Sandwich ELISA for the Quantification of Nucleocapsid Protein of SARS-CoV-2 Based on Polyclonal Antibodies from Two Different Species

In this study, a cost-effective sandwich ELISA test, based on polyclonal antibodies, for routine quantification SARS-CoV-2 nucleocapsid (N) protein was developed. The recombinant N protein was produced and used for the production of mice and rabbit antisera. Polyclonal N protein-specific antibodies served as capture and detection antibodies. The prototype ELISA has LOD 0.93 ng/mL and LOQ 5.3 ng/mL, with a linear range of 1.52-48.83 ng/mL. N protein heat pretreatment (56 °C, 1 h) decreased, while pretreatment with 1% Triton X-100 increased analytical ELISA sensitivity. The diagnostic specificity of ELISA was 100% (95% CI, 91.19-100.00%) and sensitivity was 52.94% (95% CI, 35.13-70.22%) compared to rtRT-PCR (Ct < 40). Profoundly higher sensitivity was obtained using patient samples mostly containing Wuhan-similar variants (Wuhan, alpha, and delta), 62.50% (95% CI, 40.59 to 81.20%), in comparison to samples mostly containing Wuhan-distant variants (Omicron) 30.00% (6.67-65.25%). The developed product has relatively high diagnostic sensitivity in relation to its analytical sensitivity due to the usage of polyclonal antibodies from two species, providing a wide repertoire of antibodies against multiple N protein epitopes. Moreover, the fast, simple, and inexpensive production of polyclonal antibodies, as the most expensive assay components, would result in affordable antigen tests.

Molecular Mechanisms of Possible Action of Phenolic Compounds in COVID-19 Protection and Prevention

The worldwide outbreak of COVID-19 was caused by a pathogenic virus called Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2). Therapies against SARS-CoV-2 target the virus or human cells or the immune system. However, therapies based on specific antibodies, such as vaccines and monoclonal antibodies, may become inefficient enough when the virus changes its antigenicity due to mutations. Polyphenols are the major class of bioactive compounds in nature, exerting diverse health effects based on their direct antioxidant activity and their effects in the modulation of intracellular signaling. There are currently numerous clinical trials investigating the effects of polyphenols in prophylaxis and the treatment of COVID-19, from symptomatic, via moderate and severe COVID-19 treatment, to anti-fibrotic treatment in discharged COVID-19 patients. Antiviral activities of polyphenols and their impact on immune system modulation could serve as a solid basis for developing polyphenol-based natural approaches for preventing and treating COVID-19.

Relative impact of acute heart failure and acute kidney injury on short- and long-term prognosis of patients with STEMI treated with primary PCI

Background

Although both acute heart failure (AHF) and acute kidney injury (AKI) have been separately recognized as contributors to an increased mortality risk in patients with ST-segment elevation myocardial infarction (STEMI), their relative importance has not been extensively studied.

Purpose

Our aim was to investigate the relative impact of AHF and AKI on 30-day and 5-year mortality following primary PCI for STEMI.

Methods

8 054 patients referred to primary PCI during the years 2009–2019, and with the available repeated creatinine measurements, were analyzed. AKI was defined as ≥25% relative or ≥0.5 mg/dl absolute rise in creatinine from baseline, within 72 hours of intervention. Acute heart failure was defined as Killip class ≥2 on admission to hospital. Cox regression model was used to assess the effect of the interaction of AHF and AKI on mortality. Median follow-up was 5 years.

Results

The incidence of AKI was 9.9% (n=805) and of AHF 12.3% (n=1050). Concurrence of AHF and AKI was noted in 1.7% of the included patients (n=315). The combined presence of AHF and AKI significantly increased mortality both at 30 days (30.7%) and at 5 years (73.3%), as compared with AKI alone (8.2% at 30 days and 32.3% at 5 years) and AHF alone (13.0% and 53.0%). When adjusted for other significant predictors, such as age, prior stroke, hyperlipidemia, atrial fibrillation, ejection fraction, final TIMI flow in the culprit artery, the use of intra-aortic balloon pump and multivessel disease, both AKI and AHF were independently associated with mortality. The adjusted relative impact of AKI on mortality was stronger than that of AHF at 30 days (adjusted HR 3.5 and 2.2, respectively), whereas it was comparable at 5 years (adjusted HR 1.3 and 1.4, respectively). Furthermore, the combined presence of AHF on admission and the post-primary PCI development of AKI was associated with the highest magnitude of risk at both 30 days (HR 5.0, CI95% 3.0–8.3, p&lt;0.001) and 5 years (HR 2.4, CI95% 1.83–3.16, p&lt;0.001).

Conclusion

Acute kidney injury following primary PCI for STEMI was associated with a higher adjusted risk of short-term mortality when compared with acute heart failure, whereas their relative impact was comparable in the long-term.

Funding Acknowledgement

Type of funding sources: None.

Expression, purification and immunological characterization of recombinant nucleocapsid protein fragment from SARS-CoV-2

Serological testing is important method for diagnosis of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Nucleocapsid (N) protein is the most abundant virus derived protein and strong immunogen. We aimed to find its efficient, low-cost production. SARS-CoV-2 recombinant fragment of nucleocapsid protein (rfNP; 58-419 aa) was expressed in E. coli in soluble form, purified and characterized biochemically and immunologically. Purified rfNP has secondary structure of full-length recombinant N protein, with high percentage of disordered structure (34.2%) and of β-sheet (40.7%). rfNP was tested in immunoblot using sera of COVID-19 convalescent patients. ELISA was optimized with sera of RT-PCR confirmed positive symptomatic patients and healthy individuals. IgG detection sensitivity was 96% (47/50) and specificity 97% (67/68), while IgM detection was slightly lower (94% and 96.5%, respectively). Cost-effective approach for soluble recombinant N protein fragment production was developed, with reliable IgG and IgM antibodies detection of SARS-CoV-2 infection.

Prognostic value of mitral regurgitation in patients with asymmetric hypertrophic cardiomyopathy

Funding Acknowledgements

Type of funding sources: None.

Introduction

Since mitral regurgitation (MR) is a very common finding in patients with hypertrophic cardiomyopathy (HCM), the evaluation of the mitral valve anatomy and the degree of MR is of utmost importance in this population. However, data regarding the prognostic value of different degrees of MR in HCM remains scarce.

Purpose

The aim of this study was to determine whether the presence of a higher degree of MR affects: 1) long term prognosis; 2) clinical and echocardiographic presentation of HCM patients.

Material and Methods

We included prospectively 102 patients, diagnosed with primary asymmetric HCM. The degree of MR was determined echocardiographicaly according to current recommendations of the American Association of Echocardiography. According to the MR severity, patients were divided into 2 groups: Group 1 (n = 52) with no/trace or mild MR and Group 2 with moderate or moderate to severe MR. All patients had clinical and echocardiographic examination, 24-hour Holter ECG and NT pro BNP analysis performed. The primary outcome was a composite of: 1) HCM related death or sudden death; 2) hospitalization due to acute heart failure; 3) sustained ventricular tachycardia; 4) ischemic stroke.

Results

Patients with higher MR degree had more frequent chest pain (p = 0.039), syncope (p = 0.041) and NYHA II functional class (p &lt; 0.001). Group 2 patients had mostly obstructive form of HCM (p &lt; 0.001) with more frequent presence of previous atrial fibrillation (AF) (p = 0.032), as well as the new onset of AF (p = 0.014) compared to patients in Group 1. Patients with higher MR degree had significantly more SAM (p &lt; 0.001) resulting in a more frequent eccentric MR jet (p &lt; 0.001), along with calcified mitral annulus (p = 0.007), enlarged left atrial volume index (p &lt; 0.001), and elevated right ventricular pressure (p = 0.001). As a result of higher MR grade, Group 2 had higher E/e" values (p &lt; 0.001), elevated LV filling pressure (lateral E/e’ &gt;10), as well as higher levels of NT pro BNP (p = 0.001). By Kaplan-Meier analysis we demonstrated that the event free survival rate during follow up of median 75 (IQR 48-103) months was significantly higher in Group 1 compared to the Group 2 (79% vs. 46%, p &lt; 0.001), Figure 1. After adjustment for relevant confounders, moderate/moderate to severe MR remained as an independent predictor of adverse outcome (hazard ratio 2.58, 95% CI: 1.08-6.13, p &lt; 0.001).

Conclusion

Presence of moderate, or moderate to severe MR was associated with poor long-term outcome of HCM patients. These results indicate the importance of an adequate MR assessment and detailed evaluation of the mitral valve anatomy in the prediction of complications and adequate treatment of patients with HCM.

Abstract Figure.

Prognostic impact of elevated baseline CRP levels in primary PCI-treated patients with residual cholesterol risk

Background

Recent large randomized studies have indicated the potential of anti-inflammatory therapies to reduce adverse cardiovascular events in patients with myocardial infarction, with the most pronounced benefit in patients with baseline elevated C-reactive protein (CRP).

Purpose

Our aim was to assess the association of CRP levels with 30-day and 1-year mortality in patients with acute myocardial infarction treated with primary PCI and with residual cholesterol risk.

Methods

The study included 1531 patients admitted for primary PCI, with the residual cholesterol risk, i.e. low-density lipoprotein cholesterol (LDL-C) levels of &gt;1.80 mmol/l (70 mg/dl), from a prospectively kept electronic registry of a high-volume tertiary center, for whom in-hospital CRP measurements were available. Elevated CRP was defined as ≥5 mg/l (local laboratory cut off value), measured during index hospitalization. Cox regression models were constructed to assess the impact of elevated CRP on 30-day and 1-year mortality.

Results

72% of the included patients with LDL-C &gt;1.80 mmol/l had elevated in-hospital CRP (n=1107). Compared with patients with CRP levels within reference limit, elevated CRP was associated with older age (62 vs. 60, p&lt;0.001), higher rates of diabetes (25.8% vs. 18.5%, p=0.002), renal failure (6.4% vs. 2.1%, p&lt;0.001) and Killip class &gt;1 at presentation (22.5% vs. 12.3%, p&lt;0.001), as well as lower EF (44% vs. 48%, p&lt;0.001) and lower haemoglobin on admission (13.9 g/dl vs. 14.2 g/dl, p&lt;0.001). Crude mortality rates were increased in patients with CRP ≥5mg/l at both 30 days (6.0% vs. 2.4%, p=0.003) and 1 year (13.2% vs. 6.3%, p&lt;0.001) (Figure). After adjusting for the observed baseline differences, CRP ≥5mg/l remained an independent predictor of mortality at 1 year (HR 1.691, 95% CI: 1.050–2.724, p=0.03), but not at 30 days (HR 1.690, 95% CI: 0.859–3.324, p=0.13).

Conclusion

In primary PCI-treated patients with residual cholesterol risk, elevated in-hospital CRP was independently associated with 1-year mortality. Our findings may thus suggest a potential window of opportunity, for anti-inflammatory therapies to improve outcomes beyond the acute phase.

Figure 1

Funding Acknowledgement

Type of funding source: None

Characteristics, predictors and outcomes after unprotected left main stem primary percutaneous coronary intervention

Background

Reports about outcomes of patients undergoing primary percutaneous coronary intervention (PCI) for unprotected left main (ULM) coronary artery are limited. We aimed to investigate the characteristics, in-hospital and the long-term outcomes of these patients.

Methods

From a high-volume, single-centre, prospective registry, in a period from 2009–2019, we identified 111 pts (0.96%) who undergone primary PCI for ULM culprit lesion. The short- and the long-term outcomes in this subset was evaluated and compared to 9463 (82.5%) patients undergoing pPCI for lesions located in other segments (Non-LM group). Technical success was defined as final TIMI 3 flow in both, left main and distal vessels, anterior descending and circumflex artery, without significant residual stenosis (&gt;20% following balloon angioplasty or stent implantation) and side branch compromise (residual stenosis &gt;75%).

Results

Patients with ULM were older and more likely to present as Non-ST-elevation MI (77% vs. 93%; p&lt;0.000) and in cardiogenic shock (40% vs. 2.2%; p&lt;0.000), having less occlusive disease with TIMI 0–1 flow prior to PCI (44% vs. 78%; p&lt;0.000) compared to Non-LM patients. Also, greater procedure complexity was observed with longer lesions &gt;20mm (50% vs. 29%; p&lt;0.000), more intraluminal thrombus (86% vs. 45%; p&lt;0.000), greater number (1,48±0,9 vs. 1,28±0,7; p&lt;0.01) and longer stents (30,5±15,8 vs. 27,4±14,3; p=0.028), more GP IIb/IIIa inhibitors (32% vs. 23%; p=0.022), intra-aortic counterpulsations (7% vs. 0.6%; p&lt;0.000) and contrast media used (202±96 vs. 172±66; p&lt;0.000) in ULM group. Despite obtaining comparable rates of final TIMI 3 flow in main branch (91.9% vs. 95.4%; p=0.084), patients with LMCA had significantly higher in-hospital (27% vs. 4.7%: p&lt;0.000), and one-year all-cause mortality (41% vs. 11%: p&lt;0.000), but for the remaining duration of clinical follow-up (available for 97.8% pts, median duration 51±37 months) survival rates were comparable between ULM and Non-LM pts (18% vs. 15%: p=0.506) (Figure 1).

Regression analysis showed that final TIMI 3 in main branch at 30 days (HR 0.05 [95% CI 0.005–0.604]; p=0.018), while peri-procedural cardiogenic shock (hazard ratio (HR) 8.3 [95% CI 2.5–28.1]; p=0.001), creatinine clearance &lt;60 ml/min (HR 7.5 [95% CI 2.3–25.1]; p=0.001) and technical success (HR 0.16 [95% CI 0.45–0.57]; p=0.005) at 5 years, independently predicted mortality in ULM patients.

Conclusions

Despite performance of primary PCI, patients with MI due to ULM lesions are associated with worse in-hospital and one-year mortality but following that period mortality was comparable to control group. Suboptimal final coronary flow best predicted the 30 day, while peri-procedural cardiogenic shock, renal dysfunction at admission and suboptimal technical procedure result, predicted long-term mortality in these patients.

Figure 1

Funding Acknowledgement

Type of funding source: None

Clinical characteristics and long-term mortality of patients with midrange ejection fraction undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction

Background

Previous studies associated midrange ejection fraction (mrEF) with impaired prognosis in patients with ST-elevation myocardial infarction (STEMI).

Purpose

Our aim was to assess clinical profile and short- and long-term mortality of patients with mrEF after STEMI treated with primary percutaneous coronary intervention (PCI).

Methods

This analysis included 8148 patients admitted for primary PCI during 2009–2019, from a high-volume tertiary center, for whom echocardiographic parameters obtained during index hospitalization were available. Midrange EF was defined as 40–49%. Adjusted Cox regression models were used to assess 30-day and 5-year mortality hazard of mrEF, with the reference category being preserved EF (&gt;50%).

Results

mrEF was present in 29.8% (n=2 427), whereas low ejection fraction (EF&lt;40%) was documented in 24.7% of patients (n=2 016). mrEF was associated with a higher baseline risk as compared with preserved EF patients, but lower when compared with EF&lt;40%, in terms of prior MI (14.5% in mrEF vs. 9.9% in preserved EF vs. 24.2% in low EF, p&lt;0.001), history of diabetes (26.5% vs. 21.2% vs. 30.0%, p&lt;0.001), presence of Killip 2–4 on admission (15.7% vs. 6.9% vs. 26.5%, p&lt;0.001) and median age (61 vs. 59 vs. 64 years, p&lt;0.001). At 30 days, mortality was comparable in mrEF vs. preserved EF group, while it was significantly higher in the low EF group (2.7% vs. 1.6% vs. 9.4%, respectively, p&lt;0.001). At 5 years, mrEF patients had higher crude mortality rate as compared with preserved EF, but lower in comparison with low EF (25.1% vs. 17.0% vs. 48.7%, p&lt;0.001) (Figure). After adjusting for the observed baseline differences mrEF was independently associated with increased mortality at 5 years (HR 1.283, 95% CI: 1.093–1.505, p=0.002), but not at 30 days (HR 1.444, 95% CI: 0.961–2.171, p&lt;0.001).

Conclusion

Patients with mrEF after primary PCI for STEMI have a distinct baseline clinical risk profile, as compared with patients with reduced (&lt;40%) and preserved (≥50%) EF. Importantly, mrEF did not have a significant impact on short-term mortality following STEMI, but it did independently predict the risk of 5-year mortality.

Funding Acknowledgement

Type of funding source: None

Prognostic impact of gender and young age in patients with acute myocardial infarction undergoing primary PCI

Background

Previous studies showed higher unadjusted mortality rates in female patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI). However, after adjusting for differences in baseline characteristics, including age, female gender was not consistently associated with higher mortality.

Purpose

Our aim was to investigate the impact of gender on short- and long-term mortality in patients aged 18 to 55 years with AMI undergoing primary PCI.

Methods

We included 11 288 patients admitted for primary PCI during 2009–2019, from a prospectively kept, electronic registry of a high-volume tertiary center. Adjusted Cox regression models were used to assess 30-day and 5-year mortality hazard. Median follow up was 1 507 days.

Results

3 505 patients were younger than 55 years (31%). In this age group, 18.9% were female patients (n=661). Baseline characteristics were similar for females vs. males below the age of 55 years, including similar reperfusion times (338 min. vs. 341 min., p=0.8), with only exceptions being a higher rate of previous hypertension (64% vs. 58%, p=0.002) and stroke (3.6% vs. 2.2%, p=0.049), as well as lower ejection fraction (48% vs. 51%, p&lt;0.001), in female patients. MINOCA (Myocardial Infarction with Nonobstructive Coronary Arteries) was more frequently present in female vs. male patients aged ≤55 years (10.1% vs. 5.0%, p&lt;0.001). In the overall population, crude mortality was higher in female patients at 30 days (9.8% vs. 6.0%, p&lt;0.001) and 5 years (38.4% vs. 30.2%, p&lt;0.001). In younger patients (≤55 years), mortality rates were low and similar between the sexes at both 30 days (3.6% in females vs. 2.5% in males, p=0.136) and 5 years (14.5% vs. 13.4%, p=0.58). On the contrary, in patients aged &gt;55 years, crude mortality was higher in female patients at both 30 days (11.3% vs. 7.9%, p&lt;0.001) and 5 years (43.9% vs. 39.4%, p=0.02), albeit mainly driven by the differences in baseline characteristics between the sexes in this older age group (adjusted HR for female sex 1.220, CI95% 0.920–0.617, p=0.17, at 30 days; and adjusted HR 1.033, CI95% 0.908–0.175, p=0.62, at 5 years).

Conclusion

Differences in crude mortality rates between sexes in patients with AMI admitted for primary PCI appear to be mainly dependent on age, with similar rates of both short- and long-term mortality in younger patients (≤55 years). The observed excess in mortality in older (&gt;55 years) female vs. male patients could be explained by the differences in baseline clinical characteristics.

Funding Acknowledgement

Type of funding source: None

Prognostic impact of atrial fibrillation in patients undergoing primary PCI with versus without left ventricular function impairment

Background

Atrial fibrillation (AF) and impaired left ventricular (LV) function have both been separately associated with increased risk of mortality following primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI).

Purpose

Our aim was to comparatively evaluate the impact of LV dysfunction and AF on the risk of mortality in primary PCI-treated patients.

Methods

This analysis included 8561 patients admitted for primary PCI during 2009–2019, from a prospectively kept, electronic registry of a high-volume tertiary center, from whom echocardiographic parameters were available. LV dysfunction was defined as EF&lt;40%. Adjusted Cox regression models were used to assess 30-day and 1-year mortality hazard.

Results

AF was present in 3.2% (n=273), whereas 37% had LV dysfunction (n=3189). Crude mortality rates were increased in the presence of either AF or LV dysfunction, and were the highest in the group of patients having both AF and impaired LV function, at 30 days (1.8% in no AF and no LV dysfunction vs. 5.4% if AF only vs. 7.0% if EF&lt;40% only vs. 14.9% if AF and LV dysfunction concurrently present, p&lt;0.001) and at 3 years (10.5% if no AF and no LV dysfunction vs. 35.8% if AF only vs. 28.5% if EF&lt;40% only vs. 60.3% if AF and LV dysfunction both present, p&lt;0.001). After multivariable adjustment for other significant mortality predictors, including age, previous stroke, MI, diabetes, hyperlipidemia, anemia and Killip≥2, LV dysfunction alone and in combination with AF was an independent predictor of mortality at both 30 days (HR=2.2 and HR=2.5, respectively, p&lt;0.001 for both) and at 3 years (HR=1.9 and HR=2.9, respectively, p&lt;0.001 for both). However, presence of AF alone, in the absence of an impaired LV function, was not independently associated with mortality at 30 days (HR 1.34, CI 95% 0.58–3.1, p=0.48), but rather at 3 years (HR 1.74, CI 95% 1.91–2.54, p=0.004).

Conclusion

Atrial fibrillation is associated with long-term mortality in STEMI patients undergoing primary PCI, irrespective of the LV function. Conversely, short-term prognostic relevance of atrial fibrillation in STEMI is dependent on the presence of LV dysfunction.

Kaplan Meier curve_AF_LV dysfunction

Funding Acknowledgement

Type of funding source: None

Comparison of contrast induced nephropathy definitions and in-hospital mortality in patients undergoing primary percutaneous coronary intervention for acute myocardial infarction

Background

Contrast induced nephropathy (CIN) has been associated with increased mortality in patients with acute myocardial infarction (AMI). However, different definitions of CIN have so far been used.

Purpose

We aimed to compare predictive accuracy of the 2 contemporary CIN definitions in patients with AMI undergoing primary percutaneous coronary intervention (PCI).

Method

From a high-volume, single-centre, prospective registry, in a period from 2009–2019, we identified 7987 pts who underwent primary PCI for AMI in whom creatinine measurements were available for analysis. CIN incidence was evaluated according to relative creatinine increases of ≥25% (CIN25) and ≥50% (CIN50) from baseline levels within 72 hours after intervention. The primary end point was in-hospital mortality.

Results

Overall, 1116 (13.9%), and 345 (4.3%) patients developed CIN25, CIN50, respectively. Crude in-hospital mortality rate was 3.9% (312 pts) in the overall population. Both definitions were independently associated with in-hospital mortality (CIN25 adjusted odds ratio (OR) 4.2, 95% CI 2.7–6.6; p&lt;0.001, and CIN 50 adjusted OR 8.2, 95% CI 4.9–13.9; p&lt;0.001). Comparison of ROC curves showed that only the addition of the CIN50 (and not CIN25) definition to the combined model of clinical predictors of in-hospital mortality, which included pre-intervention TIMI flow 0–1, cardiogenic shock on admission, baseline creatinine clearance, prior stroke, chronic occlusion of non-culprit artery, post-intervention TIMI flow 3, left ventricular ejection fraction and procedure time, improved prognostic accuracy of the model (Figure 1).

Conclusion

Only acute kidney injury according to the CIN50 definition, but not the CIN25 definition, offers additional prognostic information above and beyond the combination of baseline predictors of in-hospital mortality in patients with AMI undergoing primary PCI.

Figure 1

Funding Acknowledgement

Type of funding source: None

Impact of a CTO in a non-infarct-related artery on long-term mortality in patients undergoing primary PCI

Background

Previous studies showed increased mortality rates in patients with ST-elevation myocardial infarction (STEMI) and a chronic total occlusion (CTO) in a non-infarct-related artery, but long-term data are scarce.

Purpose

Our aim was to assess all-cause mortality during 5 years follow-up in patients with a remaining nonculprit CTO after being treated with primary PCI.

Methods

The study included 9504 patients admitted for primary PCI during 2009–2019, with available baseline angiography, from an electronic, prospective registry of a high-volume catheterization laboratory. Kaplan Meier cumulative mortality curves for non-culprit CTO vs. no CTO were compared with the log-rank test, with landmarks set at 30 days and then annually up to 5 years follow-up. Adjusted Cox regression models were constructed to assess 30-day and 5-year mortality risk of a non-culprit CTO. Median follow-up was 1507 days.

Results

Nonculprit CTO was present in 13.2% of patients (n=1253). Presence of a nonculprit CTO was associated with older age (64 vs. 61, p&lt;0.001), more frequent history of cardiovascular disease including prior MI (33% vs. 14%, p&lt;0.001), stroke (10.3% vs. 5.9%, p&lt;0.001) and CABG (10.5% vs. 1.5%, p&lt;0.001), higher rates of renal failure (10.7% vs. 4.8%, p&lt;0.001), as well as more often Killip class 2–4 on admission (29% vs. 16%, p&lt;0.001) and a lower ejection fraction (40% vs. 47%, p&lt;0.001). Crude mortality rates were significantly increased in patients with a nonculprit CTO vs. no CTO, at both 30 days (15.7% vs. 5.6%, p&lt;0.001) and 5 years (54.6% vs. 27.9%, p&lt;0.001). After adjusting for the observed baseline differences, nonculprit CTO was still associated with an elevated mortality risk at both 30-days (HR 1.5, CI95% 1.1–1.9, p=0.007) and 5 years (HR 1.6, CI95% 1.4–1.9, p&lt;0.001). Landmark analyses showed continuously increasing risk of mortality in the presence of a nonculprit CTO, as compared with primary PCI-treated patients with no CTO (30 days to 1 year 11.4% vs. 4.9%, p&lt;0.001; 1st to 2nd year of follow-up 6.3% vs. 3.4%, p&lt;0.001; 2nd to 3rd year 6.2% vs. 2.8%, p&lt;0.001; 3rd to 4th year 7.4% vs. 3.0%, p&lt;0.001; and 4th to 5th year 5.2% vs. 3.6%, p=0.1).

Conclusions

Presence of a nonculprit CTO is independently associated with 5-year mortality after primary PCI. Importantly, the mortality risk increases continuously with an average annual absolute difference of 3%, in patients with a nonculprit CTO vs. those with no CTO.

Nonculprit CTO vs. no CTO

Funding Acknowledgement

Type of funding source: None

Comparison of the FASTEST and the ZWOLLE risk scores for identification of very low-risk patients for all-cause mortality and MACE following primary PCI

Background

Prior studies suggest that low-risk ST-segment-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI) can be considered for early discharge in order to reduce healthcare costs and improve resource utilization. Novel, simple, the FASTEST score, demonstrated additional prognostic value over guideline recommended ZWOLLE score in a derivation cohort, but robust data about external validation are lacking.

Purpose

We aimed to compare overall predictive ability and discriminating power in identification of low-risk patients of novel FASTEST score compared to validated ZWOLLE score.

Methods

From a high-volume, single-center, prospective registry, in a period from 2009–2019, we included STEMI patients who underwent successful pPCI in whom both, FASTEST (1 point added for: femoral access, age&gt;65, LVEF &lt;50, TIMI &lt;3, creatinine &gt;1.5 mg/dl; left main disease; and Killip≥2) and ZWOLLE (age, anterior infarct, Killip class, TIMI flow, ischemia time, 3 vessel disease) scores were both calculated. Predictive ability of scores for in-hospital, 30 days and 1 year mortality and hospital MACE was tested using ROC analysis and comparing AUC. Also, event rate was compared between low-risk patients as classified by FASTEST (score=0) or ZWOLLE (score≤3).

Results

We included 5650 patients (age 60.8±11.4, male (71%), anterior STEMI (44%) and femoral approach (81%)). Overall, mortality rates were 2.1%, 3.1% and 8.1% for hospital, 30 days and one-year. As Low-risk subjects, ZWOLLE identified broader proportion of population compared to FASTEST (67% vs. 5.5%) mainly due to high prevalence of femoral approach (FASTEST low-risk 30% in radial approach subset), still, later had numerically lower mortality rates at hospital (0.7% vs. 0.3% (only 1 pt); p=0.62), 30 days (1.3% vs. 0.7%; p=0.39) and at one-year (4% vs. 2%; p=0.14). Both scores showed similar and very good predictive ability for in-hospital (AUC 0.81 vs. 0.81; p=0.66) and 30 days mortality (AUC 0.79 vs. 0.77; p=0.29), while at one-year, discrimination of crude mortality by FASTEST trended, but didn't reach statistical significance compared to ZWOLLE score, respectively (AUC 0.77 vs. 0.75; p=0.07). FASTEST showed better prediction for composite endpoint of in-hospital MACE - death, stroke, reinfarction and bleeding BARC class 3 or higher (AUC 0.71 vs. 0.67; p&lt;0.000) (Figure 1).

Conclusion

Both the FASTEST and the ZWOLLE scores showed very good discriminating power for in-hospital, 30 day mortality and one-year mortality, yet the FASTEST score offered comparative advantage for prediction of in-hospital MACE and could be used to identify selected patients where an early hospital discharge can be considered.

ZWOLLE vs FASTEST ROC analisys

Funding Acknowledgement

Type of funding source: None

The interactions of the ruthenium(II)-cymene complexes with lysozyme and cytochrome c

The reactions of four cymene-capped ruthenium(II) compounds with pro-apoptotic protein, cytochrome c (Cyt), and anti-proliferative protein lysozyme (Ly) in carbonate buffer were investigated by ESI-MS, UV-vis absorption, and CD spectroscopy. The complexes with two chloride ligands (C2 and C3) were more reactive toward proteins than those with only one (C1 and C4), and the complex with S,N-chelating ligand (C4) was less reactive than one with O,N-chelating ligand (C1). Dehalogenated complexes are most likely species, initially coordinating proteins for all tested complexes. During the time, protein adducts vividly exchanged non-arene organic ligand L with CO₃^2- and OH^-, while cymene moiety was retained. In water, only dehalogenated adducts were identified suggesting that in vivo, in the presence of various anions, dynamic ligand exchange could generate different intermediate protein species. Although all complexes reduced Cyt, the reduction was not dependent on their reactivity to protein, implying that initially noncovalent binding to Cyt occurs, causing its reduction, followed by coordination to protein. Cyt reduction was accompanied with rupture of ferro-Met 80 and occupation of this hem coordination site by a histidine His-33/26. Therefore, in Cyt with C2 and C3, less intensive reduction of hem iron leaves more unoccupied target residues for Ru coordination, leading to more efficient formation of covalent adducts, in comparison to C1 and C4. This study contributes to development of new protein-targeted Ru(II) cymene complexes, and to the design of new cancer therapies based on targeted delivery of Ru(II) arene complexes bound on pro-apoptotic/anti-proliferative proteins as vehicles.

P4619Comparison of the CRUSADE, ACUITY-HORIZONS, and ACTION bleeding risk scores for predicting in-hospital bleeding in acute myocardial infarction patients undergoing primary PCI

Background

Considering clinical importance of bleeding complications in patients with acute myocardial infarction (AMI), bleeding risk stratification is a key part of the management of these patients. CRUSADE, ACTION and ACUITY-HORIZONS bleeding risk scores are available for predicting in-hospital major bleeding events in patients with acute myocardial infarction.

Purpose

We aimed to evaluate performance of the three above mentioned risk scores for predicting in-hospital bleeding events defined according to The Bleeding Academic Research Consortium (BARC) criteria.

Methods

From a prospective electronic registry of a high-volume catheterization laboratory in a period from January 2009 to December 2017, a total of 6505 consecutive patients with acute myocardial infarction who underwent pPCI were included in analysis. Calibration and discrimination of the three risk models were evaluated by the Hosmer-Lemeshow (H-L) goodness-of-fit test and C-statistic, respectively.

Results

Overall there were 372 (5.7%) bleeding events out of which 117 (1.8%) fulfilled stage BARC 3 or higher bleeding criteria. All three scores showed good model calibration as assessed by the H-Ls test and very good discriminative power for BARC 3 of higher bleeding events detection as assessed by C-statistics (Table 1 & Figure 1):

Bleeding events stage BARC 3 or higher were statistically highly related with higher in-hospital mortality (13.7% vs. 3.5%; p<0.000).

Table 1 Risk score H-L H-L p AUC 95% CI p CRUSADE 11.46 0.177 0.761 0.750–0.771 vs. ACUITY = ns vs. ACTION <0.000 ACUITY-HORIZONS 10.47 0.236 0735 0.724–0.745 vs. ACTION = ns ACTION 5.74 0.677 0.701 0.698–0.712

Figure 1

Conclusions

All three evaluated scores showed very good discriminative capacity for predicting BARC 3 or higher bleeding events in patients undergoing pPCI for AMI.

P5481Predictors of mortality in patients with non-anterior ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

Background

Previous studies have indicated that patients with non-anterior ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) have a more favorable prognosis compared with anterior STEMI, especially in the short term.

Purpose

Our aim was to identify predictors of increased 30-day mortality in patients with non-anterior STEMI undergoing primary PCI.

Methods

This analysis included 8188 patients referred to primary PCI during 2009–2017, from a prospective electronic registry of a high-volume catheterization laboratory, for whom 30-day follow-up was available. Non-anterior infarction was defined as presence of ST-segment elevation in inferior and/or lateral ECG leads or true posterior MI. Multivariable Cox regression was used to assess the mortality risk at 30 days.

Results

59.4% (n=4863) of the included patients presented with a non-anterior STEMI. Mortality rate was significantly lower in patients with non-anterior vs. anterior STEMI (4.2% vs. 8.3%, p<0.001). Older age (> median of 61, HR 2.2, p=0.002), baseline renal failure (eGFR <60, HR 4.0, p<0.001), Killip class ≥2 (HR 3.8, p<0.001), previous stroke (HR 1.8, p=0.004), non-culprit chronic total occlusion (CTO, HR 2.0, p<0.001) and final TIMI flow grade <3 in the infarct-related artery (HR 3.1, p<0.001) were independently associated with an increased risk of 30-day mortality in non-anterior STEMI. The presence of at least one of these high-risk factors was noted in 61.2% of patients with non-anterior STEMI and was associated with a significantly higher risk of 30-day mortality (HR 18.2, p<0.001), similarly to the overall risk associated with anterior STEMI (HR 22.9, p<0.001), as compared with patients with non-anterior STEMI but without any of the here identified high-risk factors (Figure).

Figure 1

Conclusions

Crude mortality rate was significantly lower in patients with non-anterior vs. anterior STEMI. However, the majority of non-anterior STEMI patients had at least one of the high-risk factors (older age, previous CVI, baseline renal failure, Killip class ≥2, non-culprit CTO or final TIMI flow <3), which predisposed these patients to a similar increase in short-term mortality risk as in patients with anterior STEMI.

P953Comparison of the original and updated ACTION risk scores for predicting in-hospital and one-year mortality in patients with acute myocardial infarction undergoing primary PCI

Background

The Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry-Get With The Guidelines (GWTG) AMI mortality model and risk score (ACTION) were introduced in 2011 to predict in-hospital mortality. In 2016 score was updated to enable a more accurate assessment, but, up-to-date, external validation in direct comparison was not performed.

Purpose

We aimed to externally validate and compare the prognostic value of original and updated ACTION score for in-hospital and one-year mortality.

Method

From a prospective electronic registry of a high-volume catheterization laboratory in a period from January 2009 to December 2017, a total of 5615 consecutive patients who underwent pPCI were available for analysis. For each patient, original (O-) and updated (U-) ACTION scores were calculated using required clinical and angiographic characteristics. In-hospital and one-year mortality (follow-up available for 91%) were assessed. Calibration and discrimination of the three risk models were evaluated by the Hosmer-Lemeshow (H-L) goodness-of-fit test and C-statistic, respectively.

Results

Mortality rates for in-hospital and one-year mortality were 4.2% and 9.6%, respectively. Both scores showed good model calibration as assessed by the H-L test and very good discriminative power for in-hospital and one-year mortality as assessed by C-statistics (Table 1 & Figure 1).

Net reclassification index (NRI=1.06) showed that 48% of patients with in-hospital event and 58% without event, had their risk recalculated with U-ACTION with Integrated Discrimination Improvement slope 9.1% higher than in first model.

Table 1 Risk score H-L H-L p value AUC 95% CI p value AUC 95% CI Significant p value O-ACTION 9.4 0.3 0.829 0.819 to 0.839 p<0.0001 0.781 0.769 to 0.792 p<0.0001 U-ACTION 10.9 0.2 0.918 0.911 to 0.925 0.838 0.827 to 0.848

Figure 1

Conclusion

Updated ACTION score enables better prediction of in-hospital and one-year mortality in patients undergoing pPCI for acute myocardial infarction, thus it can be used preferentially over the original ACTION score for assessment of short and long-term mortality risks of this population.

P5011Impact of guideline-recommended medical therapy at discharge on long-term mortality in patients with or without left ventricular dysfunction after primary PCI for STEMI

Background

Clinical practice guidelines provide class I recommendation for the use of angiotensin-converting enzyme inhibitors (ACE-I) and beta-blockers in patients with prior myocardial infarction and left ventricular (LV) dysfunction, whereas their use in patients without LV dysfunction is considered to be a class IIa recommendation.

Purpose

Our aim was to comparatively assess the impact of ACE-I and/or beta-blockers on 3-year mortality in patients with or without impaired left ventricular (LV) function undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).

Methods

The analysis included 4425 patients admitted for primary PCI during 2009–2015 from a prospective, electronic registry of a high-volume tertiary center, who survived initial hospitalization, and for whom information on LV function and discharge medication were available. Patients were stratified according to LV systolic dysfunction, defined as LVEF <40%. Unadjusted and adjusted Cox regression models were created to investigate the impact of beta-blocker and/or ACE-I therapy on 3-year mortality.

Results

22.9% (n=1013) had LV dysfunction, 23.0% (n=1017) received either an ACE-I or a beta-blocker and 72.2% received both medications at discharge (n=3197). The concurrent use of both ACE-I and beta-blockers was not different in LVEF≥40% vs. LVEF<40% (72.4% vs. 71.7%, p=0.43). The use of at least one of the guideline-recommended medications was associated with a significantly lower 3-year mortality in both patients with LVEF≥40% (18.7% if neither was used, 11.2% if either a beta-blocker or an ACE-I were used and 9.4% if both were used, p=0.001), and LVEF<40% (55.4% if neither was used, 32.5% if either a beta-blocker or an ACE-I were used and 22.9% if both were used, p<0.001) (Figure). After adjusting for significant mortality predictors including older age, diabetes, hypertension, renal failure, previous stroke, Killip class ≥2 and non-culprit chronic total occlusion (CTO), the concurrent use of both a beta-blocker and an ACE-I remained independently associated with lower 3-year mortality in both patients with LVEF<40% (HR 0.30, p<0.001) and LVEF≥40% (HR=0.41, p=0.001). The use of a single agent was independently associated with lower mortality in patients with LVEF<40% (HR 0.45, p=0.002), but not in patients with LVEF≥40% (HR 0.61, p=0.07).

Conclusions

Guideline-recommended use of both a beta-blocker and an ACE-I in post-MI patients was associated with a lower 3-year mortality regardless of the LV function, whereas using only one of the two agents was associated with improved prognosis only in patients with LV dysfunction, but not in patients without LV impairment.

P849Comparison of long-term mortality risk assessed with recalculated (maximal) CADILLAC score vs. baseline (admission) CADILLAC score in STEMI patients undergoing primary PCI

Background

Since patients with STEMI have high rate of adverse events not only during hospital stay, but also during short and long-term follow–up, appropriate risk stratification is a key part of the management of these patients following hospital discharge. CADILLAC score was derived and subsequently validated as accurate clinical tool for identifying patients with heightened risk following index event.

Purpose

We aimed to compare predictive value of recalculated, maximal, (M-) CADILLAC score vs. baseline (B-) CADILLAC score for long-term mortality in hospital survivors.

Methods

From a prospective electronic registry of a high-volume catheterization laboratory in a period from January 2009 to December 2017, a total of 5387 consecutive patients STEMI who underwent primary PCI were included in analysis. For each patient B-CADILLAC score was calculated, and for survivors, we recalculated M-CADILLAC score, incorporating changes in three variable score individual contributors (worsening of Killip class, anemia development and renal function deterioration). As in original score derivation, patients with cardiogenic shock were excluded from analysis. Discrimination of the two risk models was evaluated by the C-statistic, Net reclassification index (NRI) and Integrated Discrimination Improvement (IDI) index.

Results

For 111 (2.1%) patients that died in-hospital, B-CADILLAC very well predicted the event (AUC 0.87, 95% CI 0.86–0.88; p<0.0001) (Figure 1A). For hospital survivors, both evaluated scores showed good discriminative ability for long-term mortality (11.7%) but recalculated M-CADILLAC score was statistically better predictor of long-term mortality, as assessed by C-statistics (Table 1 & Figure 1B):

NRI showed that 38% of patients were reclassified with M-CADILLAC with IDI slope 0.8% higher than in first model.

Table 1 4723 pts (follow-up=90% pts, 41±27 months) AUC 95% CI p B-CADILLAC 0.756 0.744–0.768 p=0.018 M-CADILLAC 0.776 0.754–0.779

Figure 1

Conclusions

Baseline CADILLAC score has very good predictive ability for in-hospital mortality, but recalculated, maximal CADILLAC score offers discriminative advantage in hospital survivors for prediction of long-term mortality in STEMI patients undergoing primary PCI.

P845Comparison of the performance of the five validated risk scores in acute myocardial infarction patients undergoing primary PCI

Background

Several risk scores have been developed to predict mortality of patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (pPCI), with limited data on the comparative prognostic value of these models.

Purpose

We aimed to compare the prognostic value of five validated risk scores for in-hospital and one-year mortality of patients with AMI undergoing pPCI.

ume catheterization laboratory in a period from January 2009 to December 2017, a total of 3868 consecutive patients who underwent pPCI were available for analysis. For each patient, the Thrombolysis In Myocardial Infarction (TIMI), Controlled Abciximab and Device Investigation to Lower Late Angioplasty complications (CADILLAC), ACTION Registry-GWTG in-hospital mortality risk score (ACTION), Age, Creatinine, and Ejection Fraction (ACEF), and ZWOLLE risk scores were calculated using required clinical and angiographic characteristics. In-hospital and one-year mortality were assessed (follow-up available for 92% of pts). Calibration and discrimination of the three risk models were evaluated by the Hosmer-Lemeshow (H-L) goodness-of-fit test and C-statistic, respectively.

Results

Mortality rates for in-hospital and one-year mortality were 1.8% and 6.9% respectively. All five scores showed good model calibration as assessed by the H-L test and very good discriminative power for in-hospital and one-year mortality as assessed by C-statistics (Table 1 & Figure 1):

Table 1 Risk score H-L H-L p AUC in-hospital 95% CI Significant p AUC one-year 95% CI Significant p ZWOLLE 1.3 0.7 0.90 0.89–0.91 vs. CADILLAC <0.05 0.75 0.74–0.77 vs. TIMI <0.005 ACTION 13.1 0.1 0.87 0.86–0.88 vs. TIMI <0.005 0.79 0.77–0.80 CADILLAC 5.5 0.2 0.85 0.84–0.86 vs. TIMI <0.01 0.81 0.80–0.83 vs. ZWOLLE <0.000 vs. TIMI <0.000 ACEF 9.9 0.3 0.814 0.83–0.85 0.80 0.78–0.81 vs. ZWOLLE <0.000 vs. TIMI <0.05 TIMI 7.1 0.3 0.79 0.78–0.80 0.76 0.75–0.78

Figure 1

Conclusion

Risk stratification of patients with AMI undergoing pPCI using the ZWOLLE, ACTION, CADILLAC, ACEF or TIMI risk scores enables accurate identification of high-risk patients for in-hospital and one-year mortality in an all-comers population. Among evaluated scores, ZWOLLE model was better fitted for prediction of in-hospital mortality while CADILLAC and ACEF better predicted late events.