Oral Presentation No. 53 Dose-related preprocedural patency of the infarct-related artery after zalunfiban (RUC-4) administration upon arrival at the catheterization laboratory in ST-elevation myocardial infarction: insights from the phase IIa study

Background

The importance of time to reperfusion after ST-elevation myocardial infarction (STEMI) is well established. Pre-hospital use of glycoprotein IIb/IIIa (GPIIb/IIIa) inhibitors improves pre-percutaneous coronary intervention (PCI) perfusion rates, but they require intravenous administration and continuous infusions and so are difficult for ambulance services to administer. Zalunfiban (RUC-4) is a novel, subcutaneously administered, GPIIb/IIIa inhibitor specifically developed to facilitate pre-hospital administration, thereby maximizing the chance for early reperfusion. This sub-analysis investigated the incidence of complete reperfusion (TIMI grade 3 flow) before primary PCI in patients treated with zalunfiban on arrival at the catheterization laboratory as a function of the dose of zalunfiban.

Material and methods

This was a prospective, single-centre, open-label, phase IIa study designed to assess the pharmacodynamics, pharmacokinetics, and tolerability of zalunfiban in patients with STEMI undergoing primary PCI. Zalunfiban was administered immediately upon arrival at the catheterization lab, which was ∼10–15 minutes before the initial angiogram used to assess TIMI grade flow.

Results and conclusion

A total of 27 patients received a weight-adjusted subcutaneous injection of zalunfiban in escalating doses (0.075 mg/kg [n = 8], 0.090 mg/kg [n = 9], or 0.110 mg/kg [n = 10]). Of these, 25 patients were evaluable for angiographic analysis. TIMI flow grade 3 pre-PCI was observed in 1/7, 2/9 and 5/9 patients and showed a dose-related effect (Ptrend = 0.04). The ongoing international, phase III, double-blinded, randomized, placebo-controlled, CELEBRATE trial is designed to assess whether a single, ambulance-based pre-hospital injection of zalunfiban results in improved clinical outcome.

Funding

This study was supported by CeleCor Therapeutics.

Prognostic impact of newly diagnosed atrial fibrillation and episode characteristics in patients with acute coronary syndrome

Background/Introduction

Newly diagnosed atrial fibrillation (AF) frequently occurs during acute coronary syndrome (ACS). In contrast to known AF, little is known about the prognostic and therapeutic implications of new AF.

Purpose

To evaluate the prognostic impact of newly diagnosed and known AF in patients with ACS. Furthermore, we evaluated the association of episode characteristics of new AF with clinical outcomes: early vs late occurrence, short vs long duration, post-CABG occurrence, and OAC treatment.

Methods

This analysis was performed within the prospective, multicentre, FORCE-ACS registry which studies ACS patients in the Netherlands. All ECGs during index ACS admission were retrospectively examined for the occurrence of AF. Patients were classified as no, new, or known AF. New AF episodes were described regarding early or late occurrence, duration of the episode, and post-CABG occurrence, and OAC prescription at discharge was evaluated. The primary outcome was MACE, a composite of death, myocardial infarction and stroke. Secondary outcomes include the separate MACE components and bleeding. Crude and adjusted outcomes were evaluated by univariable and multivariable Cox regression.

Results

3902 patients were included of which 299 (10.2%) had new and 367 (9.4%) had known AF. Major adverse cardiac events happened significantly more in both new and known AF patients than in patients without AF (22.2%, 17.4%, and 9.2%, p<0.001). Ischemic stroke occurred significantly more in new AF but not in known AF patients, compared to patients without AF (3.5% vs 0.9% vs 1.1%). After one year follow-up, a total of 234 patients (6.3%) deceased, of whom 138 in the group without AF (4.6%), and significantly more in the groups with new AF (n=59, 15.9%), and known AF (n=37, 10.8%). The timing of onset of the AF episode showed no significant association with clinical outcomes. Longer duration of the episode, however, was associated with increased MACE (HR 2.0, 95% CI 1.2–3.1) and all-cause mortality (HR 2.0, 95% CI 1.2–3.4). Episodes of new AF that occurred post-CABG were associated with less MACE (HR 0.31, 95% CI 0.14–0.67) and all-cause mortality (HR 0.20, 95% CI 0.07–0.55). No significant association between OAC treatment and MACE nor any of its separate components was found.

Conclusion

Newly diagnosed atrial fibrillation in acute coronary syndromes is associated with worse clinical outcomes than known or no atrial fibrillation. Longer episodes were associated with worse outcomes than short episodes. Post-operative new AF was associated with better outcomes than non-post-operative new AF.

Funding Acknowledgement

Type of funding sources: None.

Effects of CYP3A4*22 carrier and CYP3A5 expressor status on clinical outcome in patients treated with ticagrelor for acute coronary syndrome

Background

Current guidelines recommend using ticagrelor in patients with acute coronary syndrome. Ticagrelor is predominantly metabolized by CYP3A4 and to a lesser extent by CYP3A5. CYP3A4*22 allele and the CYP3A5 expressor status influence the metabolization of ticagrelor, increasing plasma concentration and platelet inhibition. Nevertheless, little is known about the impact of the CYP3A4*22 allele or CYP3A5 expressor status on clinical outcomes in ticagrelor treated patients.

Purpose

Our study aims to assess the effects of the CYP3A4*22 allele and CYP3A5 expressor status in patients with STEMI and treated with ticagrelor, with regards to clinical outcomes and the clinical side-effect dyspnea.

Methods

Patients from the POPular Genetics trial treated with ticagrelor were genotyped for the CYP3A4*22 and CYP3A5*3 alleles. Patients were divided into two groups based on their CYP3A4 (*22 carriers vs. *22 non carriers) and CYP3A5 status (expressor vs. non-expressors). The primary thrombotic endpoint was a composite of cardiovascular death, myocardial infarction, definite stent thrombosis and stroke. The primary bleeding outcome consisted of PLATO major and minor bleeding. The key secondary endpoint was clinically relevant dyspnea. The follow-up duration was one year.

Results

A total of 1,281 patients with ST-elevation myocardial infarction (STEMI) were used for the analyses. In the first analysis, CYP3A4*22 carriers (n=152) versus CYP3A4*22 non-carriers (n=1,129) were not found to have a significant correlation with the primary thrombotic outcome (1.3% vs. 2.5% adjusted hazard ratio 1.81 [0.43–7.62]) or the primary bleeding outcome (13.2% vs. 11.3% adjusted hazard ratio 0.93 [0.58–1.50]) (See Figure 1 and 2). CYP3A5 expressors (n=196) versus non-expressors (n=926) did not show a significant difference for the primary thrombotic outcome (2.6% versus 2.5% adjusted hazard ratio 1.03 [0.39–2.71] or the primary bleeding outcome (12.8% versus 10.9% adjusted hazard ratio 1.13 [0.73–1.76]). With respect to dyspnea, no significant difference was observed between CYP3A4*22 carriers versus CYP3A4*22 non-carriers 44.0% vs. 45.0%, risk ratio 1.04 [0.45–2.42] or CYP3A5 expressors versus CYP3A5 non-expressors 35.3% versus 47.8% risk ratio 0.60 [0.27–1.30].

Conclusions

In STEMI patients treated with ticagrelor, CYP3A4*22 carriers and CYP3A5 expressors did not affect clinical outcomes with regards to thrombotic events, bleeding rate, or the side-effect dyspnea.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Netherlands Organization for Health Research and Development (ZonMW). The authors are solely responsible for designing and conducting this study, conducting all study analyses, and drafting and editing the manuscript and its final contents.

Diagnostic performance of coronary CTA and CT-FFR for the detection of coronary artery disease in routine TAVI work-up

Objectives

To assess the diagnostic performance of CT-FFR for the diagnosis of CAD in the work-up for TAVI.

Background

Work-up for transcatheter aortic valve implantation (TAVI) currently utilizes computed tomography (CT) to evaluate annulus diameter and peripheral vascular access, plus invasive coronary angiography (ICA) to assess significant coronary artery disease (CAD). ICA might partially be redundant with the use of Coronary CT Angiography (CCTA). Prior studies found improvement of the diagnostic accuracy of CCTA by use of CT derived fractional flow reserve (CT-FFR).

Methods

Consecutive patients with severe symptomatic aortic valve stenosis who underwent TAVI work-up between 2015–2019 were included in this cross-sectional study. All patients underwent CCTA and ICA within 3 months and diagnostic performance of both CCTA and CT-FFR were assessed using ICA as reference.

Results

Seventy-six of the 338 patients included in the analysis had ≥1 significant coronary stenosis at ICA. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy per-patient were 76.9%, 64.5%, 34.0%, 92.1% and 66.9% for CCTA and 84.6%, 88.3%, 63.2%, 96.0% and 87.6% for CT-FFR. The area under the receiver-operating characteristic-curve significantly differ between CCTA and CT-FFR (0.84 versus 0.90 p=0.02). A CT-FFR guided approach could avoid ICA in 57.1% versus 43.6% using CCTA.

Conclusions

CT-FFR significantly improves the diagnostic accuracy of CCTA without additional testing and increases the proportion of patients in whom ICA could have been safely avoided It has the potential to be integrated in the current clinical work-up for TAVI for diagnosing stable CAD requiring treatment.

Funding Acknowledgement

Type of funding sources: None.

Conservative management in a contemporary cohort of patients with acute coronary syndrome: results from the FORCE-ACS registry

Background

Contemporary real-world data on conservatively managed patients with acute coronary syndrome (ACS) is scarce.

Objective

To evaluate conservative management compared with revascularization therapy in ACS patients, focused on ischemic and bleeding outcomes at one year follow-up, and to provide insight in physician's rationale of choice for conservative management.

Methods

From January 2015 to January 2020, ACS patients were enrolled in the FORCE-ACS registry. Patients without coronary revascularization were identified and classified into three groups: 1) No coronary angiography (CAG) performed (CAG−), 2) documented obstructive coronary artery disease (CAD) with CAG (CAG+, CAD+) and 3) no obstructive CAD found with CAG (CAG+, CAD−). The first two groups were established as conservatively managed ACS patients, and were compared with those who received coronary revascularization. Survival analyses were used to assess differences in clinical endpoints and were adjusted for potential confounders using cox proportional hazard models. The primary endpoint was all-cause mortality, secondary endpoints included myocardial infarction (MI), stroke and major bleeding defined as Bleeding Academic Research Consortium (BARC) 3 or 5. Reasons for conservative management were assessed in all patients without coronary revascularization and details on antithrombotic therapy (type and duration) were explored.

Results

In 5,379 patients admitted with ACS, 93.8% underwent CAG. In total, 19.9% of patients did not receive coronary revascularization. In the non-revascularized patients, CAG was not performed in 34.8% (CAG−), documented CAD was found during CAG in 32.4% (CAG+, CAD+) and 32.7% of patients did not show obstructive CAD on CAG (CAG+, CAD−). Conservatively managed patients (14.2%) had lower survival rates compared with revascularized patients (HR 2.68; 95% CI: 1.89–3.81; p<0.0001). No significant differences were found in MI, stroke, or major bleeding between the two groups. The estimated one-year survival was the lowest in CAG− group compared to the CAG+, CAD+ group (adjusted HR 12.24; 95% CI: 4.15–36.07; p<0.001). Most frequent reasons for choosing conservative management in ACS patients included multi-comorbidity, complex coronary anatomy or a “watchful waiting” strategy. Conservatively treated patients received dual or triple antithrombotic therapy less often than the revascularized group (84.5% vs 94.6%).

Conclusion

In this contemporary ACS cohort, conservatively managed patients are at higher mortality risk than revascularized patients. This heterogeneous group of conservatively managed patients less often received guideline-recommended therapy.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Netherlands Organisation for Health, Research and Development (ZonMw)AstraZeneca

Electrocardiogram-based mortality prediction in patients with COVID-19 using machine learning

Background and purpose

The electrocardiogram (ECG) is frequently obtained in the work-up of COVID-19 patients. So far, no study has evaluated whether ECG-based machine learning models have added value to predict in-hospital mortality specifically in COVID-19 patients.

Methods

Using data from the CAPACITY-COVID registry, we studied 882 patients admitted with COVID-19 across seven hospitals in the Netherlands. Raw format 12-lead ECGs recorded within 72 h of admission were studied. With data from five hospitals (n = 634), three models were developed: (a) a logistic regression baseline model using age and sex, (b) a least absolute shrinkage and selection operator (LASSO) model using age, sex and human annotated ECG features, and (c) a pre-trained deep neural network (DNN) using age, sex and the raw ECG waveforms. Data from two hospitals (n = 248) was used for external validation.

Results

Performances for models a, b and c were comparable with an area under the receiver operating curve of 0.73 (95% confidence interval [CI] 0.65–0.79), 0.76 (95% CI 0.68–0.82) and 0.77 (95% CI 0.70–0.83) respectively. Predictors of mortality in the LASSO model were age, low QRS voltage, ST depression, premature atrial complexes, sex, increased ventricular rate, and right bundle branch block.

Conclusion

This study shows that the ECG-based prediction models could be helpful for the initial risk stratification of patients diagnosed with COVID-19, and that several ECG abnormalities are associated with in-hospital all-cause mortality of COVID-19 patients. Moreover, this proof-of-principle study shows that the use of pre-trained DNNs for ECG analysis does not underperform compared with time-consuming manual annotation of ECG features.

Supplementary Information

The online version of this article (10.1007/s12471-022-01670-2) contains supplementary material, which is available to authorized users.

Clinical presentation, disease course, and outcome of COVID-19 in hospitalized patients with and without pre-existing cardiac disease: a cohort study across 18 countries

AIMS

Patients with cardiac disease are considered high risk for poor outcomes following hospitalization with COVID-19. The primary aim of this study was to evaluate heterogeneity in associations between various heart disease subtypes and in-hospital mortality.

METHODS AND RESULTS

We used data from the CAPACITY-COVID registry and LEOSS study. Multivariable Poisson regression models were fitted to assess the association between different types of pre-existing heart disease and in-hospital mortality. A total of 16 511 patients with COVID-19 were included (21.1% aged 66-75 years; 40.2% female) and 31.5% had a history of heart disease. Patients with heart disease were older, predominantly male, and often had other comorbid conditions when compared with those without. Mortality was higher in patients with cardiac disease (29.7%; n = 1545 vs. 15.9%; n = 1797). However, following multivariable adjustment, this difference was not significant [adjusted risk ratio (aRR) 1.08, 95% confidence interval (CI) 1.02-1.15; P = 0.12 (corrected for multiple testing)]. Associations with in-hospital mortality by heart disease subtypes differed considerably, with the strongest association for heart failure (aRR 1.19, 95% CI 1.10-1.30; P < 0.018) particularly for severe (New York Heart Association class III/IV) heart failure (aRR 1.41, 95% CI 1.20-1.64; P < 0.018). None of the other heart disease subtypes, including ischaemic heart disease, remained significant after multivariable adjustment. Serious cardiac complications were diagnosed in <1% of patients.

CONCLUSION

Considerable heterogeneity exists in the strength of association between heart disease subtypes and in-hospital mortality. Of all patients with heart disease, those with heart failure are at greatest risk of death when hospitalized with COVID-19. Serious cardiac complications are rare during hospitalization.

The WOEST 2 registry : A prospective registry on antithrombotic therapy in atrial fibrillation patients undergoing percutaneous coronary intervention

Background

Patients on oral anticoagulants (OACs) undergoing percutaneous coronary intervention (PCI) also require aspirin and a P2Y12 inhibitor (triple therapy). However, triple therapy increases bleeding. The use of non-vitamin K antagonist oral anticoagulants (NOACs) and stronger P2Y12 inhibitors has increased. The aim of our study was to gain insight into antithrombotic management over time.

Methods

A prospective cohort study of patients on OACs for atrial fibrillation or a mechanical heart valve undergoing PCI was performed. Thrombotic outcomes were myocardial infarction, stroke, target-vessel revascularisation and all-cause mortality. Bleeding outcome was any bleeding. We report the 30-day outcome.

Results

The mean age of the 758 patients was 73.5 ± 8.2 years. The CHA₂DS₂-VASc score was ≥ 3 in 82% and the HAS-BLED score ≥ 3 in 44%. At discharge, 47% were on vitamin K antagonists (VKAs), 52% on NOACs, 43% on triple therapy and 54% on dual therapy. Treatment with a NOAC plus clopidogrel increased from 14% in 2014 to 67% in 2019. The rate of thrombotic (4.5% vs 2.0%, p = 0.06) and bleeding (17% vs. 14%, p = 0.42) events was not significantly different in patients on VKAs versus NOACs. Also, the rate of thrombotic (2.9% vs 3.4%, p = 0.83) and bleeding (18% vs 14%, p = 0.26) events did not differ significantly between patients on triple versus dual therapy.

Conclusions

Patients on combined oral anticoagulation and antiplatelet therapy undergoing PCI are elderly and have both a high bleeding and ischaemic risk. Over time, a NOAC plus clopidogrel became the preferred treatment. The rate of thrombotic and bleeding events was not significantly different between patients on triple or dual therapy or between those on VKAs versus NOACs.

Supplementary Information

The online version of this article (10.1007/s12471-022-01664-0) contains supplementary material, which is available to authorized users.

Feasibility and safety of cangrelor in patients with suboptimal P2Y12 inhibition undergoing percutaneous coronary intervention: rationale of the Dutch Cangrelor Registry

BACKGROUND

Despite the advances of potent oral P2Y12 inhibitors, their onset of action is delayed, which might have a negative impact on clinical outcome in patients undergoing percutaneous coronary intervention (PCI). Trials conducted in the United States of America have identified cangrelor as a potent and rapid-acting intravenous P2Y12 inhibitor, which has the potential of reducing ischemic events in these patients without an increase in the bleeding. As cangrelor is rarely used in The Netherlands, we conducted a nationwide registry to provide an insight into the use of cangrelor in the management of patients with suboptimal platelet inhibition undergoing (primary) PCI (the Dutch Cangrelor Registry).

STUDY DESIGN

The Cangrelor Registry is a prospective, observational, multicenter, single-arm registry with cangrelor administered pre-PCI in: (1) P2Y12 naive patients with ad-hoc PCI, (2) patients with STEMI/NSTEMI with suboptimal P2Y12 inhibition including (3) stable resuscitated/defibrillated patients with out-of-hospital cardiac arrest (OHCA) due to acute ischemia and (4) STEMI/NSTEMI patients with a high thrombotic burden. Primary endpoint is 48 h Net Adverse Clinical Events (NACE), which is a composite endpoint of all-cause death, recurrent myocardial infarction (MI), target vessel revascularization (TVR), stroke, stent thrombosis (ST) and BARC 2-3-5 bleeding. The Dutch Cangrelor Registry will assess the feasibility and safety of cangrelor in patients with suboptimal P2Y12 inhibition undergoing (primary) PCI in the setting of acute coronary syndrome (ACS) and stable coronary artery disease (CAD) in the Netherlands.