Detectable troponin below the 99th percentile predicts survival in patients undergoing coronary angiography

Background

Cardiac troponin I (cTnI) above the 99th percentile is associated with an increased risk of major adverse events. Patients with detectable cTnI below the 99th percentile are a heterogeneous group with a less well-defined risk profile. The purpose of this study is to investigate the prognostic relevance of detectable cTnI below the 99th percentile in patients undergoing coronary angiography.

Methods

The study included 14,776 consecutive patients (mean age of 65.4 ± 12.7 years, 71.3 % male) from the Essen Coronary Artery Disease (ECAD) registry. Patients with cTnI levels above the 99th percentile and patients with ST-segment elevation acute myocardial infarction were excluded. All-cause mortality was defined as the primary endpoint.

Results

Detectable cTnI below the 99th percentile was present in 2811 (19.0 %) patients, while 11,965 (81.0 %) patients were below detection limit of the employed assay. The mean follow-up was 4.25 ± 3.76 years. All-cause mortality was 20.8 % for patients with detectable cTnI below the 99th percentile and 15.0 % for those without detectable cTnI. In a multivariable Cox regression analysis, detectable cTnI was independently associated with all-cause mortality with a hazard ratio of 1.60 (95 % CI 1.45-1.76; p < 0.001). There was a stepwise relationship with increasing all-cause mortality and tertiles of detectable cTnI levels with hazard ratios of 1.63 (95 % CI 1.39-1.90) for the first tertile to 2.02 (95 % CI 1.74-2.35) for the third tertile.

Conclusions

Detectable cTnI below the 99th percentile is an independent predictor of mortality in patients undergoing coronary angiography with the risk of death growing progressively with increasing troponin levels.

Impact of untreated chronic obstructive coronary artery disease on outcomes after transcatheter aortic valve replacement

BACKGROUND AND AIMS

In transcatheter aortic valve replacement (TAVR) recipients, the optimal management of concomitant chronic obstructive coronary artery disease (CAD) remains unknown. Some advocate for pre-TAVR percutaneous coronary intervention, while others manage it expectantly. The aim of this study was to assess the impact of varying degrees and extent of untreated chronic obstructive CAD on TAVR and longer-term outcomes.

METHODS

The authors conducted a retrospective cohort study of TAVR recipients from January 2015 to November 2021, separating patients into stable non-obstructive or varying degrees of obstructive CAD. The major outcomes of interest were procedural all-cause mortality and complications, major adverse cardiovascular events, and post-TAVR unplanned coronary revascularization.

RESULTS

Of the 1911 patients meeting inclusion, 75%, 6%, 10%, and 9% had non-obstructive, intermediate-risk, high-risk, and extreme-risk CAD, respectively. Procedural complication rates overall were low (death 0.4%, shock 0.1%, extracorporeal membrane oxygenation 0.1%), with no difference across groups. At a median follow-up of 21 months, rates of acute coronary syndrome and unplanned coronary revascularization were 0.7% and 0.5%, respectively, in the non-obstructive population, rising in incidence with increasing severity of CAD (P < .001 for acute coronary syndrome/unplanned coronary revascularization). Multivariable analysis did not yield a significantly greater risk of all-cause mortality or major adverse cardiovascular events across groups. One-year acute coronary syndrome and unplanned coronary revascularization rates in time-to-event analyses were significantly greater in the non-obstructive (98%) vs. obstructive (94%) subsets (Plog-rank< .001).

CONCLUSIONS

Transcatheter aortic valve replacement can be performed safely in patients with untreated chronic obstructive CAD, without portending higher procedural complication rates and with relatively low rates of unplanned coronary revascularization and acute coronary syndrome at 1 year.

Acute coronary occlusion with vs. without ST-elevation: impact on procedural outcomes and long-term all-cause mortality

BACKGROUND

Acute total occlusion (ATO) is diagnosed in a substantial proportion of patients with Non-ST-elevation myocardial infarction (NSTEMI). We compared procedural outcomes and long- term mortality in patients with ST-elevation myocardial infarction (STEMI) with NSTEMI with vs. without ATO.

METHODS

We included patients with acute myocardial infarction undergoing invasive coronary angiography between 2004 and 2019 at our center. ATO was defined as TIMI 0-1 flow in the infarct-related artery or TIMI 2-3 flow with highly elevated peak troponin (>100-folds the upper reference limit). Association between presentation and long-term mortality was evaluated using multivariable adjusted Cox regression analysis.

RESULTS

From 2269 acute myocardial infarction patients (mean age 66 ± 13.2 years, 74% male), 664 patients with STEMI and 1605 patients with NSTEMI (471 [29.3%] with ATO) were included. ATO(+)NSTEMI had higher frequency of cardiogenic shock and no-reflow than ATO(-)NSTEMI with similar rates compared to STEMI patients (cardiogenic shock: 2.76 vs. 0.27 vs. 2.86%, p < 0.0001, p = 1; no-reflow: 4.03 vs. 0.18 vs. 3.17%, p < 0.0001, p = 0.54). ATO(+)NSTEMI and STEMI were associated with 60% and 55% increased incident mortality, as compared to ATO(-)NSTEMI (ATO(+)NSTEMI: 1.60[1.27-2.02], p < 0.0001, STEMI: 1.55[1.24-1.94], p < 0.0001). Likewise, left ventricular ejection fraction (48.5 ± 12.7 vs. 49.1±11 vs. 50.6 ± 11.8%, p = 0.5, p = 0.018) and global longitudinal strain (-15.2±-5.74 vs. -15.5±-4.84 vs. -16.3±-5.30%, p = 0.48, p = 0.016) in ATO(+)NSTEMI were comparable to STEMI but significantly worse than in ATO(-)NSTEMI.

CONCLUSION

NSTEMI patients with ATO have unfavorable procedural outcomes, resulting in increased long-term mortality, resembling STEMI. Our findings suggest that the occlusion perspective provides more appropriate classification of acute myocardial infarction than differentiation into STEMI vs. NSTEMI.

Bicuspid Aortic Valve Disease: Classifications, Treatments, and Emerging Transcatheter Paradigms

Bicuspid aortic valve (BAV) is a common congenital valvular malformation, which may lead to early aortic valve disease and bicuspid-associated aortopathy. A novel BAV classification system was recently proposed to coincide with transcatheter aortic valve replacement being increasingly considered in younger patients with symptomatic BAV, with good clinical results, yet without randomized trial evidence. Procedural technique, along with clinical outcomes, have considerably improved in BAV patients compared with tricuspid aortic stenosis patients undergoing transcatheter aortic valve replacement. The present review summarizes the novel BAV classification systems and examines contemporary surgical and transcatheter approaches.

The degree of permanent pacemaker dependence and clinical outcomes following transcatheter aortic valve implantation: implications for procedural technique

Aims

Conduction abnormalities necessitating permanent pacemaker (PPM) implantation remain the most frequent complication post-transcatheter aortic valve implantation (TAVI), yet reliance on PPM function varies. We evaluated the association of right-ventricular (RV)-stimulation rate post-TAVI with 1-year major adverse cardiovascular events (MACE) (all-cause mortality and heart failure hospitalization).

Methods and results

This retrospective cohort study of patients undergoing TAVI in two high-volume centers included patients with existing PPM pre-TAVI or new PPM post-TAVI. There was a bimodal distribution of RV-stimulation rates stratifying patients into two groups of either low [≤10%: 1.0 (0.0, 3.6)] or high [>10%: 96.0 (54.0, 99.9)] RV-stimulation rate post-TAVI. Hazard ratios (HR) and 95% confidence intervals (CI) were calculated comparing MACE in patients with high vs. low RV-stimulation rates post-TAVI. Of 4659 patients, 408 patients (8.6%) had an existing PPM pre-TAVI and 361 patients (7.7%) underwent PPM implantation post-TAVI. Mean age was 82.3 ± 8.1 years, 39% were women. A high RV-stimulation rate (>10%) development post-TAVI is associated with a two-fold increased risk for MACE [1.97 (1.20, 3.25), P = 0.008]. Valve implantation depth was an independent predictor of high RV-stimulation rate [odds ratio (95% CI): 1.58 (1.21, 2.06), P=<0.001] and itself associated with MACE [1.27 (1.00, 1.59), P = 0.047].

Conclusion

Greater RV-stimulation rates post-TAVI correlate with increased 1-year MACE in patients with new PPM post-TAVI or in those with existing PPM but low RV-stimulation rates pre-TAVI. A shallower valve implantation depth reduces the risk of greater RV-stimulation rates post-TAVI, correlating with improved patient outcomes. These data highlight the importance of a meticulous implant technique even in TAVI recipients with pre-existing PPMs.

Differences in treatment strategies for LDL-cholesterol reduction in a university lipid clinic vs. standard care apart from the use of PCSK9 inhibitors

BACKGROUND

Lipid-lowering therapy (LLT) in patients with cardiovascular disease (CVD) is insufficient despite clear guideline recommendations. Lipid clinics have specialized in patients with dyslipidemia, but the magnitude and reduction of low-density lipoprotein cholesterol (LDL-C) in lipid clinics has not yet been studied in depth.

OBJECTIVE

To assess LDL-C reduction in very high-risk CVD patients achieved in a lipid clinic through different forms of LLT in comparison to standard care without the initiation of PSCK9 inhibitors.

METHODS

Data from 96 lipid clinic patients were analyzed retrospectively and compared to 84 standard care patients. Very high-risk patients were defined according to the European Society of Cardiology (ESC). Different combinations of LLT focusing on statins and ezetimibe were investigated. Achievement of LDL-C treatment goals according to ESC guidelines as well as LDL-C reduction were assessed.

RESULTS

Baseline and follow-up data of 180 very high-risk CVD patients (mean age 67.7 (±9.8) y; 60.6% male) were used. Achievement of the LDL-C goal in lipid clinic patients increased significantly from 14.6% at baseline to 41.7% at the latest visit (p<0.001) while standard care patients improved from 21.4% to 33.3% (p=0.08). The largest relative LDL-C reduction via an adjustment in LLT was achieved by initiation of high-intensity statins (50.8 ± 4.9%, n = 5, p < 0.05).

CONCLUSION

Treatment in a lipid clinic leads to a superior LDL-C goal achievement in very high-risk CVD patients as compared to standard care with the highest reduction under LLT with high-intensity statins and ezetimibe. Referral algorithms have to be established for high-risk patients.

Predictors of Major Adverse Cardiovascular Events in Patients With Moderate Aortic Stenosis: Implications for Aortic Valve Replacement

BACKGROUND

Although the prognosis and management of severe aortic stenosis has been extensively studied, the risk stratification and outcomes of patients with moderate aortic stenosis remain elusive.

METHODS

This study included 674 patients from the Cleveland Clinic Health System with moderate aortic stenosis (aortic valve area, 1-1.5 cm²; mean gradient, 20-40 mm Hg; and peak velocity <4 m/s) and an NT-proBNP (N-terminal pro-B-type natriuretic peptide) level within 3 months of index diagnosis. The primary outcome of major adverse cardiovascular events (defined as the composite outcome of progression to severe aortic stenosis requiring aortic valve replacement, heart failure hospitalization, or death) was extracted from the electronic medical record.

RESULTS

The mean age was 75.3±12 years, and 57% were men. During a median follow-up of 316 days, the composite end point occurred in 305 patients. There were 132 (19.6%) deaths, 144 (21.4%) heart failure hospitalizations, and 114 (16.9%) patients underwent aortic valve replacement. Elevated NT-proBNP (1.41 [95% CI, 1.01-1.95]; P=0.048), diabetes (1.46 [95% CI, 1.08-1.96]; P=0.01), elevated averaged mitral valve E/e' ratio (hazard ratio, 1.57 [95% CI, 1.18-2.10]; P<0.01), and presence atrial fibrillation at the time of index echocardiogram (hazard ratio, 1.83 [95% CI, 1.15-2.91]; P=0.01) were each independently associated with an increased hazard for the composite outcome and when taken collectively, each of these factors incrementally increased risk.

CONCLUSIONS

These results further elucidate the relatively poor short-medium term outcomes and risk stratification of patients with moderate aortic stenosis, supporting randomized trials assessing the efficacy of transcatheter aortic valve replacement in this population.

Epicardial adipose tissue and obstructive coronary artery disease in acute chest pain: the EPIC-ACS study

Aims

We tested the hypothesis that epicardial adipose tissue (EAT) quantification improves the prediction of the presence of obstructive coronary artery disease (CAD) in patients presenting with acute chest pain to the emergency department.

Methods and results

Within this prospective observational cohort study, we included 657 consecutive patients (mean age 58.06 ± 18.04 years, 53% male) presenting to the emergency department with acute chest pain suggestive of acute coronary syndrome between December 2018 and August 2020. Patients with ST-elevation myocardial infarction, haemodynamic instability, or known CAD were excluded. As part of the initial workup, we performed bedside echocardiography for quantification of EAT thickness by a dedicated study physician, blinded to all patient characteristics. Treating physicians remained unaware of the results of the EAT assessment. The primary endpoint was defined as the presence of obstructive CAD, as detected in subsequent invasive coronary angiography. Patients reaching the primary endpoint had significantly more EAT than patients without obstructive CAD (7.90 ± 2.56 mm vs. 3.96 ± 1.91 mm, P < 0.0001). In a multivariable regression analysis, a 1 mm increase in EAT thickness was associated with a nearby two-fold increased odds of the presence of obstructive CAD [1.87 (1.64-2.12), P < 0.0001]. Adding EAT to a multivariable model of the GRACE score, cardiac biomarkers and traditional risk factors significantly improved the area under the receiver operating characteristic curve (0.759-0.901, P < 0.0001).

Conclusion

Epicardial adipose tissue strongly and independently predicts the presence of obstructive CAD in patients presenting with acute chest pain to the emergency department. Our results suggest that the assessment of EAT may improve diagnostic algorithms of patients with acute chest pain.

Frequency and prognosis of CVD and myocardial injury in patients presenting with suspected COVID-19 - The CoV-COR registry

Background

The COVID-19 pandemic led to an alteration of algorithms in emergency medicine, which may influence the management of patients with similar symptoms but underlying cardiovascular diseases. We evaluated key differential diagnoses to acute COVID-19 infection and the prevalence and the prognosis of myocardial injury in patients presenting for suspected COIVD-19 infection.

Methods

This prospective observational study includes patients presenting with symptoms suggestive of COVID-19 infection during the pandemic. In patients without COVID-19, leading diagnoses was classified according to ICD-10. Myocardial injury was defined as elevated high-sensitivity Troponin I with at least one value above the 99th percentile upper reference limit and its prevalence together with 90-days mortality rate was compared in patients with vs without COVID-infection.

Results

From 497 included patients (age 62.9 ± 17.2 years, 56 % male), 314 (63 %) were tested positive on COVID-19 based on PCR-testing, while another cause of symptom was detected in 183 patients (37 %). Cardiovascular diseases were the most frequent differential diagnoses (40 % of patients without COVID-19), followed by bacterial infection (24 %) and malignancies (16 %). Myocardial injury was present in 91 patients (COVID-19 positive: n = 34, COVID-19 negative: n = 57). 90-day mortality rate was higher in patients with myocardial injury (13.4 vs 4.6 %, p = 0.009).

Conclusion

Cardiovascular diseases represent the most frequent differential diagnoses in patients presenting to a tertiary care emergency department with symptoms suggestive of an acute infection. Screening for cardiovascular disease is crucial in the initial evaluation of symptomatic patients during the COVID pandemic to identify patients at increased risk.Trial Registration:Clinicaltrials.gov Identifier: NCT04327479.

High- vs. Low-Intensity Statin Therapy and Changes in Coronary Artery Calcification Density after One Year

Background: Statin therapy promotes the progression of coronary artery calcification (CAC). Comparing patients on high (HIST) vs. low-to-intermediate intensity statin therapy (LIST), randomized controlled trials with a one-year follow-up failed to document a relevant difference in the Agatston score and CAC volume. We evaluated whether statin intensity modifies CAC density at one year. Methods: We performed a pooled analysis of two randomized-controlled trials (BELLES, EBEAT), comparing the effects of HIST (Atorvastatin 80 mg) vs. LIST (Pravastatin 40 mg, Atorvastatin 10 mg) on CAC measures after one year. The differences in CAC density and its change were compared using the two-sided t-test. Results: Data from 852 patients (66.7% female) with available baseline and follow-up CT were evaluated from both trials. HIST vs. LIST more effectively reduced LDL-cholesterol (annualized change: −45.8 ± 38.5 vs. −72.9 ± 46.0 mg/dL, p < 0.001). Mean CAC density increased from 228.8 ± 35.4 HU to 232.6 ± 37.0 HU (p < 0.0001) at one-year follow-up. Comparing patients on HIST vs. LIST, CAC density at follow-up (HIST: 231.9 ± 36.1 HU vs. LIST: 233.3 ± 37.7 HU, p = 0.59) and its change from baseline (HIST: 4.0 ± 19.1 HU vs. LIST: 3.6 ± 19.6 HU, p = 0.73) did not differ. Subgroup analyses, stratifying by LDL reduction (<median: 2.0 ± 24.3 HU, ≥median: 3.6 ± 21.9 HU, p = 0.34), Agatston score at baseline (<100: 2.6 ± 22.5 HU vs. 3.2 ± 25.6 HU, p = 0.82; ≥100: 4.8 ± 17.0 HU vs. 3.8 ± 16.6 HU, p = 0.44, for HIST vs. LIST; respectively), and equal number of lesions in both CT scans (3.7 ± 20.3 HU vs. 7.0 ± 22.2 HU, p = 0.24) showed similar results. Conclusion: HIST vs. LIST leads to a higher reduction in cholesterol levels, which does not translate into relevant differences in the change of CAC density at one-year follow-up.

Association between haematological parameters and outcomes following transcatheter aortic valve implantation at mid-term follow-up

BACKGROUND

Patients undergoing transcatheter aortic valve implantation (TAVI) often have multiple comorbidities, such as anaemia and chronic inflammatory disorders. We sought to investigate the association between preoperative and postoperative haematological parameters and clinical outcomes in TAVI patients at mid-term follow-up.

METHODS

In the present study, consecutive patients (N=908) who underwent TAVI at the Cleveland Clinic between 2017 and 2019 with available complete blood counts were studied. Data were collected on preoperative and postoperative anaemia and elevations in neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR). Survival analysis was used to study the association of haematologic parameters with all-cause mortality and major adverse cardiac and cerebrovascular events (MACCE).

RESULTS

We found that preoperative anaemia and elevated NLR were significantly associated with a higher risk of all-cause mortality (aHR=1.6 (95% CI: 1.1 to 2.0) and 1.4 (95% CI: 1.1 to 1.6), respectively) and MACCE (aHR=1.9 (95% CI: 1.3 to 2.8) and 1.6 (95% CI: 1.1 to 2.4), respectively). While an elevated preoperative PLR was not associated with increased mortality risk, it had a significant association with MACCE risk (aHR: 1.6 (95% CI: 1.1 to 2.4)). Further, postoperative anaemia, elevated NLR and PLR were associated with increased risks of all-cause mortality and MACCE.

CONCLUSION

Pathological alterations in haematological parameters were associated with higher risks of post-TAVI mortality and MACCE at mid-term follow-up. Our findings advocate for further incorporating haematological parameters in the preoperative evaluation of TAVI candidates.

Association of lipoprotein(a) levels with all-cause mortality following percutaneous coronary intervention

Background

Although lipoprotein(a) (Lp(a)) is a causal genetic risk factor for atherosclerotic cardiovascular disease, the prognostic value of elevated Lp(a) in coronary artery disease (CAD) patients is inconsistent in previous studies. The precise impact of Lp(a) itself on all-cause mortality in addition to the changes in low-density lipoprotein cholesterol (LDL-C) levels remains uncertain.

Purpose

We tested the hypothesis that Lp(a) levels in CAD patients is associated with long-term mortality, and such an association can by modified by LDL-C levels.

Methods

The present analysis is based on the longitudinal ECAD registry of consecutive patients undergoing coronary angiography with percutaneous revascularization therapy at the West German Heart and Vascular Center between 2004 and 2019. Lp(a) was quantified at hospital admission using a particle-enhanced immunonephelometric method. The incidence of death due to any cause was evaluated during follow-up. Cox regression analysis was used to determine the association between Lp(a) and all-cause mortality, adjusting for age, sex, LDL-C, smoking status, and family history of premature cardiovascular disease.

Results

Among 4941 patients (mean age 66.4±11.5 years, 77.8% male), median Lp(a) was 16 (7; 56) mg/dL and 1817 (36.8%) patients had elevated Lp(a) levels (≥30 mg/dl). During a median follow-up 3.1 years, 604 patients (12.2%) died. In multivariable Cox regression analysis, elevated Lp(a) was associated with an increased risk of all-cause mortality (Hazard ratio (HR): 1.23, [95% confidence interval (CI): 1.04; 1.45] p=0.01). When stratified by LDL-C category, only patients with LDL-C ≥100 mg/dL showed a significant association between Lp(a) and higher all-cause mortality (HR: 1.47; [1.16, 1.19], p&lt;0.001), whereas Lp(a) levels were not linked with adverse prognosis, if LDL was better controlled (LDL&lt;100mg/dl: 1.00; [0.79, 1.26], p=0.98).

Conclusions

In a large longitudinal registry cohort of patients with CAD undergoing invasive coronary angiography, elevated Lp(a) was associated with increased long-term mortality. LDL-C control seem to interact with the impact of Lp(a) levels on the patient's prognosis following percutaneous revascularization therapy.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only.

Epicardial and pericoronary fat volume and attenuation, lipid lowering therapy and coronary high risk coronary plaque burden

Background

Epicardial (EAT) and pericoronary adipose tissue (PCAT) are known as risk predictors of subclinical atherosclerosis and coronary artery disease. We aimed to evaluate the association of EAT and PCAT volume and attenuation with the presence of high risk coronary plaque burden in patients with vs. without lipid lowering therapy.

Methods

In the present retrospective analysis a total of 321 patients undergoing coronary CTA at the XXX were included. EAT and PCAT were manually traced from CT imaging for assessment of fat volume and attenuation. According to the SCCT guidelines for the interpretation of coronary CTA, each coronary segment was evaluated for the presence of high risk plaque features (napkin ring sign, spotty calcification, positive remodeling, and low attenuation plaque).

Results

Overall data from 321 patients (mean age: 55.5±14.7 years, 62% male) and a total of 5778 coronary segments were included in our analysis. The cohorts consists of 116 patients without plaque and stenosis, 96 patients with plaque but no significant stenosis and 109 patients with obstructive coronary stenosis. Highest rates of the presence of coronary plaque were detected in proximal LAD (17.9%), followed by mid LAD (12.9%) and proximal RCA (10.8%). Coronary stenosis was also most common in proximal LAD (14.6%), followed by mid LAD (12.1%) and proximal RCA (11%). High risk plaque features were found in 401 segments and were most frequently located in the proximal LAD (21.4%). EAT volume increased with higher rates of stenosis and plaque (44.7±25.2ml vs. 68,2±28,5ml vs. 85.2±31.7ml, p&lt;0.001). Prevalence of high risk plaque increased by higher EAT volume (OR [95% CI]: 3.17 [2.33–4.33], p&lt;0.0001) and remains stable after upon adjustment for risk factors (2.32 [1.46–3.7], p&lt;0.0001). EAT attenuation also significantly associated with the presence of high risk plaques with 0.68-folded risk in the unadjusted (0.68 [0.53–0.88], p=0.003), and 0.62-folded risk in the multivariate (MV) adjusted regression analysis (0.62 [0.45–0.85], p=0.003). However, for PCAT only its volume but not its attenuation was significantly associated with presence of high risk plaques in MV-adjusted regression analysis (PCAT volume: 2.25 [1.02–4.96], p=0.044; PCAT attenuation: 0.84 [0.63–1.12], p=0.24). Furthermore, patients receiving lipid-lowering therapy showed a significantly lower probability for high risk plaque detection (0.17 [0.14–0.21], p&lt;0.0001). These findings remained stable after multivariate adjustment (0.27 [0.21–0.35], p&lt;0.0001).

Conclusion

EAT volume and attenuation as well as PCAT volume associate with high risk plaques independent of traditional cardiovascular risk factors. In contrast, we found no significant association of PCAT attenuation with high risk coronary atherosclerosis. Our results encourage further research to evaluate the interplay of lipid-lowering therapy and EAT on plaque composition.

Funding Acknowledgement

Type of funding sources: None.

High- vs. low-intensity statin therapy and changes in coronary artery calcification density after one year

Introduction

High-dose statin therapy (HIST) halts coronary plaque progression and reduces the risk of cardiovascular events by increasing atheroma calcification. The Agatston score is well established in the clinical routine for assessment of coronary artery calcification using non-contrast computed tomography. However, randomized controlled trials failed to detect an influence of HIST vs. low-to-intermediate statin therapy (LIST) on the Agatston and CAC volume score after one year. Coronary plaques with lower density including spotty calcifications may represent dynamic and early stages of atherosclerosis. We evaluated whether CAC density differentiates in HIST- vs. LIST-treated patients after one year.

Methods

The meta-analysis contains data from two prospective, randomized, double-blind studies (BELLES, EBEAT) that were designed to detect CAC changes after one year comparing HIST vs. LIST. In both studies, patient's coronary calcification burden was measured at baseline and one-year follow-up using electron beam computed tomography (EBCT). Patients data were pooled and stratified by intensity of statin therapy. Furthermore, the cohort was divided into several subgroup analyses, accounting for LDL-Cholesterol reduction, initial Agatston score and a consistent number of lesions.

Results

Data from 852 patients, 66% female were included. The amount of CAC overall increased after 1 year [Agatston score: 169.3 (80.0, 377.1) vs. 214.9 (95.4, 450.0); p&lt;0.0001NP; volume score: 292.1±445.4 vs. 355.5±482.4; p&lt;0.0001; number of lesions: 6 (3,10) vs. 7 (4,12); p&lt;0.0001NP, at baseline and follow-up, respectively]. Likewise, the average CAC density was higher at follow-up [CAC density: 228.8±35.4 vs. 232.6±37.0; p&lt;0.0001]. HIST vs. LIST more effectively reduced LDL-cholesterol (annualized change: −58.6±50.9 vs. −44.4±43.7 mg/dL, p=0.005). Comparing patients on HIST vs. LIST, CAC density at follow-up (231.9±36.1 HU vs. 233.3±37.7, p=0.59) and its change from baseline (4.0±19.1 HU vs. 3.6±19.6 HU, p=0.73) did not differ. Subgroup analyses, stratifying by LDL-reduction (

Conclusion

HIST vs. LIST leads to a higher reduction in cholesterol levels, which does not translate into relevant differences in the change of CAC density at one-year follow-up.

Funding Acknowledgement

Type of funding sources: None.

Neuronal nets and logistic regression analysis provide improved prediction of infective endocarditis compared to the modified Duke Score: a post-hoc analysis of the prospective PRO-ENDOCARDITIS study

Introduction

The modified Duke score is the currently recommended diagnostic algorithm in suspected infective endocarditis (IE). The categorization in major and minor criteria enables an easy clinical application, but may not optimally utilize individual patient's information. In contrast, detailed statistical evaluation of multiple characteristics using artificial intelligence and logistic regression report improved prediction of various cardiovascular diseases over conventional clinical strategies. We tested the hypothesis that neuronal nets and logistic regression analysis would provide improved prediction of IE as compared to the modified Duke score.

Methods

This post-hoc evaluation of the prospective observational PRO-ENDOCARDITIS study was conducted at the West German Heart and Vascular center between December 2017 and May 2019 and includes 261 patients. Duke criteria and clinical characteristics were prospectively collected. Transesophageal echocardiography (TEE) imaging was evaluated by a blinded cardiologist at a central core-lab. IE as primary endpoint was adjudicated by an independent clinical endpoint committee. The database was divided into a training (70%) and validation cohort (30%). We compared the value of the Duke score, neuronal nets and logistic regression analysis for prediction of the primary endpoint.

Results

The mean age was 60.1±16.1 years, 37.2% were female. In 47 cases, IE was present. The modified Duke score achieved an AUC of 0.863 in the training cohort and 0.913 within the validation cohort. The logistic regression and the neural net exceeded the predictive value in both cohorts (training cohort: 0.992 and 0.986; validation cohort: 0.964, 0.957; for logistic regression and neuronal nets, respectively, Figure 1). Without the use of TEE, the remaining Duke criteria only poorly predicted IE (training cohort: 0.771, 0.951 and 0.938; validation cohort: 0.835, 0.862 and 0.780, for the Duke score, logistic regression and neuronal nets, respectively).

Discussion

Logistic regression analysis and neuronal nets provide improved prediction of IE as compared to the clinically established modified Duke score. Further studies on larger databases are needed to confirm our results and provide algorithms for clinical routine.

Funding Acknowledgement

Type of funding sources: None.

Hemoglobin A1c and long-term mortality in patients undergoing coronary angiography: the ECAD registry

Background

Hemoglobin A1c (HbA1c) reflects long-time glycemic control and is associated with an increased risk of cardiovascular events among diabetic and non-diabetic patients. The precise impact of HbA1c itself on the all-cause mortality in addition to the control of other cardiovascular risk factors remains uncertain.

Purpose

We tested the hypothesis that HbA1c levels associate with long-term mortality.

Methods

The present analysis is based on the longitudinal ECAD registry of consecutive patients undergoing coronary angiography with percutaneous coronary intervention at the West German Heart and Vascular Center between 2004 and 2019. HbA1c was quantified at hospital admission using standardized enzymatic methods. The incidence of death due to any cause was evaluated during follow-up. Cox regression analysis was used to determine the association of HbA1c with incident mortality, adjusting for age, sex, systolic blood pressure, low-density lipoprotein cholesterol, smoking status, and family history of premature cardiovascular disease. In addition to the analysis on HbA1c as continuous variable, the association of HbA1c-groups (≤10th percentile, &gt;10th-&lt;25th percentile, 25th-&lt;50th percentile, 50th-&lt;75th percentile, 75th-&lt;90th percentile, and ≥90thpercentile) with incident mortality was determined using HbA1c &gt;10th-&lt;25th percentile as reference.

Results

Among 4700 patients, mean age was 66.1±11.4 years and 77.1% were men. Mean HbA1c was 6.3±1.2%. During a median follow-up of 3.0 years, 558 patients (8.4%) died. In multivariable analysis, higher HbA1c levels were independently associated with all-cause mortality (hazard ratio [95% confidence interval]: 1.15 [1.06, 1.25] per 1 standard deviation change in HbA1c, p&lt;0.001). Using HbA1c &gt;5.3–5.6% as reference, we observed a U-shaped event rate for different HbA1c groups (≤5.3%: 1.69 [1.20; 2.37], p=0.003; &gt;5.6–5.9%: 0.95 [0.68; 1.63], p=0.8, &gt;5.9–6.6%: 1.19 [0.87; 1.61], p=0.3, &gt;6.6–7.8: 1.66 [1.18; 2.35], p=0.004, &gt;7.8%: 2.04 [1.43; 2.9], p&lt;0.001).

Conclusions

In a large longitudinal registry cohort of patients following percutaneous coronary intervention, we observe a U-shaped association of HbA1c levels with long-term mortality with best prognosis of patients in the range of HbA1c levels between 5.3 and 5.9%.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only.

Longitudinal High-Sensitivity C-Reactive Protein and Longer-Term Cardiovascular Outcomes in Optimally-Treated Patients With High-Risk Vascular Disease

The relation between serial high-sensitivity C-reactive protein (hsCRP) and long-term major cardiovascular events (MACEs; cardiovascular death, myocardial infarction, stroke, coronary revascularization, hospitalization for unstable angina) has not been explored in optimally-treated patients with atherosclerotic cardiovascular disease. We tested the hypothesis that longitudinal follow-up hsCRP (repeated measures over time) would associate with 30-month MACE rates. We performed a post hoc analysis of ACCELERATE (Assessment of Clinical Effects of Cholesteryl Ester Transfer Protein Inhibitor with Evacetrapib in Patients with High-Risk for Vascular Outcomes), involving optimally-treated patients with high-risk vascular disease, with available baseline and at least 1 follow-up hsCRP level. Using multivariable Cox proportional hazard models, we determined the association of longitudinal follow-up hsCRP with MACE at 30 months among 8,563 patients (aged 64.6 ± 9 years, 22% women). Patients with incident MACE (n = 961) had higher baseline hsCRP levels (1.77 vs 1.46 mg/L, p <0.0001 for patients with and without MACE, respectively) and showed an upward trajectory during follow-up, whereas median hsCRP levels remained <2 mg/L at all time points (1.83 vs 1.53 mg/L, 1.91 vs 1.53 mg/L, 1.76 vs 1.37 mg/L, at 3, 12, and 24 months, respectively). In a multivariable analysis, higher longitudinal hsCRP levels were independently associated with MACE (hazard ratio [95% confidence interval] per SD 1.19 [1.10 to 1.29], p <0.001), the majority of its individual components and all-cause death. Multivariable models containing longitudinal hsCRP provided improved predictive ability of MACE over baseline hsCRP. In the setting of established medical therapies, longitudinal follow-up hsCRP was independently associated with long-term MACE. In conclusion, these findings suggest that longitudinal hsCRP represents a novel approach of residual cardiovascular risk even when on-treatment hsCRP levels remain <2 mg/L.

Higher BNP/NT-pro BNP levels stratify prognosis equally well in patients with and without heart failure: a meta-analysis

AIMS

The initial and dynamic levels of B-type natriuretic peptide (BNP) and N-terminal-prohormone BNP (NT-proBNP) are routinely used in clinical practice to identify patients with acute and chronic heart failure. In addition, BNP/NT-proBNP levels might be useful for risk stratification in patients with and without heart failure. We performed a meta-analysis to investigate, whether the value of BNP/NT-proBNP as predictors of long-term prognosis differentiates in cohorts with and without heart failure.

METHODS AND RESULTS

We systematically searched established scientific databases for studies evaluating the prognostic value of BNP or NT-proBNP. Random effect models were constructed. Data from 66 studies with overall 83 846 patients (38 studies with 46 099 patients with heart failure and 28 studies with 37 747 patients without heart failure) were included. In the analysis of the log-transformed BNP/NT-proBNP levels, an increase in natriuretic peptides by one standard deviation was associated with a 1.7-fold higher MACE rate (hazard ratio [95% confidence interval]: 1.74[1.58-1.91], P < 0.0001). The effect sizes were comparable, with a substantial overlap in the confidence intervals, when comparing studies involving patients with and without heart failure (1.75[1.54-2.0], P < 0.0001 vs. 1.74[1.47-2.06], P < 0.0001). Similar results were observed when stratifying by quartiles of BNP/NT-proBNP. In studies using pre-defined cut-off-values for BNP/NT-proBNP, elevated levels were associated with the long-term prognosis, independent of the specific cut-off value used.

CONCLUSIONS

BNP/NT-proBNP levels are predictors for adverse long-term outcome in patients with and without known heart failure. Further research is necessary to establish appropriate thresholds, especially in non-heart failure cohorts.

Epicardial fat and incident heart failure with preserved ejection fraction in patients with coronary artery disease

BACKGROUND

We aimed to determine, whether epicardial adipose tissue (EAT) as local source of inflammation, as well as its change over time, associates with the development of heart failure with preserved ejection fraction (HFpEF) in patients with coronary artery disease.

METHODS AND RESULTS

We retrospectively included 379patients (aged 65.2 ± 11.7 years, 70.2%male) with coronary artery disease but without heart failure at baseline, undergoing clinical and echocardiographic assessment in 2010-2013 and receiving a second assessment in 2014-2018. EAT thickness was defined as space between the myocardium and the pericardium and indexed (EATi) by body surface area. Change in EATi was calculated as the difference of follow-up and baseline EATi. HFpEF was defined according to presence of dyspnea, elevated natriuretic peptides, and structural and/or functional alterations on echocardiography in accordance with current European Society of Cardiology guidelines. During a median follow-up of 4.3 years, 142patients (37.5%) developed HFpEF. Patients with onset of HFpEF had higher EATi at baseline (2.4 ± 1.3 vs. 1.9 ± 0.9 mm/m², p = 0.001). In multivariable regression analysis, EATi associated with onset of HFpEF (1.25 [1.01-1.54], p = 0.04). Likewise, an increase in EATi over time was linked HFpEF development, independent of other risk factors and baseline EATi (1.39 [1.04-1.87], p = 0.03). EATi was significantly associated with follow-up b-type natriuretic peptide (BNP) levels (4.31[0.58-8.05], p = 0.024), but not with baseline BNP (2.24[-0.27-4.76], p = 0.08).

CONCLUSION

EATi is associated with the development of HFpEF. The finding of changes in EATi altering the risk of HFpEF manifestation support the rationale for further research on epicardial fat modulation as a treatment target for HFpEF.

Risk Stratification and Management of Advanced Conduction Disturbances Following TAVI in Patients With Pre-Existing RBBB

Background

Pre-existing right bundle branch block (RBBB) is a strong predictor of increased need for a permanent pacemaker (PPM) following transcatheter aortic valve implantation (TAVI). Yet, further risk stratification and management remain challenging in patients with pre-existing RBBB owing to limited data. Therefore, we sought to investigate the incidence, predictors, and management of advanced conduction disturbances after TAVI in patients with pre-existing RBBB.

Methods

We retrospectively reviewed 261 consecutive patients with pre-existing RBBB (median age 81 years; 28.0% female; 95.0% received a balloon-expandable valve) without a pre-existing PPM who underwent TAVI at our institution in 2015-2019. Outcomes were high-degree atrioventricular block/complete heart block (HAVB/CHB) and PPM requirement.

Results

Overall, the 30-day HAVB/CHB rate was 28.0%, of which 76.7% occurred during the TAVI procedure. The delayed HAVB/CHB rate was 8.3%. Implantation depth below aortic annulus (per 1-mm increase) was significantly associated with increased risk of procedural HAVB/CHB (adjusted odds ratio = 1.25, 95% confidence interval = 1.07-1.46), delayed HAVB/CHB (1.34 [1.01-1.79]), and 30-day PPM (1.32 [1.11-1.55]). Predilation was associated with delayed HAVB/CHB (4.02 [1.22-13.23]). The combination of no predilation and implantation depth of ≤2.0 mm had lower rates of procedural HAVB/CHB (11.2% vs. 26.7%-30.4%, p = 0.011), delayed HAVB/CHB (2.1% vs. 7.6%-28.1%, p < 0.001), and 30-day PPM (10.3% vs. 20.0%-43.5%, p < 0.001) than the other strategies of valve deployment. Complete HAVB/CHB recovery after PPM implantation was uncommon at 7.1%.

Conclusions

In patients with pre-existing RBBB, the majority of HAVB/CHB events occurred during the TAVI procedure. Avoidance of predilation coupled with high valve deployment may result in relatively low rates of procedural and delayed HAVB/CHB, along with 30-day PPM rates.

Early Resolution of New-Onset Left Bundle Branch Block After Transcatheter Aortic Valve Implantation With the SAPIEN 3 Valve

New-onset left bundle branch block (LBBB) is common after transcatheter aortic valve implantation (TAVI) but can resolve in the post-TAVI period. We sought to examine the incidence, predictors, and outcomes of early resolution of new-onset LBBB among TAVI recipients with a SAPIEN 3 (S3) valve. Among 1,203 S3-TAVI recipients without a pre-existing pacemaker or wide QRS complex at our institution between 2016 and 2019, we identified 143 patients who developed new-onset LBBB during TAVI and divided them according to the resolution or persistence of LBBB by the next day post-TAVI to compare high-degree atrioventricular block (HAVB) and permanent pacemaker (PPM) rates. Patients with resolved LBBB (n = 74, 52%), compared with those with persistent LBBB, were more often women and had a shorter QRS duration at baseline and post-TAVI, with a smaller S3 size and a shallower implantation depth. A multivariable logistic regression model demonstrated significant associations of post-TAVI QRS duration (per 10 ms increase, odds ratio = 0.60 [95% confidence interval = 0.44 to 0.82]) and implantation depth (per 1-mm-depth-increase, 0.77 [0.61 to 0.97]) with a lower likelihood of LBBB resolution. No patient with resolved LBBB developed HAVB within 30 days post-TAVI. Meanwhile, 8 patients (11.6%) with persistent LBBB developed HAVB. The 2-year PPM rate was significantly higher after persistent LBBB than after resolved LBBB (30.3% vs 4.5%, log-rank p <0.001), mainly driven by higher 30-day PPM rate (18.8% vs 0.0%). In conclusion, about half of new-onset LBBBs that occurred during S3-TAVI resolved by the next day post-TAVI without HAVB. In contrast, new-onset persistent LBBB may need follow-up with ambulatory monitoring within 30 days because of the HAVB risk.

Evaluation of the 2021 European Society of Cardiology guidelines in pre-existing right bundle branch block patients undergoing transcatheter aortic valve implantation with a balloon-expandable valve

Aims

The 2021 European Society of Cardiology guidelines recommend early pacemaker implantation in pre-existing right bundle branch block (RBBB) patients who develop PR prolongation or QRS axis change after transcatheter aortic valve implantation (TAVI). We aimed to evaluate this recommendation in TAVI recipients with a balloon-expandable valve (BEV).

Methods and results

We retrospectively reviewed 188 pre-existing RBBB patients without pre-existing permanent pacemaker (PPM) who underwent TAVI with a BEV at our institution in 2015–19. Patients who developed high-degree atrioventricular block (HAVB) during TAVI or within 24 h post-TAVI were excluded. Eligible patients were divided according to the guideline-directed criteria (ΔPR interval ≥20 ms and/or QRS axis change). Patients who met the criteria (n = 102, 54.3%), compared with those who did not (n = 86), had a higher prevalence of baseline right axis deviation and were more likely to have received a larger valve with greater oversizing. The 30-day delayed HAVB rate did not differ significantly between the groups (3.9% vs. 4.7%, P = 1.00; odds ratio = 0.84, 95% confidence interval = 0.20–3.45). There was also no significant difference in terms of death (5.0% vs. 8.4% at 1 year; overall log-rank P = 0.94) or a composite of death or PPM implantation (14.8% vs. 16.6% at 1 year; overall log-rank P = 0.94) during follow-up post-TAVI. The majority of PR prolongations (79.4%) and QRS axis changes (52.0%) regressed within the following 24 h.

Conclusion

The present data did not demonstrate an association of significant changes in PR interval or QRS axis with heightened delayed HAVB risk in BEV recipients with pre-existing RBBB. Prospective studies are warranted to confirm these findings.

HbA1c, Coronary atheroma progression and cardiovascular outcomes

Background and aims

We tested the hypothesis that on-treatment HbA1c levels independently associate with coronary atheroma progression and major adverse cardiovascular events (MACE: death, myocardial infarction, cerebrovascular accident, coronary revascularization, or hospitalization for unstable angina) rates.

Methods

We performed a post-hoc pooled analysis of data from seven prospective, randomized trials involving serial coronary intravascular ultrasonography (IVUS). The percent atheroma volume (PAV) was calculated as the proportion of the entire vessel wall occupied by atherosclerotic plaque. Using multivariable mixed modeling, we determined the association of on-treatment HbA1c with annualized change in PAV. Cox proportional hazard models were used to assess the association of HbA1c with incidence of MACE.

Results

Among 3,312 patients (mean age 58.6±9years, 28.4%women) average on-treatment HbA1c was 6.2±1.1%. Overall, there was no net significant annualized change in PAV (0.12±0.19%, p = 0.52). In a fully adjusted multivariable analysis (following adjustment of age, sex, body mass index, systolic blood pressure, smoking, low- and high-density lipoprotein cholesterol, triglyceride levels, peripheral vascular disease, trial, region, and baseline PAV), higher on-treatment HbA1c levels were independently associated with annualized changes in PAV [beta-estimate (95% confidence interval): 0.13(0.08, 0.19), p < 0.001]. On-treatment HbA1c levels were independently associated with MACE [hazard ratio (95% confidence interval): 1.13(1.04, 1.23), p = 0.005].

Conclusions

Independent of achieved cardiovascular risk factor control, greater HbA1c levels significantly associate with coronary atheroma progression rates and clinical outcomes. These results support the notion of a direct, specific effect of glycemic control upon coronary atheroma and atherosclerotic events, supporting the rationale of therapies designed to directly modulate it.

Epicardial adipose tissue is a robust measure of increased risk of myocardial infarction - a meta-analysis on over 6600 patients and rationale for the EPIC-ACS study

BACKGROUND

Epicardial adipose tissue (EAT) surrounds the heart and the coronary vessels. EAT produces pro- and anti-inflammatory cytokines. Several studies have already documented the association of EAT and cardiovascular risk factors as well as coronary artery disease manifestations. Currently computed tomography (CT) is considered the gold standard for measurement of 3-dimensional volume of EAT. In addition, echocardiography might be an easy accessible alternative in particular in an emergency setting.

METHODS

We performed a metaanalysis of existing studies describing the differences of EAT in patients with and without myocardial infarction. We used established databases and were searching for "epicardial adipose tissue" or "pericardial adipose tissue" and "myocardial infarction", "coronary events", or "acute coronary syndrome". We included over 6600 patients from 7 studies. Random effect models were calculated and all analyses were performed by using the Review Manager 5.3.

RESULTS

Patients with myocardial infarction had 37% (confidence interval [0.21-0.54], P value <.001)] higher measures of EAT compared to patients without myocardial infarction. Comparing studies using echocardiography vs CT for assessment of EAT thickness, similar relative differences in EAT with wide overlap of confidence intervals were observed (for echocardiography: 0.4 [0.04-0.76], for CT: 0.36 [0.16-0.57], P value <.001 for both).

CONCLUSIONS

Patients with myocardial infarction have more EAT as compared to patients without myocardial infarction independently of the used imaging modality. Further prospective studies are needed to evaluate, how quantification of EAT in clinical routine can improve patients management.

Positive family history of premature coronary artery disease and long-term mortality in patients undergoing conventional coronary angiography. The ECAD registry

Background

The clinical value of positive family history of premature coronary artery disease (CAD) in risk prediction of cardiovascular diseases is controversial. While an association with risk factors and disease manifestation has been described in observational studies, it is not implemented in clinically established risk algorithms.

Purpose

We evaluated the association of positive family history of premature CAD with cardiovascular risk factors, presence of obstructive CAD, and long-term mortality.

Methods

The present analysis is based on the ECAD registry of patients undergoing invasive coronary angiography at the Department of Cardiology and Vascular Medicine at the University Clinic Essen between 2004 and 2019. For this analysis, we excluded all patients with missing follow-up information. Self-reported family history of premature CAD was categorized as positive, negative, or unknown. Baseline characteristics and presence of obstructive CAD were compared between patient with and without positive family history. Cox regression analysis was used to determine the association of positive family history with morality.

Results

Overall, data from 33,865 patient admissions (mean age: 65.0±13.1 years, 69% male) were included. Positive family history was present in 4,995 (14.8%) patients, negative family history in 17,806 patients (52.6%), while family history of premature CAD was unknown in 11,064 (32.7%) patients. Patients with positive family history were significantly younger (63.6±12.4 vs. 65.9±13.3 years, p&lt;0.0001), more frequently had diabetes (11.4 vs. 9.3%, p&lt;0.0001), and more frequently were active smokers (23.5 vs. 13.8%, p&lt;0.0001). Obstructive CAD with need for revascularization therapy was more frequently present in patients with positive family history (36.2 vs. 30.2%, p&lt;0.0001), while highest rate of obstructive CAD was observed in patients without known status regarding family history (37.9%, p&lt;0.0001). In multivariable Cox regression analysis, known positive family history as compared to no family history of premature CAD was associated with best long-term survival (hazard ratio [95% confidence interval]: 0.65 [0.59–0.70], p&lt;0.0001), while slightly higher mortality was observed for patients with unknown status (1.14 [1.08–1.21], p&lt;0.0001). Kaplan-Meier analysis revealed, that patients with unknown family status regarding premature disease had worst short to intermediate-term survival (figure 1).

Conclusion

Positive family history of premature CAD is associated with younger age, higher rates of smoking and diabetes, and higher frequency of obstructive coronary artery disease, while long-term survival was improved as compared to patients without family history of premature CAD. In contrast, patients with unknown status regarding family history of CAD seem to represent a heterogeneous cohort and may qualify for intensified workup, as they have highest rates of obstructive CAD and poorest short- to intermediate survival.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Survival by status of family history

HbA1c, coronary atheroma progression and cardiovascular events

Background

Hemoglobin A1c (HbA1c) reflects long-term glycemic control and is associated with an increased risk of cardiovascular events among diabetic and non-diabetic patients. The specific impact of HbA1c upon atheroma progression and incident cardiovascular events relative to the presence of other cardiovascular risk factors remains uncertain.

Purpose

We tested the hypothesis that on-treatment HbA1c levels independently associate with coronary atheroma progression measured with serial intravascular ultrasonography (IVUS) and major adverse cardiovascular events (MACE: death, myocardial infarction, cerebrovascular accident, coronary revascularization, or hospitalization for unstable angina) rates.

Methods

We performed a post-hoc pooled analysis of data from eight prospective, randomized trials involving serial coronary IVUS. HbA1c was measured at baseline and the average of the follow-up values was taken. The percent atheroma volume (PAV) was calculated as the proportion of the entire vessel wall occupied by atherosclerotic plaque, throughout the segment of interest. Using multivariable mixed modeling, we determined the association of HbA1c with annualized change in PAV. Cox proportional hazard models were used to assess the association of HbA1c with incidence of MACE.

Results

Among 2,791 patients, mean age was 58.9±9 years and 29.1% were women. Mean on-treatment low-density lipoprotein (LDL)-cholesterol was 80.2±33.7 mg/dl and median on-treatment triglycerides (TG) were 125.5 (94.7, 170.2) mg/dl. Mean baseline and follow-up HbA1c was 6.2±1.2% and 6.3±1.2%, respectively. Overall, there was no net significant annualized change in PAV (0.15±0.21, p=0.47). In a fully adjusted multivariable analysis (following adjustment of age, sex, body mass index (BMI), systolic blood pressure, smoking, LDL- and high-density lipoprotein cholesterol, TG levels, peripheral artery disease, trial, region, and baseline PAV), higher on-treatment HbA1c levels were independently associated with annualized changes in PAV [beta-estimate (95% confidence interval): 0.13 (0.07, 0.19), p&lt;0.001]. On-treatment HbA1c levels were significantly and independently associated with incidence of MACE [hazard ratio (95% confidence interval): 1.17 (1.07, 1.28), p&lt;0.001].

Conclusions

Independent of achieved cholesterol levels, vascular risk factors and BMI, greater HbA1c levels significantly associate with coronary atheroma progression and clinical outcomes. These results support the notion of a direct, specific effect of glycemic control upon the natural history of coronary atheroma and atherosclerotic events, supporting the rationale of therapies designed to directly modulate it.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Iryna Dykun was supported by the German Research Foundation

Increased long-term mortality in patients with type 2 myocardial infarction, data from the ECAD registry

Background

The characterization of five different clinical types of acute myocardial infarction (MI) was recently updated in 2018. Type 1 MI is caused by plaque rupture leading to an acute atherothrombotic coronary event. Type 2 MI is an entity where a condition other than coronary artery disease leads to a critical imbalance between oxygen supply and demand. There exist controversial data about the prognosis of patients with type 2 MI. While some studies have shown that type 2 MI is associated with higher mortality rates compared to type 1 MI, other trials revealed comparable mortality rates after multivariate adjustment.

Purpose

The aim of the present study was to compare the mortality rates of patients without MI with patients, which presented with type 1 and type 2 MI.

Methods

The present analysis is a longitudinal registry analysis based on the Essen Registry of Coronary Artery Disease (ECAD registry) of patients undergoing coronary angiography at the West German Heart and Vascular Center, Department of Cardiology and Vascular Medicine, at the University Hospital Essen between 2004 and 2019. Type 1 MI was defined as a significant increased troponin level (Siemens Troponin I (Dimension) &gt;0,1 ng/ml and Troponin I Ultra (Centaur) &gt;40 ng/l) and coronary stenosis requiring intervention. Type 2 MI was defined as a significant troponin increase without percutaneous coronary intervention. During follow up, the all-cause mortality of patients without MI and patients with type 1 and 2 MI was investigated. Cox regression analysis was used to determine the association of type 1 and 2 MI with all-cause mortality. Multivariable adjustment was performed for age, sex, low-density lipoprotein cholesterol, systolic blood pressure, diabetes, family history of coronary artery disease and nicotine abuse.

Results

Overall, data from 18,286 coronary angiography exams (mean age 65.3±13.0 years, 71.6% male) were included in our analysis. 14,883 patients (81.3%) had no MI, 1,699 patients (9.3%) presented with type 1 MI and 1,704 patients (9.3%) presented with type 2 MI. During a mean follow-up of 3.4±3.6 years, 3321 deaths occurred (18.2%). Compared to patients without MI (16.1%), patients with type 1 MI (25.2%) and type 2 MI (29.1%) had significant higher mortality rates (p= &lt;0.0001). In Cox unadjusted and multivariable adjusted regression analysis, Type 1 MI (Hazard ratio [standard deviation]: 1.42 [1.14–1.76], p=0.0015) and type 2 MI (2.326 [1.91–2.84], p= &lt;0.0001) were significantly associated with an increased all-cause mortality compared to patients without MI. Kaplan-Meier analysis confirmed the lowest survival rates for patients with type 2 MI (Figure 1).

Conclusion

In this large longitudinal registry cohort of patients undergoing invasive coronary angiography, type 2 MI was associated with impaired long-term survival. Prospective studies are required to determine risk stratification for these high-risk populations.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Regional wall motion abnormalities predict culprit lesions in patients presenting with acute chest pain

Background

Current ESC guidelines for non-ST-segment elevation myocardial infarction suggest the utilization of echocardiography in patients with inconclusive initial electrocardiography and cardiac enzymes. Besides detection of alternative pathologies associated with chest pain, echocardiography can screen for wall motion abnormalities (WMA) as sign of myocardial necrosis.

Purpose

We evaluated the ability of the assessment of regional WMA, detected via transthoracic echocardiography, to predict the presence of culprit lesions in patients presenting with acute chest pain to the emergency department.

Methods

In this prospective single-centre observational cohort study, we included consecutive patients presenting to the emergency department of our University Hospital with acute chest pain, suggestive of an acute coronary syndrome, between December 2018 and August 2020. Patients with ST-elevation myocardial infarction, hemodynamic instability, or known coronary artery disease were excluded. As part of initial workup, patients received bedside echocardiography for the assessment of regional WMA by a dedicated study physician, blinded to all patients' characteristics. The primary endpoint was defined as the presence of culprit lesions as detected in subsequent invasive coronary angiography, requiring coronary revascularization therapy. Logistic regression analysis was performed in different models adjusted for traditional cardiovascular risk factors, cardiac biomarkers as well as established risk scores. Area under the receiver operating characteristics curve (AUC) was calculated to assess a potential improvement in the prediction of culprit lesions.

Results

Overall, 657 patients (age 58.06±18.04 years, 53% male) were included in our study. WMA were detected in 76 patients (11.6%). Patients with WMA were older (66.92±13.85 vs. 56.90±18.21 years, p&lt;0.001), had significantly higher Troponin-levels (18.5 [6.0; 91.5] vs. 6.0 [6.0; 15.0], p&lt;0.001) and higher blood pressure (139.0±19.29 vs. 135.1±19.21, p=0.04). WMA were significantly more frequent in patients reaching the primary endpoint (26.2% vs. 7.6%, p&lt;0.001). In multivariable regression analysis, the presence of WMA was associated with 3-fold increased odds of the presence of culprit lesions (3.41 [1.99–5.86], p&lt;0.001). Adding WMA to a multivariable model containing the TIMI risk score, cardiac biomarkers and traditional risk factors significantly improved the AUC for prediction of obstructive coronary artery disease (0.777 to 0.804, p=0.009).

Conclusion

WMA strongly and independently predict the presence of culprit lesions in patients presenting with acute chest pain to the emergency department. Our results suggest that routine bedside echocardiography for assessment of WMA in emergency department may improve diagnostic algorithms in suspected acute coronary syndrome.

Funding Acknowledgement

Type of funding sources: None.

Epicardial adipose tissue and culprit lesions in acute chest pain. The EPIC-ACS study

Background

The amount of epicardial adipose tissue (EAT) is associated with prevalent and incident myocardial infarction. However, clinical studies, specifically designed to determine, how the assessment of EAT can affect patient management, are lacking. Within Epicardial adipose tissue thickness PredIcts obstructive Coronary artery disease in Acute Coronary Syndrome patients (EPIC-ACS) study we tested the hypothesis that EAT quantification improves the prediction of the presence of culprit lesions in patients presenting with acute chest pain to the emergency department.

Methods

In this observational cohort study, we prospectively included consecutive patients presenting to the emergency department with acute chest pain suggestive of acute coronary syndrome between December 2018 and August 2020. Patients with ST-elevation myocardial infarction, hemodynamic instability, or known coronary artery disease were excluded. As part of the initial workup, bedside echocardiography for quantification of EAT thickness was performed by a dedicated study physician, blinded to all patients' characteristics. Treating physicians remained unaware of the results of the EAT assessment. The primary endpoint was defined as presence of a culprit lesion, as detected in subsequent invasive coronary angiography within 90 days after initial presentation. Logistic regression analysis was performed in different models adjusted for traditional cardiovascular risk factors, cardiac biomarkers as well as established cardiovascular risk scores.

Results

Overall, 657 patients (mean age 58.06±18.04 years, 53% male) were included in our study. Patients reaching the primary endpoint had significantly more EAT than patients without culprit lesions (7.90±2.56mm vs. 3.96±1.91mm, p&lt;0.0001, figure 1). In unadjusted regression analysis, 1mm increase in EAT thickness was associated with a nearby 2-fold increased odds of the presence of culprit lesions [1.98 (1.77–2.21), p&lt;0.0001]. Effect sizes remained stable and highly significant, when controlling for age, gender, and BMI as well as when ancillary controlling for traditional cardiovascular risk factors and cardiac biomarkers [1.87 (1.64–2.12), p&lt;0.0001]. Effect sizes for the association of EAT with presence of culprit lesions were similar in troponin-positive [1.85 (1.5–2.28), p&lt;0.0001] and troponin-negative acute chest pain [1.94 (1.66–2.26), p&lt;0.0001; p-value for interaction: 0.24]. Adding EAT to a multivariable model of GRACE score, cardiac biomarkers and traditional risk factors significantly improved the area under the receiver operating characteristics curve (0.759 to 0.901, p&lt;0.0001).

Conclusion

EAT strongly and independently predicts the presence of culprit lesions in patients presenting with acute chest pain to the emergency department. Our results suggest that the bedside echocardiographic assessment including the quantification of EAT may improve diagnostic algorithms of patients with acute chest pain.

Funding Acknowledgement

Type of funding sources: None. Distribution of EAT thickness

BNP/ NT-pro BNP thresholds for the assessment of the prognosis in patients without heart failure

Background

Natriuretic peptides (BNP/NT-proBNP) are predominantly used for risk stratification, diagnosis and therapeutic monitoring in heart failure patients. A potential value of BNP/NT-proBNP serum levels for the prediction of prognosis in the general population and for non-heart failure patient cohorts is suggested in the literature. However, for non-heart failure patients, no thresholds are established. We aimed to determine cut-off levels that allow prediction of long-term survival in patients without known heart failure.

Methods

The present analysis is based on a registry of patients undergoing coronary angiography between 2004 and 2019. Patients with existing diagnosis of heart failure or elevated natriuretic peptides (BNP &gt;100pg/nl, NT-proBNP &gt;400pg/nl), with missing follow-up information or without BNP/NT-proBNP levels at admission were excluded. As either BNP or NT-proBNP was available for singular patients and to adjust for the skewed distribution, BNP/NT-proBNP levels ranked based on gender specific percentile from 0 to 99. The cohort was then divided into a derivation and a validation cohort using random sampling. Incidence of death of any cause during follow-up was recorded. In the derivation cohort, cox regression analysis was used to determine the association of natriuretic peptides with incident mortality per 1 standard deviation increase in BNP/NT-proBNP rank. Multivariable models controlled for age, sex, LDL-cholesterol, systolic blood pressure, smoking status, and family history of premature cardiovascular disease. Receiver operating characteristics curve analysis was performed, with corresponding area under the curve, along with Youden's J index assessment, to establish a threshold for prediction of survival. The association of this threshold with incident mortality was tested in the validation cohort.

Results

Overall, 3,687 patients (age 62.9±12.5 years, 71% male) were included. During a mean follow-up of 2.6±3.4 years, 169 deaths occurred. In the derivation cohort, BNP/NT-proBNP was significantly associated with mortality (Hazard ratio [95% confidence interval]: 1.25 [1.01–1.54], p=0.04). Based on Youden's J index, BNP-thresholds of 9.6 and 29pg/ml and NT-proBNP thresholds of 65 and 77pg/ml for men and women, respectively, were determined. In the derivation cohort, BNP/NT-proBNP levels above these thresholds were significantly associated with increased mortality (2.44 [1.32–4.53], p=0.005). The predictive value of the determined thresholds was confirmed in the validation cohort (2.78 [1.26–6.14], p=0.01).

Conclusion

We here describe gender-specific BNP/NT-proBNP thresholds that allow prediction of impaired survival in patients without heart failure. Utilization of these thresholds in clinical routine may qualify for risk prediction in non-heart failure cohorts, independent of traditional cardiovascular risk factors.

Funding Acknowledgement

Type of funding sources: None.

Detectable troponin below the 99th percentile predicts survival in patients with cardiovascular disease

Background

Patients with cardiovascular disease and elevated troponin above the 99th percentile of the upper reference limit are at increased risk for major adverse events, and usually require urgent treatment, including coronary angiography. Meanwhile, patients with detectable troponin levels below the 99th percentile represent a more heterogeneous collective at need for further risk stratification.

Purpose

This study aims to determine the prognostic implications of detectable troponin below the 99th percentile of the upper reference limit compared to troponin lower than the detectable range in patients with cardiovascular disease.

Methods

The ECAD registry was screened for patients without detectable troponin and with detectable troponin below the 99th percentile upon admission. Patients with ST-segment elevation myocardial infarction and patients with admission troponin above the 99th percentile were excluded. Troponin was determined by Siemens Dimension Troponin I (detectable limit: 40 ng/L, 99th percentile: 70 ng/L) and contemporary Centaur high-sensitive Troponin I Ultra (detectable limit: 6 ng/L, 99th percentile: 40 ng/L) assays. Overall survival was defined as the primary endpoint. Cox regression analysis was used to determine the association of troponin groups with incident mortality, adjusting for age, sex, systolic blood pressure, low-density lipoprotein (LDL) cholesterol, smoking status, and family history of premature cardiovascular disease.

Results

14,776 consecutive patients (mean age was 65.35±12.74 years, with 71.3% male) with hospital admissions between 2004 and 2019 were included to the analysis. 11,965 patients had troponin levels below the detectable limits, while 2,811 patients had detectable troponin below the 99th percentile. During a mean follow-up of 4.25±3.76 years, 2379 (16.1%) deaths of any cause occurred. The overall mortality was higher in patients with detectable troponin below the 99th percentile compared to patients without detectable troponin (20.8% vs. 15.0%, p&lt;0.001). In multivariable regression analysis, detectable troponin below the 99th percentile was significantly associated with all-cause mortality (HR 1.71; 95% CI 1.46–2.01; p&lt;0.001). At 30 months, there was a significant stepwise relationship with increasing overall mortality between the tertiles of troponin levels (tertile 1, HR 1.62 (1.39–1.90); tertile 2, HR 1.88 (1.63–2.16); tertile 3, HR 2.02 (1.74–2.35)).

Conclusions

Detectable troponin below the 99th percentile is an independent predictor of overall mortality in patients with cardiovascular disease, and shows a gradually higher risk with increasing troponin levels. Every finding of detectable troponin in patients with cardiovascular disease should therefore prompt further diagnostic work-up.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): UMEA Young Clinical Scientist Grant, Medical faculty, University Duisburg-Essen (Hendricks)

Utilization of IVUS improves all-cause mortality in patients undergoing invasive coronary angiography

Background and aims

Available data suggest that the use of IVUS for guidance of percutaneous coronary interventions (PCIs) improves the prognosis of patients undergoing complex interventions. We aimed to examine how the utilization of intravascular ultrasound (IVUS) affects patient survival irrespective of procedure complexity.

Methods

The present analysis is based on the longitudinal ECAD registry of consecutive patients undergoing coronary angiography between 2004 and 2019. The incidence of death due to any cause was evaluated during a mean follow-up of 3.4 years. Cox regression analysis was used to determine the association of IVUS utilization with incident mortality.

Results

Overall, data from 30,814 coronary angiography exams (mean age 64.9 ± 12.5 years, 70.3% male) were included, among which 4991 procedures (16.2%) were guided by IVUS. Utilization of IVUS was associated with a 35% reduction in mortality, independent of traditional risk factors (0.64(0.58-0.71), p < 0.0001). The effect of IVUS on mortality was equally present in patients undergoing IVUS-guided coronary interventions (0.75[0.67-0.84], p < 0.0001) as well as purely diagnostic coronary angiography exams (0.62[0.56-0.72], p < 0.0001). In patients without coronary intervention, IVUS utilization led to a higher frequency of aspirin (82.6% vs. 61.9% for IVUS vs. no IVUS, p < 0.0001) and statin therapy (74.9% vs. 62.5%, p < 0.0001).

Conclusions

In a large longitudinal registry cohort of patients undergoing invasive coronary angiography, IVUS utilization was associated with lower long-term mortality. The beneficial role of IVUS utilization on survival was equally present for coronary interventions and diagnostic coronary angiograms. Our results support the use of intravascular imaging for decision making in interventional cardiology.

Stroke due to Left Atrial Appendage Thrombus after Pulmonary Vein Isolation despite Novel Oral Anticoagulant: A Case Report

In patients with atrial fibrillation, catheter ablation is suggested to reduce the mortality rate and is thus frequently performed. However, peri- and postprocedural thromboembolic complications as well as high recurrence rates of atrial fibrillation limit its advantages and require concomitant anticoagulation. With the advent of novel oral anticoagulants (NOACs), fixed dosing without routine laboratory monitoring became feasible. Nevertheless, several factors are associated with either an overdose or an insufficient drug activity of NOACs. We report on a patient with atrial fibrillation undergoing catheter ablation and cardioversion suffering from ischemic stroke despite being under oral anticoagulation. It turned out that the drug activity of the NOACs used was repeatedly insufficient in spite of regular intake and adequate dosing. In sum, drug activity controls should be taken into consideration in patients with thrombotic events despite oral anticoagulation with NOACs.

Implications of Alterations in Pre-test Probability in the 2019 Update of ESC Guidelines for Chronic Coronary Syndromes on Diagnostic Accuracy of Pharmacological Stress-Echocardiography: A Retrospective Cohort Study

BACKGROUND

With the 2019 update of European Society of Cardiology (ESC) guidelines for chronic coronary syndromes, the pre-test probabilities (PTPs) based on age, sex, and symptoms have undergone major revisions. We aimed to determine implications of these alterations on diagnostic accuracy of dobutamine stress echocardiography (DSE).

METHODS

We retrospectively included consecutive patients undergoing pharmacological stress-echocardiography for evaluation of suspected obstructive coronary artery disease. DSE was performed as non-invasive imaging test and was indicated by individual treating physician's decision. Sensitivity, specificity, positive and negative predictive value as well as accuracy were assessed for detection of obstructive coronary artery disease, defined as revascularization therapy following DSE.

RESULTS

We included 206 patients (mean age 63.2 ± 12.4 years, 59.7% male). 51% of the cohort had a PTP of < 15% according to both scores. 9.2% of patients with PTP < 15% according to the original Diamond and Forrester score had a PTP > 15% according to 2019 ESC guidelines, predominantly due to the accountancy of dyspnea. In contrast, 13.6% of patient had a PTP ≥ 15% according to the original Diamond and Forrester score, while PTP was assessed below this threshold by updated guidelines. The differences in patient selection according to updated guidelines did not alter the diagnostic accuracy of DSE (68% for both).

CONCLUSIONS

Changes in assessment of PTP according to updated ESC guidelines from 2019 led to a relevant reclassification of patients with suspected coronary artery disease, ultimately changing the group of patients appropriate for DSE for evaluation of myocardial ischemia. Comparing the diagnostic performance in appropriate PTP groups, however, led to similar results.

Epicardial adipose tissue differentiates in patients with and without coronary microvascular dysfunction

BACKGROUND/OBJECTIVES

Coronary microvascular dysfunction (CMD) is a common disorder, leading to symptoms similar to obstructive coronary artery disease and bears important prognostic implications. Local inflammation is suggested to promote development of CMD. Epicardial adipose tissue (EAT) is a local visceral fat depot surrounding the heart and the coronary arteries, modifying the inflammatory environment of the heart. We compared EAT in patients with and without CMD.

METHODS

We retrospectively included consecutive patients undergoing diagnostic coronary angiography as well as transthoracic echocardiography between March and October 2016. EAT thickness was defined as space between the epicardial wall of the myocardium and the visceral layer of the pericardium and EAT index was calculated as EAT thickness/body surface area. Logistic regression analysis was used to determine the association of EAT index with the presence of CMD.

RESULTS

Overall, 399 patients (mean age 60.2 ± 14.0 years, 46% male) were included. EAT thickness was significantly higher in patients with CMD compared to patients without CMD (EAT thickness 4.4 ± 1.8 vs. 4.9 ± 2.4 mm, p = 0,048 for patients without and with CMD, respectively). In univariate regression analysis, EAT index was associated with a 30% higher frequency of CMD (odds ratio [95% confidence interval]: 1.30 [1.001-1.69], p = 0.049). Effect sizes remained stable upon adjustment for body mass index (BMI, 1.30 [1.003-1.70], p = 0.048), but were attenuated when ancillary adjusting for age and gender (1.17 [0.90-1.54, p = 0.25). The effect was more pronounced in patients >65 years of age and independent of BMI and sex (1.85 [1.14-3.00], p = 0.013).

CONCLUSION

EAT thickness is independently associated with CMD and can differentiate between patients with and without CMD especially in older age groups. Our results support the hypothesis that modulation of local inflammation by epicardial fat is involved in the development of CMD.

Anemia increases long-term mortality in patients undergoing conventional coronary angiography – the ECAT registry

Background

Anemia is a frequent comorbidity in patients with coronary artery disease (CAD). Besides a complemental effect on myocardial oxygen undersupply of CAD and anemia, available data suggests that it may independently impact the prognosis in CAD patients. We aimed to determine the association of anemia with long-term survival in a longitudinal registry of patients undergoing conventional coronary angiography.

Methods

The present analysis is based on the ECAD registry of patients undergoing conventional coronary angiography at the Department of Cardiology and Vascular Medicine at the University Clinic Essen between 2004 and 2019. For this analysis, we excluded all patients with missing hemoglobin levels at baseline admission or missing follow-up information. Anemia was defined as a hemoglobin level of &lt;13.0g/dl for male and &lt;12.0g/dl for female patients according to the world health organization's definition. Cox regression analysis was used to determine the association of anemia with morality, stratifying by clinical presentation of patients. Hazard ratio and 95% confidence interval are depicted for presence vs. absence of anemia.

Results

Overall, data from 28,917 patient admissions (mean age: 65.3±13.2 years, 69% male) were included in our analysis (22,570 patients without and 6,347 patients with anemia). Prevalence of anemia increased by age group (age &lt;50 years: 16.0%, age ≥80 years: 27.7%). During a mean follow-up of 3.2±3.4 years, 4,792 deaths of any cause occurred (16.6%). In patients with anemia, mortality was relevantly higher as compared to patients without anemia (13.4% vs. 28.0% for patients without and with anemia, respectively, p&lt;0.0001, figure 1). In univariate regression analysis, anemia was associated with 2.4-fold increased mortality risk (2.27–2.55, p&lt;0.0001). Effect sizes remained stable upon adjustment for traditional risk factors (2.38 [2.18–2.61], p&lt;0.0001). Mortality risk accountable to anemia was significantly higher for patients receiving coronary interventions (2.62 [2.35–2.92], p&lt;0.0001) as compared to purely diagnostic coronary angiography examinations (2.31 [2.15–2.47], p&lt;0.0001). Likewise, survival probability was slightly worse for patients with anemia in acute coronary syndrome (2.70 [2.29–3.12], p&lt;0.0001) compared to chronic coronary syndrome (2.60 [2.17–3.12], p&lt;0.0001). Interestingly, within the ACS entity, association of anemia with mortality was relevantly lower in STEMI patients (1.64 [1.10–2.44], p=0.014) as compared to NSTEMI and IAP (NSTEMI: 2.68 [2.09–3.44], p&lt;0.0001; IAP: 2.67 [2.06–3.47], p&lt;0.0001).

Conclusion

In this large registry of patients undergoing conventional coronary angiography, anemia was a frequent comorbidity. Anemia relevantly influences log-term survival, especially in patients receiving percutaneous coronary interventions. Our results confirm the important role of anemia for prognosis in patients with coronary artery disease, demonstrating the need for specific treatment options.

Figure 1. Kaplan Meier analysis

Funding Acknowledgement

Type of funding source: None

Higher BNP/NT-proBNP levels stratify prognosis in patients with coronary artery disease but without heart failure

Background

Natriuretic peptides (BNP/NT-proBNP) are routinely used for the diagnosis of heart failure and predicts outcome in patients with both heart failure with preserved and reduced ejection fraction. In addition, natriuretic peptides are associated with incident cardiovascular disease manifestation in primary prevention cohorts. Whether the assessment of BNP/NT-proBNP is of value in patients with coronary artery disease but without heart failure has not been investigated in detail. We here evaluate the association of BNP/NT-pro BNP with mortality patients with coronary artery disease but without known chronic heart failure.

Methods

The present analysis is based on the ECAD registry of patients undergoing conventional coronary angiography at the Department of Cardiology and Vascular Medicine between 2004 and 2019. For this analysis, we excluded all patients with a diagnosis of heart failure or with elevated BNP/NT-proBNP values at baseline (&gt;100pg/nl for BNP, &gt;400pg/nl for NTproBNP). Moreover, patients with missing follow-up information or without BNP/NT-proBNP levels at admission were excluded. As either BNP or NT-proBNP was available for singular patients, we standardized BNP and NT pro BNP levels based on percentile rank in levels from 0 to 99. Cox regression analysis was used to determine the association of BNP/NT-proBNP with morality in unadjusted and risk factor adjusted models with effect sizes depicted per one standard deviation change in BNP/NT-proBNP rank.

Results

Overall, 3738 patients (mean age: 62.8±12.6 years, 71% male) were included in our analysis. During a mean follow-up of 2.6±3.5 years, 172 deaths of any cause occurred. Patients without fatal events had significantly lower BNP/NT-prBNP values compared to patients who died (48.4±28.8 vs. 58.4±27.5, p&lt;0.0001). In unadjusted cox regression analysis, BNP/NT-proBNP increase by one standard deviation was associated with a 47% increased risk of morality (HR (95% CI): 1.47 (1.25–1.72), p&lt;0.0001). Upon adjustment for cardiovascular risk factors, the significant link between BNP/NT-proBNP levels and morality remained (HR (95% CI): 1.38 (1.14–1.66). Effect sizes were similar for patients receiving coronary revascularization therapy as part of the coronary angiography (1.32 [1.03–1.70], p=0.03) as well as for patients with purely diagnostic procedures (1.58 [1.28–1.94], p&lt;0.0001).

Conclusion

In patients without heart failure undergoing coronary angiography, BNP/NT-proBNP levels stratify mortality risk independently of traditional cardiovascular risk factors. Our results support the routine assessment of natriuretic peptides also in patients without heart failure to identify patients at increased risk.

Funding Acknowledgement

Type of funding source: None

Impact of Diabetes Mellitus on Outcomes after High-Risk Interventional Coronary Procedures

An increasing number of patients with coronary artery disease are at high operative risk due to advanced age, severe comorbidities, complex coronary anatomy, and reduced ejection fraction. Consequently, these high-risk patients are often offered percutaneous coronary intervention (PCI) as an alternative to coronary artery bypass grafting (CABG). We aimed to investigate the outcome of patients with diabetes mellitus (DM) undergoing high-risk PCI. We analyzed consecutive patients undergoing high-risk PCI (period 01/2016–08/2018). In-hospital major adverse cardiac and cerebrovascular events (MACCEs), defined as in-hospital stroke, myocardial infarction and death, and the one-year incidence of death from any cause were assessed in patients with and without DM. There were 276 patients (age 70 years, 74% male) who underwent high-risk PCI. Eighty-six patients (31%) presented with DM (insulin-dependent DM: n = 24; non-insulin-dependent DM: n = 62). In-hospital MACCEs occurred in 9 patients (3%) with a non-significant higher rate in patients with DM (n = 5/86, 6% vs. n = 4/190 2%; p = 0.24). In patients without DM, the survival rate was insignificantly higher than in patients with DM (93.6% vs. 87.1%; p = 0.07). One-year survival was not significantly different in DM patients with more complex coronary artery disease (SYNTAX I-score ≤ 22: 89.3% vs. > 22: 84.5%; p = 0.51). In selected high-risk patients undergoing high-risk PCI, DM was not associated with an increased incidence of in-hospital MACCEs or a decreased one-year survival rate.

Association of echocardiographic measures of left ventricular diastolic dysfunction and hypertrophy with presence of coronary microvascular dysfunction

Background

Coronary microvascular dysfunction (CMD) is a common disorder, leading to symptoms similar to obstructive coronary artery disease. We aimed to determine whether measures of left ventricular (LV) diastolic function and hypertrophy may predict presence of CMD.

Methods

We retrospectively included patients undergoing diagnostic coronary angiography and transthoracic echocardiography, excluding patients with obstructive coronary artery disease, previous revascularization therapy, moderate or severe mitral valve disease, or atrial fibrillation. The following markers of LV diastolic function and hypertrophy were assessed: E- and A-wave velocity, E-wave deceleration time, E/A- and E/E′-ratio, left atrial area, left LV mass index, LV ejection time (LVET) and mitral valve closure to opening time. Logistic regression analysis was used to determine the association of echocardiographic parameters with presence of CMD.

Results

From 378 patients (mean age ± SD 59.7 ± 13.6 years, 45.6% male) included, the majority had CMD (n = 293, 77.5%). Patients with CMD were older (60.5 ± 13.4 years vs. 56.9 ± 14.3 years, p = 0.03), were less frequent male (42.3% vs. 57.0%, p = 0.02), and had higher systolic blood pressure (137.9 ± 25.7 mmHg vs. 124.7 ± 25.6 mmHg, p < 0.0001). LVET was significantly associated with CMD (1.42 [1.02–1.96], p = 0.04), while a non-statistically significant link was observed for A-wave velocity and E/E′-ratio (1.39 [0.96–2.00], p = 0.08 and 1.40 [0.92–2.13], p = 0.1, respectively). For all other echocardiography-derived measures, odds ratio for the association with CMD was <1.3 per each SD increase.

Conclusions

In this cross-sectional single-center cohort study, CMD was a frequent finding in patients undergoing coronary angiography for suspected obstructive coronary artery disease. LVET from transthoracic echocardiography is associated with the presence of CMD.

Impact of left-ventricular end-diastolic pressure as a predictor of periprocedural hemodynamic deterioration in patients undergoing Impella supported high-risk percutaneous coronary interventions

Background

An increasing number of high-risk percutaneous coronary interventions (PCI) are performed with mechanical circulatory support (MCS) to minimize the risk of periprocedural hemodynamic compromise. Prior studies have demonstrated that an elevated left-ventricular end-diastolic pressure (LVEDP) is associated with worse outcome after acute myocardial infarction or cardiac surgery. Although LVEDP is frequently measured, little is known about the usefulness for predicting periprocedural hemodynamic deterioration in high-risk PCI. The objective of this study is to assess the impact of preprocedural measured LVEDP in non-shock patients undergoing high-risk PCI with MCS on periprocedural hemodynamic deterioration.

Methods and Results

We reviewed the PCI protocol and the Automated Impella Controller in a consecutive series of 64 patients (mean age 73 years, 80% male), who underwent high-risk PCI with Impella MCS (period 01/2017–12/2018). LVEDP (17 ± 8 mm Hg) was measured in all cases before Impella insertion and start of PCI. Periprocedural hemodynamic deterioration was defined as: systolic blood pressure (SBP) drop (decrease ≥20 mm Hg or ≤90 mm Hg), or transient loss of arterial pressure pulsatility. Hemodynamic deterioration occurred in 33% (n = 21) of all patients but did not lead to a hemodynamic compromise due to the Impella support. Regression analysis of LVEDP for periprocedural hemodynamic deterioration or in-hospital major adverse cardiac and cerebrovascular events (MACCE) showed no significant results.

Conclusion

LVEDP was not associated with periprocedural hemodynamic deterioration or a higher rate of in-hospital MACCE. Our data propose that LVEDP may not be used as a risk stratification variable for MCS usage in non-shock patients undergoing high-risk PCI.

P821Treatment patterns of lipid lowering therapy in patients with coronary artery disease above vs. below 75 years of age

Introduction

In patients with coronary artery disease (CAD), lipid lowering therapy is recommended as cornerstone of secondary prevention. Treatment of elderly patients inherits a medical challenge, as they experience higher absolute risk reduction with more intensive lipid lowering regimes but may be more prone to side effects by therapy.

Purpose

To evaluate the treatment patterns in lipid lowering therapy comparing CAD-patients above vs. below 75 years of age.

Methods

We retrospectively included patients with known CAD, admitted to the West German Heart and Vascular Center in the years of 2009–2010 (n=500), 2012–2013 (n=500), and 2015–2016 (n=500). LDL-cholesterol levels and intensity of stain therapy (based on dosage and type of statin) were assessed from all available hospital records. Lipid levels and treatment regimens were evaluated comparing patients ≥75 vs. <75 years of age. The analysis was approved by the local ethics committee (17–7458-BO).

Results

A total of 1,500 patients (mean age: 68.4±11.2 years, 75.8% male) from 813 referring treating primary care physicians in 98 cities of Germany were included in our analysis. 983 patients were <75, whereas 517 were ≥75 years of age. Elderly patients were less likely male (67.9% vs. 79.9%, p<0.0001), had lower BMI (26.8kg/m2 vs. 28.4kg/m2, p<0.0001), and less likely current smokers (7.6% vs. 19.2%, p<0.0001, for patients ≥75 vs. <75 years of age, respectively). LDL-cholesterol levels were not significantly different between age groups (≥75: 96.1±35.1 mg/dl; <75: 98.9±35.7mg/dl, p=0.14). In contrast, elderly patients had higher HDL-cholesterol levels (49.9±15.1 mg/dl vs. 46.7±15.2, p=0.0002) and markedly lower triglycerides (135.6±90.0mg/dl vs. 171.4±124.6mg/dl, p<0.0001). Simvastatin was most frequently prescribed in both age groups (54.9% vs. 50.7%, p=0.16), followed by Atorvastatin (31.6% vs. 33.3%, p=0.53). Elderly patients received significantly lower dosages of statin (28.8±12.8mg vs. 31.4±13.7mg, p=0.0007). Interestingly, patients ≥75 years of age archived LDL<70mg/dl slightly more frequently than younger patients (24.0% vs. 20.1%, p=0.09). Excluding patients with myocardial infarction at presentation, CK-levels were not relevantly different between age groups (131.9±450.0U/l vs. 127.5±111.4U/l, p=0.78). Excluding patients with signs of systemic inflammation, high-sensitive CRP levels did not differ when comparing patients ≥75 vs. <75 years of age (0.15±0.12mg/dl vs. 0.14±0.12mg/dl, p=0.33).

Conclusion

Evaluating lipid lowering treatment patters of 1500 patients from 813 treating physicians, we observed that patients ≥75 years of age receive lower doses of statin therapy, but reached slightly lower LDL-cholesterol-levels. However, the majority of elderly patients miss current recommendations regarding LDL-thresholds. Interestingly, no signs of a higher frequency of statin-induced myopathy in the elderly were observed in our analysis.

P6429Epicardial adipose tissue is a robust measure of increased risk of myocardial infarction, a meta-analysis on over 6.600 patients

Background

Epicardial adipose tissue surrounds the heart and the coronary arteries. Endocrine and paracrine activity is accredited to EAT. Studies descripted the association between increased EAT and traditional cardiovascular risk factors as well as coronary events. While computed tomography is the gold standard for the assessment of 3-dimensional EAT-volume, echocardiography based EAT thickness is an easy accessible alternative in particular in an emergency setting. So far, little is known, how quantification of EAT in patients presenting with chest pain could alter patient management.

Purpose

To perform a meta-analysis on existing studies, comparing EAT in patients with and without myocardial infarction, stratifying by imaging technique.

Methods

We performed a systematic search using the Pubmed, Cochrane, SCOPUS, and Web of Science databases for studies, describing EAT in patients with and without myocardial infarction. Manuscripts, published until 1st of October 2018, were included. We made our search specific and sensitive using Medical Subject Headings terms and free text and considered studies published in English language. Search terms used were “epicardial adipose tissue” or “pericardial adipose tissue” and “myocardial infarction”, “coronary events”, or “acute coronary syndrome”. For comparability, EAT measures were normalized to mean values for patients without myocardial infarction for each study separately. Random effect models were calculated. All analyses were performed using Review Manager 5.3.

Results

Overall, 6.641 patients (mean aged 58.9 years, 53% male) from 7 studies were included. Patients with myocardial infarction had 37% higher measures of EAT compared to patients without myocardial infarction (95% CI: 21–54%, Figure A). Comparing studies using echocardiography for assessment of EAT thickness with studies using computed tomography based EAT volume, similar relative differences in EAT with wide overlap of confidence intervals were observed (Echo measures: 40 [4–76]%, CT measures: 36 [16–57]%, Figure B and C). No relevant heterogeneity and inconsistency between groups was present in all analyses (detailed data not shown).

Figure 1

Conclusion

EAT is increased in patients with myocardial infarction. Our data suggests that quantification of EAT thickness using echocardiography distinguishes equally between patients with and without myocardial infarction as compared to 3-dimensional EAT volume from computed tomography. Therefore, it may be an easy accessible alternative in clinical settings. However, further studies are warranted to determine, whether quantification of EAT may lead to improved patient management.

P5015Efficacy of lipid lowering therapy beyond statins to prevent cardiovascular events: A meta-analysis

Background

Lipid lowering therapy is a key cornerstone in secondary prevention of patients with coronary artery disease. However, only a minority of patients with statin therapy reach LDL thresholds as suggested by the ESC. Ezetimibe and proprotein convertase subtilisin/kexin type 9 (PCSK-9) inhibitors allow for reduction in LDL-cholesterol in addition to statin therapy.

Purpose

To perform a meta-analysis of existing trials, evaluating how lipid lowering therapy beyond statins impacts cardiovascular outcome.

Methods

We performed a systematic search using the Pubmed, Cochrane, SCOPUS, and Web of Science databases for studies, evaluating the impact of an intensified lipid lowering therapy via ezetimibe or PCSK-9 inhibitor in addition to statin therapy compared to statin therapy alone. Manuscript and congress presentations, published until 1st of November 2018, were included. We made our search specific and sensitive using Medical Subject Headings terms and free text and considered studies published in English language. Search terms used were “ezetimibe”, “evolocumab”, “alirocumab”, or “bococizumab” and “cardiovascular events”.

Results

A total of 100,610 patients from 9 randomized controlled trials (IMPROVE-IT, FOURIER, ODYSSEY Outcomes, SIPRE I, SPIRE II, ODYSSEY LONG TERM, OSLER-1 and OSLER-2, HIJ-PROPER) were included. Treatment with ezetimibe or a PCSK-9 inhibitor was associated with a 18% risk reduction in cardiovascular events (OR [95% CI]: 0.82 [0.75–0.89]). Effect sizes were similar for myocardial infarction (0.84 [0.76–0.92]) and even more pronounced for ischemic stroke (0.77 [0.67–0.83]). In contrast, all-cause mortality was not improved by the intensified lipid lowering therapy (0.94 [0.85–1.05]). No relevant heterogeneity and inconsistency between groups was present in all analyses (detailed data not shown). Comparing efficacy of LDL-reduction and relative risk redaction of cardiovascular events, a linear relationship was observed (figure).

Figure 1. Correlation of reduction of LDL-cholesterol at one year with relative risk reduction (95% confidence interval) of cardiovascular events in included trials.

Conclusion

Intensified LDL-lowering therapy with ezetimibe or PCSK-9 inhibitors, in addition to statins, reduces the risk of myocardial infarction and stroke, however, does not impact overall mortality. There is a linear relationship between LDL reduction and cardiovascular risk reduction, confirming the beneficial effects of LDL lowering therapy beyond statins in secondary prevention.

Disconcordance between ESC prevention guidelines and observed lipid profiles in patients with known coronary artery disease

Background

We aimed to describe whether updated low-density lipoprotein (LDL)-targets in patients with manifest coronary artery disease (CAD) led to a change in lipid profile over time.

Methods

We retrospectively included patients with manifest CAD from 2009–2010, 2012–2013, and 2015–2016 (n = 500 each). Lipid levels and medication at the different time-points as well as rate of accordance to guidelines (<100 for 2009–2010, <70 mg/dl for 2012–2013 and 2015–2016) were evaluated.

Results

Overall, 1500 subjects (mean age: 68.4 ± 11.2 years, 75.8% male) from 813 attending primary care physicians were included. Mean LDL-level was 98.0 ± 35.7 mg/dl, whereas 34.1% reached LDL-targets according to guidelines as applied at each time-point. Reduction of LDL-goals in 2011 lead to an initial decrease in LDL from 98.3 ± 33.4 mg/dl in 2009–2010 to 93.9 ± 36.3 mg/dl in 2012–2013 (p = 0.045). This effect was no longer present in 2015–2016 (101.6 ± 36.6 mg/dl, p = 0.17). The rate of patients meeting recommended LDL-targets decreased over time (2009–2010: 56.6%, 2012–2013: 25.4%, 2015–2016: 20.2%, p < 0.0001 for trend). Likewise, the frequency of statin-intake decreased over time (93.6% in 2009–2010 to 83.7% in 2015-2016, p < 0.0001). While use of medium intensity statins was most frequent (69.4%), only 20.9% of patients with medium intensity statins reached LDL-targets according to guidelines.

Conclusion

In a large clinical cohort of patients with known coronary artery disease, reduction of LDL-targets in ESC-guidelines in 2011 led to an initial decline in LDL-levels, while this effect was attenuated over time with the majority of patients missing treatment goals. Higher acceptance and compliance of statin therapy is warranted to utilize its effect in secondary prevention in CAD-patients.