RESULTS

In the analyses of baseline total leukocyte count of 26,655 participants, compared with the lowest quartile (＜4.71×109/L), participants in the fourth quartile (＞6.70×109/L) had 11% higher risk for CVD. Consistent with total leukocyte count, neutrophil count also exhibited a significant positive association with the risk of CVD. In the analyses of 5-year changes in total leukocyte count of 11,594 participants, the changes in leukocyte count were categorized into three groups, i.e., the decreased group (＜25%), stable group (25%-75%), and increased group (＞75%). Compared with participants in the stable group (-1.18 to 0.44×109/L), participants in the increased group (＞0.44×109/L) had 14% higher risk for CVD. We also observed significant positive associations of the changes in neutrophil and monocyte counts with the risk of CVD. Furthermore, the total leukocyte count in the second or third tertile at the first follow-up with a 5-year increase was related to higher CVD risk.

CONCLUSION

High baseline total leukocyte count and a 5-year increase in total leukocyte count were related to higher CVD risk.

The Prevalence of Metabolic Dysfunction-Associated Fatty Liver Disease and Its Association with Physical Function and Prognosis in Patients with Acute Coronary Syndrome

It is believed that patients with acute coronary syndrome (ACS) are at an increased risk of nonalcoholic fatty liver disease (NAFLD), which can lead to sarcopenia and physical dysfunction. However, the relationship between metabolic dysfunction-associated fatty liver disease (MAFLD) and physical dysfunction and prognosis remains unclear. We investigated the prevalence of MAFLD in patients with ACS to assess the relationship between MAFLD and muscle strength, walking speed, and 6-min walking distance (6 MWD). We reviewed patients with ACS who were assessed for hepatic steatosis using the fatty liver index, and the results were further assessed to determine the presence of MAFLD. Among 479 enrolled hospitalized patients, MAFLD was identified in 234 (48.9%) patients. Multiple regression analysis revealed that MAFLD was independently associated with lower leg strength, gait speed, and 6 MWD (leg strength, p = 0.020; gait speed, p = 0.003 and 6 MWD, p = 0.011). Furthermore, in multivariate Poisson regression models after adjustment for clinical confounding factors, combined MAFLD and reduced physical functions were significantly associated with a higher incidence of clinical events. MAFLD is common in hospitalized patients with ACS and is associated with impaired physical function. Also, the coexistence of MAFLD and lower physical function predict the incidence of clinical events in patients with ACS.

Sarcopenia and coronary heart disease synergistically increase the risk of new onset depressive symptoms in older adults

Background

Coronary heart disease (CHD), sarcopenia and depression are common disorders that markedly impair quality of life and impose a huge financial burden on society. They are also frequently comorbid, exacerbating condition and worsening prognosis. This study aimed to investigate the additive effects of CHD and sarcopenia on the risk of new onset depressive symptoms in older adults.

Methods

The prospective cohort study comprised 897 Chinese community-dwelling participants who were aged 60 years and older (386 men; mean age 66.9 ± 5.9 years) without depressive symptoms at baseline, recruited from Chadian of Tianjin, China. Sarcopenia was defined according to the Asian Working Group for Sarcopenia (AWGS) criteria. CHD was identified via medical records or new diagnosed by at least two physicians. Depressive symptoms were assessed using the Geriatric Depression Scale (GDS) ≥11. Longitudinal data on new onset depressive symptoms were collected up to 12 months after baseline.

Results

We found that 103 (11.5%) of the 897 participants without depressive symptoms at baseline had developed depressive symptoms. Participants were classified into mutually exclusive groups based on sarcopenia status and CHD: normal, CHD alone, sarcopenia alone, and co-occurring groups. A logistic regression showed that the CHD alone [odd ratios (OR) = 1.78, 95% confidence interval (CI) = 1.05–3.02], sarcopenia alone (OR = 2.79, 95% CI = 1.26–6.22), and co-occurring (OR = 7.19, 95% CI = 2.75–18.81) had higher risk of depressive symptoms than the normal group after adjusting for the covariates.

Conclusions

CHD and sarcopenia synergistically increase the risk of new onset depressive symptoms in older adults. Thus, older adults may require early detection, and appropriate interventions should be implemented.

Glycosylated apolipoprotein J in cardiac ischaemia: molecular processing and circulating levels in patients with acute ischaemic events

AIM

Using proteomics, we previously found that serum levels of glycosylated (Glyc) forms of apolipoprotein J (ApoJ), a cytoprotective and anti-oxidant protein, decrease in the early phase of acute myocardial infarction (AMI). We aimed to investigate: (i) ApoJ-Glyc intracellular distribution and secretion during ischaemia; (ii) the early changes in circulating ApoJ-Glyc during AMI; and (iii) associations between ApoJ-Glyc and residual ischaemic risk post-AMI.

METHODS AND RESULTS

Glycosylated apolipoprotein J was investigated in: (i) cells from different organ/tissue origin; (ii) a pig model of AMI; (iii) de novo AMI patients (n = 38) at admission within the first 6 h of chest pain onset and without troponin T elevation at presentation (early AMI); (iv) ST-elevation myocardial infarction patients (n = 212) who were followed up for 6 months; and (v) a control group without any overt cardiovascular disease (n = 144). Inducing simulated ischaemia in isolated cardiac cells resulted in an increased intracellular accumulation of non-glycosylated ApoJ forms. A significant decrease in ApoJ-Glyc circulating levels was seen 15 min after ischaemia onset in pigs. Glycosylated apolipoprotein J levels showed a 45% decrease in early AMI patients compared with non-ischaemic patients (P < 0.0001), discriminating the presence of the ischaemic event (area under the curve: 0.934; P < 0.0001). ST-elevation myocardial infarction patients with lower ApoJ-Glyc levels at admission showed a higher rate of recurrent ischaemic events and mortality after 6-month follow-up (P = 0.008).

CONCLUSIONS

These results indicate that ischaemia induces an intracellular accumulation of non-glycosylated ApoJ and a reduction in ApoJ-Glyc secretion. Glycosylated apolipoprotein J circulating levels are reduced very early after ischaemia onset. Its continuous decrease indicates a worsening in the evolution of the cardiac event, likely identifying patients with sustained ischaemia after AMI.

Vitamin D and Its Metabolites Deficiency in Acute Coronary Syndrome Patients Undergoing Coronary Angiography: A Case-Control Study

Background

Vitamin D deficiency is considered an emerging health problem that affects at least one billion patients worldwide. Calcitriol 1,25(OH)₂D₃ has several systemic effects, including anti-inflammatory, anti-thrombotic and anti-atherosclerotic impacts that explain its cardioprotective effects. The precise association between vitamin D and its metabolites and the value of supplements in acute coronary syndrome (ACS) is still controversial. This study aims to search the association between vitamin D₂, D₃, and metabolites and ACS in patients undergoing coronary angiography.

Materials and Methods

This was a case–control study on 73 consecutive adult patients with ACS undergoing coronary angiography compared to 50 controls without coronary artery disease and matched for age and sex from June 2019 till July 2019. Echocardiography and coronary angiography were done for all cases. Plasma vitamin D and its metabolites were measured at admission for all participants along with chemistry profiles.

Results

Vitamin D and its metabolites were statistically significantly lower in ACS patients than the controls. Multivariate regression analysis revealed that low levels of 25-hydroxyvitamin D (25(OH)D) and 1,25-dihydroxyvitamin D (1,25(OH)₂D) significantly predicted ACS occurrence; the other significant predictors were high systolic blood pressure (BP), high total cholesterol, and low high-density lipoprotein-cholesterol. Interestingly, vitamin D₂ and D₃ did not significantly predict ACS (p>0.05). We did not find a statistically significant association between the number of affected coronary vessels and vitamin D metabolites. Moreover, there was no statistically significant correlation between vitamin D and its metabolites and left ventricular ejection fraction measured by echocardiography.

Conclusion

There was a strong association between vitamin D and all its metabolites with ACS. Significantly, low 25(OH)D and 1,25(OH)₂D predicted ACS, but vitamin D₂ and D₃ did not. Large randomized controlled trials are needed to verify the beneficial values of vitamin D supplementation in ACS patients.

High Sensitivity C-reactive Protein in Patients with Coronary Artery in-stent Restenosis: A Case-control Study

Background:

Inflammation plays a pivotal role in the pathogenesis of In-Stent Restenosis (ISR). High sensitivity C-reactive protein (hsCRP) is positively associated with major cardiovascular events.

Aim:

We aimed to investigate the hsCRP inflammatory response to Percutaneous Coronary Intervention (PCI) in Coronary Artery Disease (CAD) patients with coronary ISR vs. patients without ISR.

Methods:

This case-control study included 80 CAD patients previously treated with drug-eluting stent (DES) implantation. Patients had Coronary Angiography (CAG) because of chest pain or equivalent symptoms and were subdivided into 2 groups. Group A (n=40) included CAD patients with ISR. Group B (n=40) included age and gender-matched controls with CAD but without ISR. Serum hsCRP levels were obtained before PCI (baseline) and 8, 16, 24 h post-PCI.

Results:

At baseline (before intervention/CAG), the hsCRP level was increased in the ISR group compared with the No-ISR group (p=0.007). There were 36 (90%) patients in the ISR group who had a high hsCRP (>3 mg/L) compared with 25 (62.5%) patients in the No-ISR group. Also, there was a significant relationship between high hsCRP and the ISR. Patients with ISR had higher frequencies and percentages of elevated CRP than the no-ISR control group. This difference was maintained for all measurements, baseline, after 8, 16, and 24 h (p<0.05). Repeated measures analysis of variance (ANOVA) in the ISR group revealed that mean hsCRP differed significantly between serial measurements (p<0.001). In contrast, in the control group, the mean hsCRP did not differ significantly between the serial measurements (p=0.65).

Most of our patients (n=66, 82.5%) had 1-vessel CAD disease, and the left anterior descending (LAD) coronary artery was significantly affected in 46 patients (57.5%). Management of restenosis was accomplished mainly by stenting by DES in 29 patients (72.5%).

Conclusion:

Patients with ISR had substantially higher pre- and post-PCI hsCRP levels than the no-ISR controls. This difference was maintained up to 24h post-PCI. Conversely, the mean hsCRP did not significantly differ at the follow-up points for the controls without ISR.

Effective treatment of electrical storm by a wearable cardioverter defibrillator in a patient with severely impaired left ventricular function after myocardial infarction: a case report

Background

The implantation of cardioverter defibrillators (ICDs) is an established therapy in the prevention of sudden cardiac death in patients with systolic dysfunction after myocardial infarction. To avoid immediate implantation of an ICD, wearable cardioverter defibrillator vests (WCD) can be used to protect patients against malignant rhythm disorders, while at the same time drug-based heart failure therapy has to be initiated. This drug therapy can improve left ventricular ejection fraction and primary prophylactic cardioverter defibrillator implantation may not be necessary. However, the recent Vest Prevention of Early Sudden Death Trial (VEST) questioned the regular use of the WCD in this setting.

Case presentation

A 47-year-old Caucasian man with severely impaired left ventricular function early after myocardial infarction was prescribed a WCD as primary prophylaxis to prevent sudden cardiac death. Seven days after the patient was supplied with a WCD, the patient suffered from an electrical storm with recurrent ventricular tachycardia (VT), which was successfully terminated 17 times by the WCD. On coronary angiography, the formerly infarct-related right coronary artery had TIMI (Thrombolysis in Myocardial Ischemia Trial) III flow, and a remaining stenosis in the left anterior descending artery (LAD) was stented, which did not stop recurrent VT. In the electrophysiology (EP) study, a focus was mapped in the left inferior ventricle, which was ablated. This stopped the VT. A second radio-frequency (RF) ablation in the same area was necessary after 14 days. Finally, a permanent cardioverter defibrillator was implanted.

Conclusion

We report the case of a patient who survived recurrent episodes of VT early after myocardial infarction by effective defibrillation with a WCD. The WCD is a useful device to bridge time until a final decision for implantation of a defibrillator.

Effects of hydrogen as adjuvant treatment for unstable angina

Oxidative stress and inflammation are closely related to atherosclerotic cardiovascular disease. It is established that hydrogen has significant protective effects on many diseases as a potential antioxidative and anti-inflammatory agent. The purpose of this study is to evaluate the effect of hydrogen on unstable angina in vitro and in vivo. An atherosclerosis model in vitro was constructed by ox-LDL-induced injury of human umbilical vein endothelial cells and in vitro testing indicated hydrogen inhibited ox-LDL-induced oxidative stress and inflammatory response by down-regulating LOX-1/NF-kB signaling pathway. Subsequently, the attenuating effect of hydrogen-rich water intake on unstable angina was further confirmed in clinic. Forty hospitalized subjects with unstable angina were enrolled and consumed either 1000-1200 mL/d hydrogen-rich water or the same amount of placebo pure water in addition to conventional drugs for three months. Clinical analysis showed hydrogen-rich water intake relieved angina symptoms in unstable angina patients. Serum analysis showed that hydrogen-rich water addition resulted in more effective reductions of total-cholesterol, low-density lipoprotein-cholesterol, and apolipoprotein B levels compared with conventional treatment. These results support that hydrogen as adjuvant treatment has a beneficial effect on unstable angina.

Increased Circulating Malondialdehyde-Modified Low-Density Lipoprotein Level Is Associated with High-Risk Plaque in Coronary Computed Tomography Angiography in Patients Receiving Statin Therapy

Objective: To evaluate the association of serum malondialdehyde low-density lipoprotein (MDA-LDL), an oxidatively modified LDL, with the prevalence of high-risk plaques (HRP) determined with coronary computed tomography angiography (CTA) in statin-treated patients. Methods: This study was a single-center retrospective cohort comprising 268 patients (mean age 67 years, 58% men) with statin therapy and who underwent coronary CTA for suspected stable coronary artery disease. Patients were classified into two groups according to median MDA-LDL level or median LDL-C level. Coronary CTA-verified HRP was defined when two or more characteristics, including positive remodeling, low-density plaques, and spotty calcification, were present. Results: Patients with HRP had higher MDA-LDL (p = 0.011), but not LDL-C (p = 0.867) than those without HRP. High MDA-LDL was independently associated with HRP (odds ratio 1.883, 95% confidential interval 1.082–3.279) after adjustment for traditional risk factors. Regarding incremental value of MDA-LDL for predicting CTA-verified HRP, addition of serum MDA-LDL levels to the baseline model significantly increased global chi-square score from 26.1 to 32.8 (p = 0.010). Conclusions: A high serum MDA-LDL level is an independent predictor of CTA-verified HRP, which can lead to cardiovascular events in statin-treated patients.

Evaluation of the 0 h/1 h high-sensitivity cardiac troponin T algorithm in diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI) in Han population

OBJECTIVES

A rapid 0 h/1 h algorithm using high-sensitivity cardiac troponin T (hs-cTnT) for rule-out and rule-in of non-ST-segment elevation myocardial infarction (NSTEMI) is recommended by the European Society of Cardiology. We aim to prospectively evaluate the diagnostic performance of the algorithm in Chinese Han patients with suspected NSTEMI.

METHODS

In this prospective diagnostic cohort study, 577 patients presenting to the emergency department with suspected NSTEMI and recent (<12 h) onset of symptoms were enrolled. The levels of serum hs-cTnT were measured on admission, 1 h later and 4-14 h later. All patients underwent the initial clinical assessment and were triaged into three groups (rule-out, rule-in and observe) according to the 0 h/1 h algorithm. The major cardiovascular events (MACE) were evaluated at the 7-day and 30-day follow-ups.

RESULTS

Among 577 enrolled patients, NSTEMI was the final diagnosis for 106 (18.4%) patients. Based on the hs-cTnT 0 h/1 h algorithm, 148 patients (25.6%) were classified as rule-out, 278 patients (48.2%) as rule-in and 151 patients (26.2%) were assigned to the observe group. The rule-out approach resulted in a sensitivity of 100% and negative predictive value of 100%. The rule-in approach resulted in a specificity of 62.9% [95% CI (58.5-67.2%)] and positive predictive value of 37.1% [95%CI (31.3-42.8%)]. No MACE was observed in the rule-out group within 30-day follow-up.

CONCLUSIONS

The hs-cTnT 0 h/1 h algorithm is a safe tool for early rule-out of NSTEMI, while probably not an effective strategy for accurate rule-in of NSTEMI in Chinese Han population.

Gender Differences in the Atherosclerosis Profile by Coronary CTA in Coronary Artery Calcium Score Zero Patients

Background: The coronary artery calcium score (CACS) is a powerful tool for cardiovascular risk stratification. Coronary computed tomography angiography (CTA) allows for a more distinct analysis of atherosclerosis. The aim of the study was to assess gender differences in the atherosclerosis profile of CTA in patients with a CACS of zero. Methods: A total of 1451 low- to intermediate-risk patients (53 ± 11 years; 51% females) with CACS <1.0 Agatston units (AU) who underwent CTA and CACS were included. Males and females were 1:1 propensity score-matched. CTA was evaluated for stenosis severity (Coronary Artery Disease - Reporting and Data System (CAD-RADS) 0-5: minimal <25%, mild 25-49%, moderate 50-69%, severe ≥70%), mixed-plaque burden (G-score), and high-risk plaque (HRP) criteria (low-attenuation plaque, spotty calcification, napkin-ring sign, and positive remodeling). All-cause mortality, cardiovascular mortality, and major cardiovascular events (MACEs) were collected. Results: Among the patients, 88.8% had a CACS of 0 and 11.2% had an ultralow CACS of 0.1-0.9 AU. More males than females (32.1% vs. 20.3%; p < 0.001) with a CACS of 0 had atherosclerosis, while, among those with an ultralow CACS, there was no difference (88% vs. 87.1%). Nonobstructive CAD (25.9% vs. 16.2%; p < 0.001), total plaque burden (2.2 vs. 1.4; p < 0.001), and HRP were found more often in males (p < 0.001). After a follow-up of mean 6.6 ± 4.2 years, all-cause mortality was higher in females (3.5% vs. 1.8%, p = 0.023). Cardiovascular mortality and MACEs were low (0.2% vs. 0%; p = 0.947 and 0.3% vs. 0.6%; p = 0.790) for males vs. females, respectively. Females were more often symptomatic for chest pain (70% vs. 61.6%; p = 0.004). (4) Conclusions: In patients with a CACS of 0, males had a higher prevalence of atherosclerosis, a higher noncalcified plaque burden, and more HRP criteria. Nonetheless, females had a worse long-term outcome and were more frequently symptomatic.

The new classification method in ACEF score is more useful in patients with acute coronary syndrome without ST segment elevation

Goal In this study, it was investigated whether the age, creatinine, and ejection fraction (ACEF) score [age (years) / ejection fraction (%) +1 (if creatinine &gt;2 mg / dL)] could predict in-hospital mortality in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) and its relationship with the Global Record of Acute Coronary Events (GRACE) risk score were investigated.Material and methods The study enrolled 658 NSTE-ACS patients from January 2016 to August 2020. The patients were divided into two groups according to the ACEF score with an optimum cut-off value of 1.283 who were divided into two groups according to the ACEF score: low ACEF (≤1.283, n:382) and high ACEF (&gt;1.283, n: 276). The primary outcome of the study was in-hospital all-cause mortality. The primary outcome of the study was in-hospital all-cause mortality. Statistically accuracy was defined with area under the curve by receiver-operating characteristic curve analysis.Results In total, 13 (4.71 %) patients had in-hospital mortality. The ACEF score was significantly higher in the group with higher mortality than in the group with low mortality (2.1±0.53 vs. 1.34±0.56 p=0.001). The ACEF score was positively correlated with GRACE risk score (r=0.188 p&lt;0.0001). In ROC curve analysis, the AUC of the ACEF score for predicting in-hospital mortality was 0.849 (95 % CI, 0.820 to 0.876; p&lt;0.0001); sensitivity, 92.3 %; specificity, 59.2 %, and the optimum cut-off value was &gt;1.283.Conclusion The ACEF score presented excellent discrimination in predicting in-hospital mortality. We obtained an easier and more useful result by dividing the ACEF score into two groups instead of three in NSTE-ACS patients. As a simple, useful, and easily applicable risk stratification in the evaluation of an emergency event such as the ACEF score, it can significantly contribute to the identification of patients at high risk.

Diagnostic value of copeptin combined with hypersensitive cardiac troponin T detection in early acute myocardial infarction: A protocol of randomized double-blind diagnostic trial

BACKGROUND

The sensitivity and specificity of the routine detection of acute myocardial infarction (AMI) in early diagnosis are not high, which can not meet the clinical needs. Copeptin combined with hypersensitive cardiac troponin T (hs-cTnT) is a new detection scheme, and its value in the early diagnosis of acute myocardial infarction is still unclear. Accordingly, the aim of this study is to evaluate the diagnostic value of copeptin combined with hypersensitive troponin T detection in early acute myocardial infarction.

METHODS

This is a prospective, randomized; double-blind diagnostic trial to investigate the diagnostic value of copeptin combined with hypersensitive troponin T detection in early acute myocardial infarction. Approved by the clinical research ethics of our hospital. Patients were randomly divided into one of 2 test protocols: (A) copeptin combined with hs-cTnT group and (B) cardiac troponin I (cTnI) group. Patients, doctors, nurses, inspectors, and data-gathering assistants were blinded to group allocation. We will focus on the sensitivity comparison of the 2 detection methods at different time periods and the sensitivity and specificity comparison of the two detection methods. Data were analyzed using the statistical software package SPSS version 25.0 (Chicago, IL).

DISCUSSION

The purpose of this study is to evaluate the diagnostic value of copeptin combined with hypersensitive cardiac troponin T detection in early acute myocardial infarction. The results of this study will establish clinical evidence for the detection of high sensitivity cardiac troponin T in the early diagnosis of acute myocardial infarction.

ETHICS AND DISSEMINATION

Private information from individuals will not be published. This systematic review also does not involve endangering participant rights. Ethical approval was not required. The results may be published in a peer-reviewed journal or disseminated at relevant conferences.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/6TE5Z.

A digital health intervention for cardiovascular disease management in primary care (CONNECT) randomized controlled trial

Digital health applications (apps) have the potential to improve health behaviors and outcomes. We aimed to examine the effectiveness of a consumer web-based app linked to primary care electronic health records (EHRs). CONNECT was a multicenter randomized controlled trial involving patients with or at risk of cardiovascular disease (CVD) recruited from primary care (Clinical Trial registration ACTRN12613000715774). Intervention participants received an interactive app which was pre-populated and refreshed with EHR risk factor data, diagnoses and, medications. Interactive risk calculators, motivational messages and lifestyle goal tracking were also included. Control group received usual health care. Primary outcome was adherence to guideline-recommended medications (≥80% of days covered for blood pressure (BP) and statin medications). Secondary outcomes included attainment of risk factor targets and eHealth literacy. In total, 934 patients were recruited; mean age 67.6 (±8.1) years. At 12 months, the proportion with >80% days covered with recommended medicines was low overall and there was no difference between the groups (32.8% vs. 29.9%; relative risk [RR] 1.07 [95% CI, 0.88-1.20] p = 0.49). There was borderline improvement in the proportion meeting BP and LDL targets in intervention vs. control (17.1% vs. 12.1% RR 1.40 [95% CI, 0.97-2.03] p = 0.07). The intervention was associated with increased attainment of physical activity targets (87.0% intervention vs. 79.7% control, p = 0.02) and e-health literacy scores (72.6% intervention vs. 64.0% control, p = 0.02). In conclusion, a consumer app integrated with primary health care EHRs was not effective in increasing medication adherence. Borderline improvements in risk factors and modest behavior changes were observed.

Effect of a Quality of Care Improvement Initiative in Patients With Acute Coronary Syndrome in Resource-Constrained Hospitals in China: A Randomized Clinical Trial

Importance

Prior observational studies suggest that quality of care improvement (QCI) initiatives can improve the clinical outcomes of acute coronary syndrome (ACS). To our knowledge, this has never been demonstrated in a well-powered randomized clinical trial.

Objective

To determine whether a clinical pathway-based, multifaceted QCI intervention could improve clinical outcomes among patients with ACS in resource-constrained hospitals in China.

Design, Setting, Participants

This large, stepped-wedge cluster randomized clinical trial was conducted in nonpercutaneous coronary intervention hospitals across China and included all patients older than 18 years and with a final diagnosis of ACS who were recruited consecutively between October 2011 and December 2014. We excluded patients who died before or within 10 minutes of hospital arrival. We recruited 5768 and 0 eligible patients for the control and intervention groups, respectively, in step 1, 4326 and 1365 in step 2, 3278 and 3059 in step 3, 1419 and 4468 in step 4, and 0 and 5645 in step 5.

Interventions

The intervention included establishing a QCI team, training clinical staff, implementing ACS clinical pathways, sequential site performance assessment and feedback, online technical support, and patient education. The usual care was the control that was compared.

Main Outcomes and Measures

The primary outcome was the incidence of in-hospital major adverse cardiovascular events (MACE), comprising all-cause mortality, reinfarction/myocardial infarction, and nonfatal stroke. Secondary outcomes included 16 key performance indicators (KPIs) and the composite score developed from these KPIs.

Results

Of 29 346 patients (17 639 men [61%]; mean [SD] age for control, 64.1 [11.6] years; mean [SD] age for intervention, 63.9 [11.7] years) who were recruited from 101 hospitals, 14 809 (50.5%) were in the control period and 14 537 (49.5%) were in the intervention period. There was no significant difference in the incidence of in-hospital MACE between the intervention and control periods after adjusting for cluster and time effects (3.9% vs 4.4%; odds ratio, 0.93; 95% CI, 0.75-1.15; P = .52). The intervention showed a significant improvement in the composite KPI score (mean [SD], 0.69 [0.22] vs 0.61 [0.23]; P < .01) and in 7 individual KPIs, including the early use of antiplatelet therapy and the use of appropriate secondary prevention medicines at discharge. No unexpected adverse events were reported.

Conclusions and Relevance

Among resource-constrained Chinese hospitals, introducing a multifaceted QCI intervention had no significant effect on in-hospital MACE, although it improved a few of the care process indicators of evidence-based ACS management.

Trial Registration

ClinicalTrials.gov identifier: NCT01398228.

Patient-Reported Quality of Hospital Discharge Transitions: Results from the SILVER-AMI Study

BACKGROUND

Transitions from hospital to home in older patients are a high-risk period for adverse outcomes in a population that may have more challenges navigating the healthcare system. There is little information about the association of patient-reported quality of hospital discharge processes with clinical outcomes.

OBJECTIVES

We evaluated whether patient-reported quality of hospital discharge processes was associated with emergency department utilization and rehospitalization within 30 days of discharge after hospitalization for acute myocardial infarction (AMI) in older adults.

DESIGN

Multi-center, prospective cohort study.

PATIENTS

The ComprehenSIVe Evaluation of Risk Factors in Older Patients with Acute Myocardial Infarction (SILVER-AMI) study was a longitudinal study of 3006 adults age 75 and older hospitalized with AMI recruited from 94 academic and community hospitals from across the USA.

INTERVENTION

N/A MAIN MEASURES: Patients answered a subset of questions from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Readmissions and emergency department utilization within 30 days of discharge were ascertained through medical record review.

KEY RESULTS

A total of 2132 patients were included in the study. Patients' median age was 81 years and the response rate to the survey of discharge quality was 87%. Patients who reported being asked about having the help they needed at home were significantly less likely to have emergency room utilization within 30 days of discharge in both the unadjusted (0.65, 95% CI 0.43-0.99) and adjusted (0.65, 95% CI 0.42-0.997) models, though there was no significant association with readmission.

CONCLUSION

Report of an assessment of help needed at home during hospitalization was associated with lower post-discharge emergency department utilization. Efforts to improve outcomes after hospital discharge in older patients may benefit from greater focus on assessing need of help at home.

QUality improvement in primary care to prevent hospitalisations and improve Effectiveness and efficiency of care for people Living with coronary heart disease (QUEL): protocol for a 24-month cluster randomised controlled trial in primary care

Background

Cardiovascular disease (CVD), including coronary heart disease (CHD) and stroke, is the leading cause of death and disability globally. A large proportion of mortality occurs in people with prior CHD and effective and scalable strategies are needed to prevent associated deaths and hospitalisations. The aim of this study is to determine if a practice-level collaborative quality improvement program, focused on patients with CHD, reduces the rate of unplanned CVD hospitalisations and major adverse cardiovascular events, and increases the proportion of patients achieving risk factor targets at 24 months.

Methods

Cluster randomised controlled trial (cRCT) to evaluate the effectiveness of a primary care quality improvement program in 50 primary care practices (n~ 10,000 patients) with 24-month follow-up. Eligible practices will be randomised (1:1) to participate in either the intervention (collaborative quality improvement program) or control (standard care) regimens. Outcomes will be assessed based on randomised allocation, according to intention-to-treat. The primary outcome is the proportion of patients with unplanned CVD hospitalisations at 2 years. Secondary outcomes are proportion of patients with major adverse cardiovascular events, proportion of patients who received prescriptions for guideline-recommended medicines, proportion of patients achieving national risk factor targets and proportion with a chronic disease management plan or review. Differences in the proportion of patients who are hospitalised (as well as binary secondary outcomes) will be analysed using log-binomial regression or robust Poisson regression, if necessary.

Discussion

Despite extensive research with surrogate outcomes, to the authors’ knowledge, this is the first randomised controlled trial to evaluate the effectiveness of a data-driven collaborative quality improvement intervention on hospitalisations, CVD events and cardiovascular risk amongst patients with CHD in the primary care setting. The use of data linkage for collection of outcomes will enable evaluation of this potentially efficient strategy for improving management of risk and outcomes for people with heart disease.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR) number ACTRN12619001790134 (dated 20th December 2019).

Metabolomics and its application in the treatment of coronary heart disease with traditional Chinese medicine

Traditional Chinese Medicine (TCM) is the treasure of Chinese Nation and gained the gradual acceptance of the international community. However, the methods and theories of TCM understanding of diseases are lack of appropriate modern scientific characterization systems. Moreover, traditional risk factors cannot promote to detection and prevent those patients with coronary artery disease (CAD) who have not developed acute myocardial infarction (MI) in time. To sum up, there is still no objective systematic evaluation system for the therapeutic mechanism of TCM in the prevention and cure of cardiovascular disease. Thus, new ideas and technologies are needed. The development of omics technology, especially metabolomics, can be used to predict the level of metabolites in vivo and diagnose the physiological state of the body in time to guide the corresponding intervention. In particular, metabolomics is also a very powerful tool to promote the modernization of TCM and the development of TCM in personalized medicine. This article summarized the application of metabolomics in the early diagnosis, the discovery of biomarkers and the treatment of TCM in CAD.

Inter-hospital transfer and patient outcomes: a retrospective cohort study

BACKGROUND

Inter-hospital transfer (IHT, the transfer of patients between hospitals) occurs regularly and exposes patients to risks of discontinuity of care, though outcomes of transferred patients remains largely understudied.

OBJECTIVE

To evaluate the association between IHT and healthcare utilisation and clinical outcomes.

DESIGN

Retrospective cohort.

SETTING

CMS 2013 100 % Master Beneficiary Summary and Inpatient claims files merged with 2013 American Hospital Association data.

PARTICIPANTS

Beneficiaries≥age 65 enrolled in Medicare A and B, with an acute care hospitalisation claim in 2013 and 1 of 15 top disease categories.

MAIN OUTCOME MEASURES

Cost of hospitalisation, length of stay (LOS) (of entire hospitalisation), discharge home, 3 -day and 30- day mortality, in transferred vs non-transferred patients.

RESULTS

The final cohort consisted of 53 420 transferred patients and 53 420 propensity-score matched non-transferred patients. Across all 15 disease categories, IHT was associated with significantly higher costs, longer LOS and lower odds of discharge home. Additionally, IHT was associated with lower propensity-matched odds of 3-day and/or 30- day mortality for some disease categories (acute myocardial infarction, stroke, sepsis, respiratory disease) and higher propensity-matched odds of mortality for other disease categories (oesophageal/gastrointestinal disease, renal failure, congestive heart failure, pneumonia, renal failure, chronic obstructivepulmonary disease, hip fracture/dislocation, urinary tract infection and metabolic disease).

CONCLUSIONS

In this nationally representative study of Medicare beneficiaries, IHT was associated with higher costs, longer LOS and lower odds of discharge home, but was differentially associated with odds of early death and 30 -day mortality depending on patients' disease category. These findings demonstrate heterogeneity among transferred patients depending on the diagnosis, presenting a nuanced assessment of this complex care transition.

Effect of Intensive Personalized "5As+5Rs" Intervention on Smoking Cessation in Hospitalized Acute Coronary Syndrome Patients Not Ready to Quit Immediately: A Randomized Controlled Trial

Introduction

The acute coronary syndrome (ACS) patients who are not ready to quit smoking immediately have an extremely low rate of cessation. This study aims to investigate the efficacy of intensive personalized '5As+5Rs'intervention (IPANR intervention) on smoking cessation in this population.

Methods

A parallel-group randomized controlled trial was carried out, which compared IPANR intervention with routine 5Rs (control) at Fu Xing Hospital, Capital Medical University, Bei Jing, China. Three hundred and twenty hospitalized ACS smokers who were not ready to quit were randomly distributed to IPANR intervention group comprising three individual counseling during hospitalization and 15 intensive follow-up sessions (weekly during months 1, 2, 3, and monthly thereafter until month 6) or 5Rs group in a 1:1 fashion by 8 cardiologists who were blinded to the allocation sequence. Primary end point was carbon monoxide-confirmed continuous abstinence rate (CAR) through week 9 to week 12. Secondary outcome included abstinence rate at 24 weeks.

Results

Overall, 97.5% (312/320) participants completed the trial. An intention-to-treat analysis showed statistically significant advantage of IPANR compared with control group at 4 weeks CAR (27.5% vs. 17.5%, RR = 1.571, 95% CI = 1.032-2.392, p = 0.032, number needed to treat (NNT) = 10), and abstinence rate at 24 weeks (23.8% vs.15.0%, RR 1.583, 95% CI = 0.998-2.512, p = 0.048, NNT: 11.36). At 24 weeks, cigarettes smoked per day by the patients who failed to quit were significant lower in IPANR group than 5Rs group (13.21 ± 8.23 vs. 17.45 ± 10.71; p < 0.001).

Conclusions

The IPANR initiated during hospitalization, is a feasible and effective approach for smoking cessation in ACS patients not ready to quit immediately.

Implications

Smoking has a major impact on acute stages of ACS for recurrent ischemic events and long-term outcomes. However, there are few evidence-based treatments for smokers who are not ready to quit. This study described a cessation intervention initiated during hospitalization and included 15 intensive follow-up aimed at enabling ACS smokers who were not ready to quit immediately to deliver adequate motivational and behavior change counseling. Given its effectiveness demonstrated in this prospective study, this intervention in hospitalized ACS smokers might have the potential to substantially improve the cessation rate of ACS patients who are not ready to quit smoking immediately.

Cardiovascular Medication Use and Long-Term Outcomes of First Nations and Non-First Nations Patients Following Diagnostic Angiography: A Retrospective Cohort Study

Background

In Canada, First Nations (FN) people are at greater risk of mortality than the general population following index angiography. This disparity has not been investigated while considering guideline‐recommended cardiovascular medication use.

Methods and Results

Retrospective analysis of administrative health data investigated patterns of medication dispensation during the first year after index angiography among patients in Manitoba, Canada. Medication possession ratios (MPRs) reflecting the percentage of days in which medications were supplied were calculated separately for β‐blockers, angiotensin‐converting enzyme inhibitors, statins, and antiplatelets (clopidogrel). Patients were assigned to 1 of 4 categories: (1) not dispensed (0% MPR), (2) low (1–39% MPR), (3) intermediate (40–79% MPR), (4) high (≥80% MPR). Cox regression models that adjusted for MPR categories were used to explore the association between FN patients and both 5‐year all‐cause mortality and cardiovascular mortality. FN patients were less likely to have an intermediate MPR (odds ratio: 0.75; 95% CI, 0.57–0.99) or a high MPR (odds ratio: 0.64; 95% CI, 0.50–0.81) for statin medications than non‐FN patients. FN patients also had higher adjusted risks of all‐cause and cardiovascular mortality than non‐FN patients (hazard ratio, all‐cause: 1.54 [95% CI, 1.25–1.89]; cardiovascular: 1.62 [95% CI, 1.16–2.25]).

Conclusions

FN status was independently associated with intermediate and high MPRs for statins during the first year following index angiography among patients with known ischemic heart disease. Differences in MPR categories did not explain the disparity in all‐cause and cardiovascular mortality between the 2 populations. Reduction of cardiovascular disparities may be best addressed using primary prevention strategies that include decolonizing policies and practices.

Microcirculation function assessed by adenosine triphosphate stress myocardial contrast echocardiography and prognosis in patients with nonobstructive coronary artery disease

BACKGROUND

Recent studies have demonstrated that coronary microcirculation dysfunction (CMVD) is closely correlated with adverse clinical outcomes. In this study, quantitative stress myocardial contrast echocardiography (MCE) was used to evaluate the CMVD and to investigate its association with the prognosis of patients with nonobstructive coronary artery disease (CAD).

MATERIAL AND METHODS

From 2006 to 2014, 227 consecutive patients with chest pain and a diagnostic coronary angiography without significant coronary artery stenosis (<50%) who underwent adenosine triphosphate disodium (ATP) stress MCE were enrolled. Quantitative MCE measurements were analyzed using replenishment curves.

RESULTS

Median follow-up time of this study was 5.3 years. Predictors of impaired coronary flow reserve (CFR) were smoking, diabetes, high apolipoprotein B, high low-density lipoprotein, serum uric acid, and low apolipoprotein A. During follow-up, 22 patients were reported to have 30 cardiac events (21 unstable angina, 3 nonfatal myocardial infarctions, 6 percutaneous coronary interventions). Using multivariate analysis, abnormal β reserve (≤1.6), impaired CFR (≤2.0), and diabetes were independent predictors of primary endpoint events in patients with nonobstructive CAD (P < .05). Multivariate analysis showed that CFR ≤2.0 (odds ratio [OR] =  25.21, 95% confidence interval [CI]: 3.01-182.32; P = .003), β reserve ≤1.6 (OR = 29.96, 95% CI: 3.5-241.27; P = .002), and diabetic (OR = 33.11, 95% CI: 3.65-300.02; P = .002) significantly increased the risk of the primary endpoint events.

CONCLUSIONS

ATP stress quantitative MCE is a feasible and effective method to evaluate microcirculation abnormalities in human coronary arteries and it can be used for the clinical analysis, risk stratification, and treatment of early CAD.

Impact of Pharmacist Interventions on the Long-Term Clinical Outcomes in Patients with Myocardial Infarction

Background

Controlling modifiable risk factors (MRFs) in patients with cardiovascular diseases has been shown to be effective in reducing re-hospitalization rates. The aim of this study was to investigate the rates of controlled MRFs and clinical outcomes after pharmacist interventions in patients with myocardial infarction (MI) after hospital discharge.

Methods

This prospective randomized clinical study was conducted at one medical center in Taiwan, and enrolled patients with MI from January 1, 2012 to December 31, 2014. Patients received medication reconciliation and education from a pharmacist before hospital discharge. The intervention group (IG) received continuous consultations from the pharmacist after discharge, whereas the control group (CG) did not. Primary outcomes included achieving blood pressure < 140/70 mmHg, low-density lipoprotein-cholesterol (LDL-C) < 70 mg/dL, and hemoglobin A1c (HbA1c) < 7% targets. The secondary outcome was major adverse cardiac events (MACEs), defined as re-hospitalization due to MI, unstable angina and stroke.

Results

Two hundred and eight patients completed the study protocol (106 in the IG and 102 in the CG). The rate of achieving blood pressure goal was similar between the two groups. More patients in the IG achieved LDL-C and HbA1c goals than those in the CG at 1 year and 2 years post discharge. However, there was no significant difference in the cumulative incidence of MACEs between the two groups (5.7% vs. 9.8%) (p = 0.262). Diabetes was the only independent predictor of re-hospitalization due to a MACE.

Conclusions

Pharmacist interventions led to a higher rate of optimal controlled MRFs but did not significantly reduce the MACE rate in the patients with MI.

A Machine Learning-Based Approach for the Prediction of Acute Coronary Syndrome Requiring Revascularization

The aim of this study is to predict acute coronary syndrome (ACS) requiring revascularization in those patients presenting early-stage angina-like symptom using machine learning algorithms. We obtained data from 2344 ACS patients, who required revascularization and from 3538 non-ACS patients. We analyzed 20 features that are relevant to ACS using standard algorithms, support vector machines and linear discriminant analysis. Based on feature pattern and filter characteristics, we analyzed and extracted a strong prediction function out of the 20 selected features. The obtained prediction functions are relevant showing the area under curve of 0.860 for the prediction of ACS that requiring revascularization. Some features are missing in many data though they are considered to be very informative; it turned out that omitting those features from the input and using more data without those features for training improves the prediction accuracy. Additionally, from the investigation using the receiver operating characteristic curves, a reliable prediction of 2.60% of non-ACS patients could be made with a specificity of 1.0. For those 2.60% non-ACS patients, we can consider the recommendation of medical treatment without risking misdiagnosis of the patients requiring revascularization. We investigated prediction algorithm to select ACS patients requiring revascularization and non-ACS patients presenting angina-like symptoms at an early stage. In the future, a large cohort study is necessary to increase the prediction accuracy and confirm the possibility of safely discriminating the non-ACS patients from the ACS patients with confidence.

Non-invasive fractional flow reserve derived from coronary computed tomography angiography in patients with acute chest pain: Subgroup analysis of the ROMICAT II trial

BACKGROUND

Non-invasive fractional flow reserve (FFR_CT) derived from coronary computed tomography angiography (CTA) permits hemodynamic evaluation of coronary stenosis and may improve efficiency of assessment in stable chest pain patients. We determined feasibility of FFR_CT in the population of acute chest pain patients and assessed the relationship of FFR_CT with outcomes of acute coronary syndrome (ACS) and revascularization and with plaque characteristics.

METHODS

We included 68 patients (mean age 55.8 ± 8.4 years, 71% men) from the ROMICAT II trial who had ≥50% stenosis on coronary CTA or underwent additional non-invasive stress test. We evaluated coronary stenosis and high-risk plaque on coronary CTA. FFR_CT was measured in a core laboratory.

RESULTS

We found correlation between anatomic severity of stenosis and FFR_CT ≤0.80 vs. FFR_CT >0.80 (severe stenosis 84.8% vs. 15.2%; moderate stenosis 33.3% vs. 66.7%; mild stenosis 33.3% vs. 66.7% patients). Patients with severe stenosis had lower FFR_CT values (median 0.64, 25th-75th percentile 0.50-0.75) as compared to patients with moderate (median 0.84, 25th-75th percentile, p < 0.001) or mild stenosis (median 0.86, 25th-75th percentile 0.78-0.88, p < 0.001). The relative risk of ACS and revascularization in patients with positive FFR_CT ≤0.80 was 4.03 (95% CI 1.56-10.36) and 3.50 (95% CI 1.12-10.96), respectively. FFR_CT ≤0.80 was associated with the presence of high-risk plaque (odds ratio 3.91, 95% CI 1.55-9.85, p = 0.004) after adjustment for stenosis severity.

CONCLUSION

Abnormal FFR_CT was associated with the presence of ACS, coronary revascularization, and high-risk plaque. FFR_CT measurements correlated with anatomic severity of stenosis on coronary CTA and were feasible in population of patients with acute chest pain.

Incidence and outcomes of unstable angina compared with non-ST-elevation myocardial infarction

Objective

Assess the relative incidence and compare characteristics and outcome of unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI).

Design

Two independent prospective multicentre diagnostic studies (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE] and High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome [High-STEACS]) enrolling patients with acute chest discomfort presenting to the emergency department. Central adjudication of the final diagnosis was done by two independent cardiologists using all clinical information including serial measurements of high-sensitivity cardiac troponin (hs-cTn). All-cause death and future non-fatal MI were assessed at 30 days and 1 year.

Results

8992 patients were enrolled at 11 centres. UA was adjudicated in 8.9%(95% CI 8.0 to 9.7) and 2.8% (95% CI 2.3 to 3.3) patients in APACE and High-STEACS, respectively, and NSTEMI in 15.1% (95% CI 14.0 to 16.2) and 13.4% (95% CI 12.4 to 14.3). Coronary artery disease was pre-existing in 73% and 76% of patients with UA. At 30 days, all-cause mortality in UA was substantially lower as compared with NSTEMI (0.5% vs 3.7%, p=0.002 in APACE, 0.7% vs 7.4%, p=0.004 in High-STEACS). Similarly, at 1 year in UA all-cause mortality was 3.3% (95% CI 1.2 to 5.3) vs 10.4% (95% CI 7.9 to 12.9) in APACE, and 5.1% (95% CI 0.7 to 9.5) vs 22.9% (95% CI 19.3 to 26.4) in High-STEACS, and similar to non-cardiac chest pain (NCCP). In contrast, future non-fatal MI in APACE was comparable in UA and NSTEMI (11.2%, 95% CI 7.8 to 14.6 and 7.9%, 95% CI 5.7 to 10.2), and higher than in NCCP (0.6%, 95% CI 0.2 to 1.0).

Conclusions

The relative incidence and mortality of UA is substantially lower than that of NSTEMI, while the rate of future non-fatal MI is similar.

Analysis of thrombelastogram-guided medication in patients with coronary heart disease after percutaneous coronary intervention

Effects of thrombelastogram-guided (TEG-guided) clopidogrel and aspirin on major adverse cardiovascular events (MACE) after percutaneous coronary intervention (PCI) were investigated. A retrospective analysis was performed on 203 patients undergoing PCI interventional therapy in the Cardiovascular Medicine of Weihai Central Hospital from February 2015 to September 2016. The patients were treated with clopidogrel and aspirin for anti-thrombus therapy. Among them, 104 patients who had TEG detection of anticoagulant effects for guiding medication were the experimental group, and 99 patients without TEG detection for guiding medication the control group. The coagulation function and the platelet inhibition rate of patients after medication were evaluated and compared between the two groups. The incidence of MACE and bleeding events of patients was counted during three months of follow-up. Patients in the experimental group had higher R (coagulation reaction time) value and K (blood clot formation time) value than those in the control group after treatment (P<0.05), and lower MA (maximum amplitude) value than those in the control group (P<0.05). Patients in the experimental group had higher postoperative platelet inhibition rate than those in the control group (P<0.05). Patients in the experimental group had lower incidence of MACE and bleeding events than those in the control group (P<0.05). Coronary heart disease (CHD) patients after PCI with the TEG-guided dose adjustment of clopidogrel have more satisfactory treatment effects than patients without the TEG guidance. TEG makes the treatment of patients more targeted and is worthy of promotion.

Analysis of Ticagrelor's Cardio-protective Effects on Patients with ST-segment Elevation Acute Coronary Syndrome Accompanied with Diabetes

Background

To analyze the cardio-protective effects of ticagrelor in patients with acute coronary syndrome with S-T segment elevation.

Methods

The sample was 200 patients who had been diagnosed with acute coronary syndrome accompanied by diabetes Mellitus type II. Only patients having ST segment elevation before the treatment were included. Then, the subjects were further randomly divided into an observation group and a control group. The control group of 100 patients received clopidogrel; the observation group of 100 patients of ticagrelor. The serous creatine kinase CK-MB, functional cardiac indexes of left ventricular end diastolic diameter (LVDD), cardiac troponin I, ventricular ejection fraction, and relevant major adverse cardiovascular events (MACE) were compared between the two groups.

Results

One month after a percutaneous coronary intervention (PCI) the observation group showed better results against angina, stent thrombosis, and all-cause mortality compared with those of the control subjects. Six months after treatment, both groups suffered adverse reactions. The number of patients who suffered adverse reactions in respiratory tract in the observation group was higher than in the control group. The inhibition of platelet aggregation IPA of ticagrelor was found to be significantly higher than clopidogrel, having a significant p value.

Conclusion

Ticagrelor can effectively protect myocardial function for patients with ST-segment elevation acute coronary syndrome accompanied by diabetes and can reduce the incidence of adverse reactions..

eHealth to improve patient outcome in rehabilitating myocardial infarction patients

INTRODUCTION

Cardiac rehabilitation is aimed at risk factor modification and improving quality of life. eHealth has a couple of potential benefits to improve this aim. The primary purpose of this review is to summarize available literature for eHealth strategies that have been investigated in randomized controlled trials in post-myocardial infarction (MI) patients. The second purpose of this review is to investigate the clinical effectiveness in post-MI patients. Areas covered: The literature was searched using PubMed. Randomized controlled trials (RCTs) describing interventions in patients that had experienced an ST-elevation myocardial infarction or non-ST acute coronary syndrome were eligible for inclusion. Fifteen full-texts were included and their results are described in this review. These RCTs described interventions that used remote coaching or remote monitoring in post-MI patients. Most interventions resulted in an improved cardiovascular risk profile. Remote coaching had a positive effect on activity and dietary intake. Expert opinion: eHealth might be clinically beneficial in post-MI patients, particularly for risk estimation. Moreover, eHealth as a tool for remote coaching on activity is a good addition to traditional cardiac rehabilitation programs. Further research needs to corroborate these findings.

An attention based deep learning model of clinical events in the intensive care unit

This study trained long short-term memory (LSTM) recurrent neural networks (RNNs) incorporating an attention mechanism to predict daily sepsis, myocardial infarction (MI), and vancomycin antibiotic administration over two week patient ICU courses in the MIMIC-III dataset. These models achieved next-day predictive AUC of 0.876 for sepsis, 0.823 for MI, and 0.833 for vancomycin administration. Attention maps built from these models highlighted those times when input variables most influenced predictions and could provide a degree of interpretability to clinicians. These models appeared to attend to variables that were proxies for clinician decision-making, demonstrating a challenge of using flexible deep learning approaches trained with EHR data to build clinical decision support. While continued development and refinement is needed, we believe that such models could one day prove useful in reducing information overload for ICU physicians by providing needed clinical decision support for a variety of clinically important tasks.

Factors associated with objectively measured exercise participation after hospitalization for acute coronary syndrome

BACKGROUND

Guidelines recommend exercise for secondary prevention of acute coronary syndrome (ACS), however adherence to guidelines is low. A paucity of data examining factors associated with objectively-measured exercise post-discharge in ACS survivors exists. The purpose of this study was to identify factors associated with exercise during the 5 weeks after ACS discharge.

METHODS

A sample of 151 ACS patients treated at a university hospital were enrolled into an observational cohort study and wore an accelerometer for 35 days post-discharge. Days on which participants accumulated ≥30 min of moderate-to-vigorous physical activity in bouts ≥10 min were considered exercise days. Participants were categorized as non-exercisers (0 exercise days) or exercisers (≥1 exercise day). A multi-variable logistic regression model was used to examine the association between exercise and socio-demographics, depression, SF-12 physical and mental health scores, disease severity, length of hospitalization, and percutaneous coronary intervention.

RESULTS

39.7% of participants were non-exercisers. Factors associated with non-exercise were age (OR: 1.11; 95% CI: 1.06-1.17, p < 0.001), female sex (OR: 2.76; 95% CI: 1.10-6.95, p = 0.031), and lower SF-12 physical health score (OR: 0.94; 95% CI: 0.90-0.98, p = 0.005).

CONCLUSION

In ACS patients in whom exercise participation was objectively measured for 5 weeks post-discharge, demographic and poor physical health factors were associated with non-exercise. These findings identify populations (e.g. older adults, women) at especially high risk for being physically inactive in whom more intense intervention may be warranted.

Meta-Analysis of Bleeding Risk Prediction Scores in Patients After Percutaneous Coronary Intervention on Dual Antiplatelet Therapy

The duration and type of dual antiplatelet therapy (DAPT) prescribed to patients after percutaneous coronary intervention (PCI) involves carefully balancing reduced ischemia and increased bleeding risk for individual patients. Whereas multiple bleeding risk scores exist, the performance of these models to predict long-term bleeding in the setting of DAPT across different settings and populations is unclear. Therefore, we performed a systematic review and meta-analysis to compare the performance of current bleeding risk prediction scores for predicting major long-term bleeding events in patients on DAPT post-PCI. Based on a search of MEDLINE (January 1, 1946 to March 3, 2017) and EMBASE (January 1, 1974 to March 3, 2017) for studies published in the English language, we identified 10 published studies of 11 risk unique risk prediction models across a wide variety of settings. Area under the receiver operating characteristic curve (AUC) was used to measure discrimination, when available. Our findings reveal that the prediction models created to date demonstrate only modest accuracy, with the reported AUCs ranging from 0.54 to 0.89; aggregated AUC 0.68 (95% confidence intervals 0.65 to 0.72). Although only 5 studies (50%) reported measures of calibration, the reported models were reasonably well calibrated. Only 3 models (33%) were externally validated. Meta-regression demonstrated lack of influence by age (p = 0.99) or length of follow up (p = 0.42). Sensitivity analysis did not significantly change the results. Novel prediction models are warranted to aid in maximizing the benefit of DAPT after PCI while minimizing harm.

Wearable Cardioverter-Defibrillator after Myocardial Infarction

BACKGROUND

Despite the high rate of sudden death after myocardial infarction among patients with a low ejection fraction, implantable cardioverter-defibrillators are contraindicated until 40 to 90 days after myocardial infarction. Whether a wearable cardioverter-defibrillator would reduce the incidence of sudden death during this high-risk period is unclear.

METHODS

We randomly assigned (in a 2:1 ratio) patients with acute myocardial infarction and an ejection fraction of 35% or less to receive a wearable cardioverter-defibrillator plus guideline-directed therapy (the device group) or to receive only guideline-directed therapy (the control group). The primary outcome was the composite of sudden death or death from ventricular tachyarrhythmia at 90 days (arrhythmic death). Secondary outcomes included death from any cause and nonarrhythmic death.

RESULTS

Of 2302 participants, 1524 were randomly assigned to the device group and 778 to the control group. Participants in the device group wore the device for a median of 18.0 hours per day (interquartile range, 3.8 to 22.7). Arrhythmic death occurred in 1.6% of the participants in the device group and in 2.4% of those in the control group (relative risk, 0.67; 95% confidence interval [CI], 0.37 to 1.21; P=0.18). Death from any cause occurred in 3.1% of the participants in the device group and in 4.9% of those in the control group (relative risk, 0.64; 95% CI, 0.43 to 0.98; uncorrected P=0.04), and nonarrhythmic death in 1.4% and 2.2%, respectively (relative risk, 0.63; 95% CI, 0.33 to 1.19; uncorrected P=0.15). Of the 48 participants in the device group who died, 12 were wearing the device at the time of death. A total of 20 participants in the device group (1.3%) received an appropriate shock, and 9 (0.6%) received an inappropriate shock.

CONCLUSIONS

Among patients with a recent myocardial infarction and an ejection fraction of 35% or less, the wearable cardioverter-defibrillator did not lead to a significantly lower rate of the primary outcome of arrhythmic death than control. (Funded by the National Institutes of Health and Zoll Medical; VEST ClinicalTrials.gov number, NCT01446965 .).

Platelet Function Analyzer-200 P2Y Results Are Predictive of the Risk of Major Adverse Cardiac Events in Korean Patients Receiving Clopidogrel Therapy Following Acute Coronary Syndrome

BACKGROUND

Clopidogrel is one of the most commonly used anti-platelet agents in cardiovascular diseases. We analyzed the relationship between the platelet function analyzer (PFA)-200 P2Y (INNOVANCE PFA-200 System, Siemens Healthcare, Germany) results and occurrence of major adverse cardiac events (MACEs) in Korean patients with recent-onset acute coronary syndrome (ACS) taking clopidogrel.

METHODS

Between August 2013 and June 2016, we prospectively enrolled 106 patients with recent-onset ACS who had been treated with clopidogrel. We obtained blood samples and measured closure time (CT) using the PFA-200 P2Y test. Patients were divided into two groups on the basis of a CT cut-off value of 106 seconds. We compared patient characteristics and various MACEs that occurred during the follow-up period.

RESULTS

The CTs for 78 patients exceeded the cut-off value. At the time of these analyses, 11 patients had been diagnosed with MACEs. In the time-to-event analysis, there was a difference between the two groups (P<0.001). After adjusting other variables associated with MACE occurrence, CT value was the strongest predictor of MACEs, with a 7.30-fold occurrence risk (P=0.002).

CONCLUSIONS

We found a strong relationship between CT and MACE risk in Korean patients with recent-onset ACS taking clopidogrel. Accordingly, PFA-200 P2Y results could be used as a predictive marker for MACE risk in such patients.

Low Protein Z Level: A Thrombophilic Risk Biomarker for Acute Coronary Syndrome

Acute coronary syndrome (ACS) encompasses a range of thrombotic coronary artery diseases. Protein Z (PZ)/PZ-dependent protease inhibitor complex is a natural anticoagulant system with a presumptive role for PZ deficiency in the pathogenesis of ACS. We aimed to evaluate plasma PZ level and role as a risk biomarker in Egyptian patients with ACS. Hundred patients with stable ACS and 60 matched controls were enrolled. ACS patients were divided into 3 clinical subgroups (ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction, and unstable angina), and 2 age subgroups (group A ≤ 55 years, and group B > 55 years). Plasma PZ levels were evaluated using enzyme linked immunosorbent assay. Lower PZ levels were found in ACS patients' group and clinical subgroups compared with controls. PZ levels showed a decrease with increasing age and were lower in females versus males. Lower PZ levels were found in hypertensive ACS patients in both age subgroups. Smokers and patients with family history of ACS in group A had lower PZ levels, while group B revealed lower PZ among diabetic patients. In group A, increased number of ACS conventional risk factors was associated with lower PZ levels. PZ level 3.7 μg/mL was the best cut-off value for prediction of ACS. Logistic regression analyses approved PZ as an independent risk biomarker for ACS. PZ levels are reduced in stable ACS and are significantly and independently associated with increased susceptibility for ACS, denoting PZ deficiency as a reliable thrombophilic risk biomarker in Egyptian patients with ACS.

The high-risk criteria low-attenuation plaque <60 HU and the napkin-ring sign are the most powerful predictors of MACE: a long-term follow-up study

Aims

To assess the prognostic value of coronary CT angiography (CTA) for prediction of major adverse cardiac events (MACE) over a long-term follow-up period.

Methods and Results

A total of 1469 low-to-intermediate-risk patients (65.9 years; 44.2% females) were included in our prospective cohort study. CTA was evaluated for (i) stenosis severity (minimal <10%; mild <50%; moderate 50-70%; severe >70%), (ii) plaque types (calcified, mixed dominantly calcified, mixed dominantly non-calcified, non-calcified), and (iii) high-risk plaque criteria [low-attenuation plaque (LAP) quantified by HU, napkin-ring (NR) sign, spotty calcification <3 mm, and remodelling index (RI)]. Over a follow-up of mean 7.8 years, MACE rate was 41 (2.8%) and 0% in patients with negative CTA. MACE rate increased along with stenosis severity by CTA (from 1.3 to 7.8%) (P < 0.001) and was higher in T3/T4 plaques than in T2/T1 (7.8 vs. 1.9%; P < 0.0001). LAP density was lower (35.2 HU ± 32 vs. 108.8 HU ± 53) (P < 0.001) and both NR-sign prevalence with n = 26 (63.4%) vs. n = 40 (28%) and LAP <30, <60, and <90 HU prevalence with 46.3-78% vs. 2.4-7% were higher in the MACE group (P < 0.001). On univariate and unadjusted multivariable proportional Hazards model, LAP <60 HU and NR were the strongest MACE predictors (HR 4.96; 95% CI: 2.0-12.2 and HR 3.85; 95% CI: 1.7-8.6) (P < 0.0001), while spotty calcification (HR 2.2; 95% CI: 1.1-4.3, P < 0.001), stenosis severity, and plaque type (HR 1.5; 95% CI: 1.1-2.3 and HR 1.7; 95% CI: 1.1-2.6) (P < 0.001) were less powerful. After adjusting for risk factors, CTA stenosis severity, and plaque type, LAP <60 HU and the NR sign remained significant (P < 0.001), while the effect of NR sign was even enhancing. HRP criteria were independent predictors from other risk factors.

Conclusion

Prognosis is excellent over a long-term period if CTA is negative and worsening with an increasing non-calcifying plaque component. LAP <60 HU and NR sign are the most powerful MACE predictors.

Sleep study-guided multidisciplinary therapy (SGMT) for patients with acute coronary syndrome: Trial rationale and design

Obstructive sleep apnea (OSA) is an emerging risk marker for acute coronary syndrome (ACS). This randomized trial aims to determine the effects of sleep study-guided multidisciplinary therapy (SGMT) comprising overnight sleep study, continuous positive airway pressure, and behavioral therapy for OSA during the subacute phase of ACS. We hypothesize that SGMT will reduce (1) the plasma levels of N-terminal pro brain natriuretic peptide and suppression of tumorigenicity 2; (2) the estimated 10-year risk of cardiovascular mortality as measured by the European Systematic Coronary Risk Evaluation (SCORE) algorithm; and (3) the cardiovascular event rate during a 3-year follow-up, compared with standard therapy. In the SGMT trial, 180 patients presenting with ACS will be randomly assigned to SGMT (n = 90) and standard therapy (n = 90) groups. Both groups will receive guideline-mandated treatment for ACS. Those assigned to SGMT will additionally undergo a sleep study and, if OSA is diagnosed, attend a multidisciplinary OSA clinic where they will receive personalized treatment including continuous positive airway pressure and behavioral/lifestyle counseling. The primary endpoint is the plasma N-terminal pro brain natriuretic peptide concentration at 7-month follow-up. This report presents the baseline characteristics of 117 patients (SGMT group: n =54; standard therapy group: n =63) who had been enrolled into the study as of August 31, 2017. The results of this trial will help us to understand whether active OSA diagnosis and treatment will improve the physiologic and clinical cardiovascular outcomes of this group of patients.