Fourth Universal Definition of Myocardial Infarction (2018)

Matrix Viscoelasticity Controls Differentiation of Human Blood Vessel Organoids into Arterioles and Promotes Neovascularization in Myocardial Infarction

Stem cell-derived blood vessel organoids are embedded in extracellular matrices to stimulate vessel sprouting. Although vascular organoids in 3D collagen I-Matrigel gels are currently available, they are primarily capillaries composed of endothelial cells (ECs), pericytes, and mesenchymal stem-like cells, which necessitate mature arteriole differentiation for neovascularization. In this context, the hypothesis that matrix viscoelasticity regulates vascular development is investigated in 3D cultures by encapsulating blood vessel organoids within viscoelastic gelatin/β-CD assembly dynamic hydrogels or methacryloyl gelatin non-dynamic hydrogels. The vascular organoids within the dynamic hydrogel demonstrate enhanced angiogenesis and differentiation into arterioles containing smooth muscle cells. The dynamic hydrogel mechanical microenvironment promotes vascular patterning and arteriolar differentiation by elevating notch receptor 3 signaling in mesenchymal stem cells and downregulating platelet-derived growth factor B expression in ECs. Transplantation of vascular organoids in vivo, along with the dynamic hydrogel, leads to the reassembly of arterioles and restoration of cardiac function in infarcted hearts. These findings indicate that the viscoelastic properties of the matrix play a crucial role in controlling the vascular organization and differentiation processes, suggesting an exciting potential for its application in regenerative medicine.

Cardiac Characteristics of Hospitalized Influenza Patients: An Interim Analysis From the FluHeart Study

BACKGROUND

Influenza infection has been associated with multiple cardiac complications including acute heart failure and myocardial infarction. The FluHeart study aims to uncover the potential effect of influenza infection on cardiac structure and function as assessed by echocardiography during hospitalization.

METHODS

This prospective cohort study included hospitalized influenza patients of the 2021-2022 influenza season. Participants underwent echocardiography using a prespecified protocol. Participants were successfully matched 1:1:1 on age, sex, and heart failure status with controls from the general population and controls hospitalized with COVID-19.

RESULTS

This interim analysis involved 108 participants (36 influenza patients, 36 general population controls, and 36 COVID-19 patients). Mean age was 72 ± 18 years and 58% were male. Median time from admission to echocardiography was 1 day (IQI: 1:1) for influenza patients. The prevalence of left ventricular (LV) dysfunction was 75%, and right ventricular (RV) dysfunction was observed in 20% of influenza patients. N-terminal pro-brain natriuretic peptide levels were elevated ≥ 300 pg/mL in 62%, and 19% exhibited myocardial injury with elevated high-sensitivity troponin I levels. RV tricuspid annular plane systolic excursion and LV early diastolic peak mitral inflow to early diastolic tissue velocity were significantly worse in influenza patients compared to general population controls. Echocardiographic measures did not significantly differ between patients hospitalized with influenza and COVID-19.

CONCLUSION

In this interim analysis of the FluHeart study, both RV and LV function measures were significantly impaired in hospitalized influenza patients compared with matched general population controls. The extent of impairment resembled that observed in hospitalized COVID-19 patients.

[Management of acute coronary syndrome]

Coronary artery disease (CAD) is the leading cause of death worldwide. Acute coronary syndrome (ACS) encompasses a spectrum of diagnoses ranging from unstable angina pectoris to myocardial infarction with and without ST-segment elevation and frequently presents as the first clinical manifestation. It is crucial in this scenario to perform a timely and comprehensive assessment of patients by evaluating the clinical presentation, electrocardiogram and laboratory diagnostics using highly sensitivity cardiac troponin in order to initiate a timely and risk-adapted continuing treatment with immediate or early invasive coronary angiography. In addition to revascularization, the subsequent antithrombotic and lipid-lowering treatment plays a major role in the further secondary prevention of CAD. The choice and duration of medication over time should be tailored to the individual risk profile of the patient. Furthermore, appropriate patient education regarding risk factor management is of paramount importance.

Frailty prevalence, invasive treatment frequency, and in-hospital outcome in patients hospitalized for acute coronary syndrome in Germany (2005-2022): a nationwide registry study

Background

Frailty is a significant predictor for adverse outcomes. Yet, data on prevalence and treatment of frail patients with acute coronary syndrome (ACS) remains limited. We aimed to investigate frailty prevalence, interventional treatment frequency, and in-hospital outcome for all patients hospitalized for ACS in Germany from 2005 to 2022 and validate the Hospital Frailty Risk Score (HFRS) in this population.

Methods

Data for 2005-2022 from the Statistical Federal Office included all cases with primary diagnosis of ACS treated in Germany. Patients were categorized into low, intermediate, and high frailty by HFRS. Diagnoses, procedures, and in-hospital outcomes were analyzed. Univariable and multivariable logistic regressions as well as sensitivity analyses were performed.

Findings

Between 2005 and 2022, 5,889,972 ACS patients were hospitalized in Germany. Mean age was 69 years (standard deviation (SD) ± 12.85 years) and 2,060,224 (34.98%) were female. In-hospital mortality was 6.2%. Among all, 5,001,812 (84.9%) had a low, 784,106 (13.3%) an intermediate, and 104,054 (1.8%) a high HFRS. High-frailty patients were less likely to undergo coronary intervention than low-frailty patients (47.0% vs. 70.6%, p < 0.001), had longer hospital stays (21.6 days SD 19.4 ± vs. 5.6 days SD ± 5.2, p < 0.001), and higher in-hospital mortality (adjusted odds ratio (OR) 3.34 [confidence interval (95% CI) 3.29-3.4]).

Interpretation

Nearly one-sixth of ACS-patients were frail according to HFRS. Frail patients had longer hospital stays, less often received interventional procedures, and showed substantially increased in-hospital mortality. In our aging population, frailty will play an increasing role in patient management. Frailty scores based on electronic patient records, like the HFRS, offer clinicians a tool for assessing in-hospital outcome in ACS patients, potentially enabling more individualized treatment approaches.

Funding

None.

GPX3 Overexpression Ameliorates Cardiac Injury Post Myocardial Infarction Through Activating LSD1/Hif1α Axis

Myocardial infarction (MI) often results in significant loss of cardiomyocytes (CMs), contributing to adverse ventricular remodelling and heart failure. Therefore, promoting CM survival during the acute stage of MI is crucial. This study aimed to investigate the potential role of GPX3 in cardiac repair following MI. First, plasma GPX3 levels were measured in patients with acute MI (AMI), and myocardial GPX3 expression was assessed in a mouse MI model. Furthermore, the effects of GPX3 on MI were investigated through CM-specific overexpression or knockdown in vitro and in vivo models. RNA sequencing and subsequent experiments were performed to uncover the molecular mechanisms underlying GPX3-related effects. Multi-omics database analysis and experimental verification revealed a significant upregulation of GPX3 expression in ischemic myocardium following MI and in CMs exposed to oxygen-glucose deprivation (OGD). Immunofluorescence results further confirmed elevated cytoplasmic GPX3 expression in CMs under hypoxic conditions. In vitro, GPX3 overexpression mitigated reactive oxygen species (ROS) production and enhanced CM survival during hypoxia, while GPX3 knockdown inhibited these processes. In vivo, CM-specific GPX3 overexpression in the infarct border zone significantly attenuated CM apoptosis and alleviated myocardial injury, promoting cardiac repair and long-term functional recovery. Mechanistically, GPX3 overexpression upregulated LSD1 and Hif1α protein expression, and rescue experiments confirmed the involvement of the LSD1/Hif1α pathway in mediating the protective effects of GPX3. Overall, our findings suggest that GPX3 exerts a protective role in ischemic myocardium post-MI, at least partially through the LSD1/Hif1α axis, highlighting its potential as a therapeutic target for MI treatment.

Red Blood Cell Transfusion in Critically Ill Adults: An American College of Chest Physicians Clinical Practice Guideline

BACKGROUND

Blood products frequently are administered to critically ill patients. Considering recent trials and practice variability, a comprehensive review of current evidence was deemed essential to offer pertinent guidance to critical care practitioners. This American College of Chest Physicians (CHEST) guidelines panel examined the literature on RBC transfusions among critically ill patients overall and specific subgroups, including patients with gastrointestinal bleeding, acute coronary syndrome (ACS), cardiac surgery, isolated troponin elevation, and septic shock, to provide evidence-based recommendations.

STUDY DESIGN AND METHODS

A panel of experts developed six Population, Intervention, Comparator, and Outcome questions addressing RBC transfusions in critically ill patients and performed a comprehensive evidence review. The panel applied the Grading of Recommendations, Assessment, Development, and Evaluations approach to assess the certainty of evidence and to formulate and grade recommendations. A modified Delphi technique was used to reach consensus on the recommendations.

RESULTS

The initial search identified a total of 3,082 studies, and after the initial screening, 38 articles were reviewed. Among them, 23 studies met inclusion criteria, comprising 22 randomized controlled trials and one cohort study. Based on the analysis of these studies, the panel formulated two strong and four conditional recommendations. The overall quality of evidence for recommendations ranged from very low to moderate.

CONCLUSIONS

In most critically ill patients, a restrictive strategy was preferable to a permissive approach because it does not increase the risk of death or complications, but does decrease RBC use significantly. Data from critically ill subpopulations also supported a restrictive approach, except in patients with ACS, for whom favoring a restrictive approach could increase adverse outcomes.

Lower early mortality and risk prediction improvement of obesity after acute pulmonary embolism: results from a multicenter cohort analysis with external validation

Background

The relationship between obesity (defined as body mass index [BMI] ≥ 30 kg/m2) and mortality in venous thromboembolism remains controversial.

Objectives

We aimed to compare outcomes after pulmonary embolism (PE) between patients with obesity and nonobese, nonunderweight patients.

Methods

Using a multicenter registry of prospectively recorded individual patient data, we compared outcome rates using multivariable logistic or Cox regression for 30-day and 6-month outcomes respectively (etiologic analysis). We assessed the incremental value of adding BMI information on top of the 30-day European Society of Cardiology (ESC) prognostic algorithm (prognostic analysis).

Results

We included 2390 patients with BMI of ≥18.5 kg/m2 (mean age, 66.9 ± 16.8 years; 1188 men [49.7%]); 686 patients [28.7%] were in the obese group. Mortality rates were significantly lower in patients with obesity than that in patients who were nonobese at 30 days (3.2% [95% CI, 2.0-4.8] vs 5.9% [95% CI, 4.8-7.1]), and 6 months (8.1% [95% CI, 6.2-10.4] vs 16.3% [95% CI, 14.6-18.1]). Rates of secondary nonfatal outcomes (including bleeding, recurrent venous thromboembolism, myocardial infarction, and stroke) did not differ between groups. The addition of the obesity information on top of the ESC prognostic model improved global model fit and discriminatory (Harrell C index from 0.636 to 0.657; P = .07) and calibration capacities (P (Hosmer-Lemeshow) = .02 vs .13), yielding significant reclassification (ie, 10.3%) based on the observed mortality rates with the ESC model as reference. Findings were confirmed in an external validation using 35,796 patients with PE from the RIETE registry.

Conclusion

We present evidence indicating lower early- and mid-term mortality after PE in patients classified as obese based on BMI, compared with nonobese, nonunderweight patients. BMI should likely be incorporated into algorithms or scoring systems for predicting early mortality following PE.

Dynamic perioperative platelet activity and cardiovascular events in peripheral artery disease

OBJECTIVE

Patients with peripheral artery disease (PAD) undergo lower extremity revascularization (LER) for symptomatic relief or limb salvage. Despite LER, patients remain at increased risk of platelet-mediated complications, such as major adverse cardiac and limb events (MACLEs). Platelet activity is associated with cardiovascular events, yet little is known about the dynamic nature of platelet activity over time. We, therefore, investigated the change in platelet activity over time and its association with long-term cardiovascular risk.

METHODS

Patients with PAD undergoing LER were enrolled into the multicenter, prospective Platelet Activity and Cardiovascular Events study. Platelet aggregation was assessed by light transmission aggregometry to submaximal epinephrine (0.4 μmol/L) immediately before LER, and on postoperative day 1 or 2 (POD1 or POD2) and 30 (POD30). A hyperreactive platelet phenotype was defined as >60% aggregation. Patients were followed longitudinally for MACLEs, defined as the composite of death, myocardial infarction, stroke, major lower extremity amputation, or acute limb ischemia leading to reintervention.

RESULTS

Among 287 patients undergoing LER, the mean age was 70 ± 11 years, 33% were female, 61% were White, and 89% were on baseline antiplatelet therapy. Platelet aggregation to submaximal epinephrine induced a bimodal response; 15.5%, 16.8%, and 16.4% of patients demonstrated a hyperreactive platelet phenotype at baseline, POD1, and POD30, respectively. Platelet aggregation increased by 18.5% (P = .001) from baseline to POD1, which subsequently returned to baseline at POD30. After a median follow-up of 19 months, MACLEs occurred in 165 patients (57%). After adjustment for demographics, clinical risk factors, procedure type, and antiplatelet therapy, platelet hyperreactivity at POD1 was associated with a significant hazard of long-term MACLE (adjusted hazard ratio, 4.61; 95% confidence interval, 2.08-10.20; P < .001).

CONCLUSIONS

Among patients with severe PAD, platelet activity increases after LER. Platelet hyperreactivity to submaximal epinephrine on POD1 is associated with long-term MACLE. Platelet activity after LER may represent a modifiable biomarker associated with excess cardiovascular risk.

"A Biomarker-Based Scoring System to Assess the Presence of Obstructive Coronary Artery Disease in Patients With Myocardial Infarction"

AIMS

Approximately 10% of patients with myocardial infarction present with non-obstructive coronary arteries (MINOCA), whose characteristics differ from those with obstructive coronary lesions (MICAD). Inflammation plays a key role in myocardial infarction. This study aims to develop a biomarker-based index for accurate differentiation between MINOCA and MICAD.

METHODS

A prospective, observational cohort study including 111 patients admitted for myocardial infarction: 46 with MINOCA and 65 with MICAD. Blood samples were collected within the first 24 h to measure high-sensitivity C-reactive protein, interleukin-6, asymmetric dimethylarginine, and peak high-sensitivity troponin T. The association of these biomarkers with MICAD risk was analyzed using logistic regression. Scoring systems were developed using optimization algorithms to predict the diagnosis before coronary angiography, applied to both individual biomarkers and a combined index.

RESULTS

Patients had a mean age of 67 years (SD 13.3), with a male predominance (68.5%). Higher levels of IL-6 and high-sensitivity troponin T were significantly associated with increased MICAD risk (OR: 1.58; 95% CI: 1.01-2.46, and OR: 2.27; 95% CI: 1.61-3.26, respectively). As score increases, interleukin-6 and high-sensitivity troponin T increase the likelihood of MICAD classification, while higher asymmetric dimethylarginine levels reduce it. Each one-point increase in the combined index multiplies MICAD risk by six (OR:6.16, 95%CI: 2.72-13.95; p < 0.001). While individual indexes improved the diagnostic performance of biomarkers, the combined index demonstrated superior accuracy (AUC: 0.918).

CONCLUSIONS

A biomarker-based scoring system was developed, achieving superior discriminatory capacity for differentiating MINOCA from MICAD compared to the individual analysis of biomarkers in absolute values or independent indexes.

Clinical impact of inappropriate DOAC dosing in atrial fibrillation: Insights from a real-world registry

Background

A significant number of patients with atrial fibrillation (AF) on direct oral anticoagulants (DOACs) receives off-label or inappropriate doses. This study examines the prevalence, dosages, and clinical outcomes in AF-patients on DOAC therapy admitted to an emergency department (ED).

Methods

This retrospective single-center observational study utilized data from the Heidelberg Registry of Atrial Fibrillation (HERA-FIB), consecutively including patients with AF presenting to the ED of the University Hospital of Heidelberg from June 2009 to March 2020. Rates of DOAC dosages at discharge from the ED were correlated with outcomes, focusing on a composite endpoint that included all-cause mortality, stroke, major bleeding, and myocardial infarction (MI).

Resultsand Conclusions

Among 10,222 patients included in the HERA-FIB registry, 4,239 (41.5 %) were prescribed DOACs, and 3,031were eligible for the analysis. Of these, 2,199 (72.6 %) received appropriate dosages, 627 (20.7 %) were under-dosed, and 205 (6.8 %) were over-dosed. Under-dosed AF-patients demonstrated a significantly increased risk of the composite endpoint compared to those receiving appropriate dosages (HR 1.84, 95 %CI:1.55-2.18, p < 0.0001). Over-dosage had no significant effect on the HR for the composite endpoint, all-cause mortality, stroke, MI, or major bleeding compared to correct dosing but was associated with higher risks of the composite endpoint (HR 1.43, 95 %CI:1.04-1.96, p = 0.029) relative to under-dosage. This study underscores the critical importance of accurate DOAC dosing in patients with AF presenting to an ED. Both under-dosing and over-dosing are linked to significant clinical risks, highlighting the urgent need for improved dosing protocols and careful monitoring to enhance patient outcomes.

Brief Mindfulness-Based Cognitive Therapy in Women With Myocardial Infarction: Results of a Multicenter Randomized Controlled Trial

Background

Elevated perceived stress is associated with adverse outcomes following myocardial infarction (MI) and may account for poorer recovery among women vs men.

Objectives

This randomized controlled trial tested effects of a mindfulness-based intervention on stress levels among women with MI.

Methods

Women with elevated stress (Perceived Stress Scale [PSS-4]≥6) at least 2 months after MI were enrolled from 12 hospitals in the United States and Canada and via community advertising. Participants were randomized to a remotely delivered mindfulness intervention (MBCT-Brief) or heart disease education, both 8 weeks long. Follow-up was 6 months. Changes in stress (PSS-10; primary outcome) and secondary outcomes (depressive symptoms, anxiety, quality of life, disease-specific health status, actigraphy-assessed sleep) were compared between groups.

Results

The sample included 130 women with MI (mean age 59.8 ± 12.8 years, 34% racial/ethnic minorities). In intention-to-treat analysis, PSS-10 scores declined in the MBCT-Brief arm (-0.52 [95% CI: -0.77 to -0.28]) but not the heart disease education arm (-0.19 [95% CI: -0.45 to 0.06]; group×time interaction P = 0.070). The effect was stronger in per-protocol analysis of participants who completed ≥4 intervention sessions (P = 0.049). There were no significant differences in secondary outcomes in intention-to-treat or per-protocol analyses. Within the MBCT-Brief arm, more frequent mindfulness practice was associated with greater reductions in stress (P = 0.007), depressive symptoms (P = 0.017), and anxiety (P = 0.036).

Conclusions

MBCT-Brief was associated with greater 6-month reductions in stress than an active control among adherent participants. More frequent mindfulness practice was associated with greater improvements in psychological outcomes. Strategies to engage women with MI in mindfulness training and support regular home practice may enhance these effects.

A rare complication of blood donation: MINOCA

Blood donation is a life-saving process that involves the temporary loss of a specific blood volume. Although generally safe, it may lead to adverse reactions, particularly in first-time donors. Among these, severe outcomes like myocardial infarction (MI) are extremely rare. Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a distinct clinical entity with various potential etiologies, including coronary vasospasm and sudden hemodynamic changes. This report aims to present a rare case of MINOCA following blood donation to highlight the importance of comprehensive evaluation in blood donors presenting with acute symptoms. A 39-year-old male presented to the emergency department with dizziness and blurred vision following blood donation. Initial assessment revealed normal vital signs, laboratory tests, and no prior medical history. Electrocardiography showed ST-segment elevation in leads D1 and AVL, and ST-segment depression in D3 and AVF. The patient was immediately treated with acetylsalicylic acid and underwent coronary angiography, which revealed normal coronary arteries. The pathological findings on the ECG resolved after the procedure. No changes in troponin levels were observed during intensive care follow-up, and the patient was discharged in good health after two days. MINOCA requires thorough investigation to determine underlying causes. Acute volume loss and sudden intravascular hemoglobin changes were likely contributing factors in this case. Although rare, the association between blood donation and MINOCA highlights the need for vigilance in donors with acute symptoms. Blood donors presenting with dizziness or hypotension should be evaluated comprehensively.

Prognostic Implications of Changes in Total Physiological Atherosclerotic Burden in Patients With Coronary Artery Disease-A Serial QFR Study

The association between coronary physiological progression and clinical outcomes has not been investigated. A total of 421 patients who underwent serial coronary angiography at least 6 months apart were included. Total physiological atherosclerotic burden was characterized by sum of quantitative flow ratio in 3 epicardial vessels (3V-QFR). The relationships of the 3V-QFR and its longitudinal change (△3V-QFR) with major adverse cardiovascular events (MACE) were explored. 3V-QFR values derived from follow-up angiograms were slightly lower compared with baseline (2.85 [2.77, 2.90] vs 2.86 [2.80, 2.90], P < .001). The median △3V-QFR value was -0.01 (-0.05, 0.02). The multivariable models demonstrated that follow-up 3V-QFR and △3V-QFR were independently associated with MACE (both P < .05). Patients with both low follow-up 3V-QFR (≤2.78) and low △3V-QFR (≤-0.05) presented 3 times higher risk of MACE than those without (hazard ratio: 2.953, 95% confidence interval 1.428-6.104, P = .003). Furthermore, adding patient-level 3V-QFR and △3V-QFR to clinical model significantly improved the predictability for MACE. In conclusion, total physiological atherosclerotic burden and its progression can provide incremental prognostic value over clinical characteristics, supporting the use of coronary physiology in the evaluation of disease progression and for the identification of vulnerable patients.

Impact of High-Sensitivity Cardiac Troponin I Elevation After On- and Off-Pump Coronary Artery Bypass Grafting on Long-Term Prognosis

BACKGROUND

Postoperative myocardial injury is correlated with long-term prognosis after coronary artery bypass grafting (CABG) and is diagnosed according to troponin levels, which vary substantially upon surgical strategies. We aimed to explore the troponin I cutoff values for prognostically significant myocardial injury separately in on-pump and off-pump procedures with the use of a high-sensitivity assay (hs-cTnI).

METHODS

Patients who underwent isolated CABG from 2018 to 2020 with available perioperative hs-cTnI measurements were included in this study. We explored the relationships between hs-cTnI levels and different outcomes. To identify hs-cTnI threshold levels indicative of higher risks, restrictive spline regressions were performed for on-pump and off-pump procedures.

RESULTS

A total of 7813 patients were included with a median follow-up of 2.7 years (interquartile range 1.7-3.3 years), 218 (2.8%) of whom died. Adjusting for clinical variables, the study found a significant association between peak hs-cTnI levels within the first 48 hours after surgery and all end points. The spline regressions demonstrated that the hs-cTnI levels measured within 48 hours after surgery that were associated with a hazard ratio of more than 1.00 for all-cause death were 1446 ng/L (55.6 × upper reference limit [URL], 95% confidence interval [CI] 45.0-106.5 × URL) for on-pump and 564 ng/L (21.7 × URL, 95% CI 21.0-30.2 × URL) for off-pump.

CONCLUSIONS

Elevated hs-cTnI levels after CABG were associated with poorer longer-term outcomes. A prognosis-relevant hs-cTnI cutoff value within 48 hours after CABG for on-pump is significantly higher than that for off-pump.

Serum cardiac and inflammatory biomarker levels following chemotherapy among female patients with breast cancer attending at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia

BACKGROUND

Chemotherapy is a well-established therapeutic approach for several malignancies, including breast cancer (BCa). However, the clinical efficacy of this drug is limited by cardiotoxicity. Assessing multiple cardiac biomarkers can help identify patients at risk of adverse outcomes from chemotherapy.

OBJECTIVE

To evaluate changes in serum cardiac and inflammatory biomarker levels following chemotherapy among female patients with BCa attending at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia.

METHODS

An experimental study design was used. Forty patients with breast cancer were selected using a convenience sampling method. After obtaining informed consent, 40 paired samples (40 samples before chemotherapy and 40 matched samples after three cycles of chemotherapy) were collected between May 2018 and March 2019. An Elecsys 2010 Troponin-T immunoassay analyzer was used to measure serum levels of cardiac troponin T (cTnT), creatinine kinase-myocardial band (CK-MB), C-reactive protein (CRP), and R and D systemic luminex performance assays were used to measure serum Interleukin-6 (IL-6) and Tumor Necrosis Factor-alpha (TNF- α). Data were analyzed using the SPSS version 23 package, and a p-value < 0.05 was considered statistically significant.

RESULTS

Among female patients with BCa receiving chemotherapy, 20%, 15%, and 35% of patients had elevated cTnT, CK-MB, and CRP levels, respectively, after three cycles of chemotherapy. In contrast, 15% of patients had baseline elevated CRP levels compared with their respective cutoff values. The mean serum cTnT, CK-MB, CRP, and TNF-α levels significantly increased (p < 0.05) compared with their respective baseline values. However, the IL-6 levels at baseline and after chemotherapy were not significantly different.

CONCLUSION

This study revealed significant increases in cardiac and inflammatory biomarkers following chemotherapy among female patients with breast cancer in the study area. Therefore, cardiac biomarkers and echocardiography findings were used to assess functional abnormalities and treatment outcomes.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

KEY POINTS

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

One-Year Prognosis for Patients Diagnosed with Acute Coronary Syndrome Compared to Those with Chronic Coronary Syndrome Following Complex Coronary Procedures

Background: Acute coronary syndrome (ACS) remains the primary cause of mortality worldwide. Performing complex coronary intervention in patients with ACS is considered a significant factor for worsening prognosis. This study aimed to evaluate the prognosis of patients with ACS treated with complex procedures compared to patients with chronic coronary syndrome (CCS). Methods: Among 980 patients from the Polish Complex Registry, we enrolled 829 consecutive patients who underwent complex percutaneous coronary intervention (PCI) for acute or chronic coronary syndrome with a completed one-year follow-up. The primary endpoint is defined as the major adverse cardiac event (MACE) at 12 months, a composite endpoint including all-cause death, target lesion revascularization, target vessel revascularization, and non-fatal myocardial infarction. Results: The incidence of the composite endpoint of MACE at one-year follow-up was comparable between the patients with acute and chronic coronary syndrome who underwent complex PCI (12.4% vs. 7.6%, LogRank p = 0.035). Cox multivariate analysis indicated that ACS is an independent risk factor for death at one-year follow-up. Additionally, age and comorbidities, such as heart failure and chronic kidney disease, along with procedural factors, including lesion length and pre-procedural diameter stenosis, are independent predictors of death in patients with complex lesions. Independent risk factors for MACE at one-year follow-up include age, heart failure, previous PCI, in-stent restenosis, and pre-procedural diameter stenosis. Conclusions: The prognosis of patients with acute and chronic coronary syndrome in the annual follow-up is comparable in the context of cardiovascular events. The clinical presentation of ACS is an independent risk factor for all-cause death.

Sex differences in patients with working diagnosis of myocardial infarction with nonobstructive coronary arteries (MINOCA)

Myocardial infarction with nonobstructive coronary arteries (MINOCA) constitutes 3-15% of all acute myocardial infarctions. Women are more frequently diagnosed with MINOCA, although the influence of sex on long-term outcomes is still unclear. In this study we aimed to compare sex-based differences in baseline characteristics and clinical outcomes in patients with suspected MINOCA. We have retrospectively analyzed 6063 patients diagnosed with MINOCA (3220 females and 2843 male patients) from combined 3 large polish registries (PL-ACS, SILCARD and AMI-PL). Male patients were significantly younger (63 (55-74) vs. 71 (61-79) years, p < 0.05) and less frequently diabetic (20.1% vs. 24.1%, p < 0.05). Mortality was significantly higher in male population (11.8% vs. 10.2%, p < 0.05 at 1 year and 17.6% vs. 15.0%, p < 0.05 at 3 years). Male sex was an independent predictor of both mortality (HR = 1.29; CI 1.11-1.51; p < 0.05) and myocardial infarction (HR = 1.39; CI 1.1-1.75, p < 0.05) at 3 years follow-up. All-cause readmission rates were similar in male and female patients both at 1 year (46.0% vs. 44.4, p = 0.2) and 3 years follow-up (56.4% vs. 56.5%, p = 0.93). However, cardiovascular readmissions were more prevalent in male patients at both timepoints (33.9% vs. 29.10%, p < 0.05 at 1 year, and 41.0% vs. 37.6%, p < 0.05 at 3 years). This large-scale registry-based analysis demonstrated higher 3 years rates of adverse events, including death and MI among male patients with suspected MINOCA.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Explainable AI associates ECG aging effects with increased cardiovascular risk in a longitudinal population study

Aging affects the 12-lead electrocardiogram (ECG) and correlates with cardiovascular disease (CVD). AI-ECG models estimate aging effects as a novel biomarker but have only been evaluated on single ECGs-without utilizing longitudinal data. We validated an AI-ECG model, originally trained on Brazilian data, using a German cohort with over 20 years of follow-up, demonstrating similar performance (r2 = 0.70) to the original study (0.71). Incorporating longitudinal ECGs revealed a stronger association with cardiovascular risk, increasing the hazard ratio for mortality from 1.43 to 1.65. Moreover, aging effects were associated with higher odds ratios for atrial fibrillation, heart failure, and mortality. Using explainable AI methods revealed that the model aligns with clinical knowledge by focusing on ECG features known to reflect aging. Our study suggests that aging effects in longitudinal ECGs can be applied on population level as a novel biomarker to identify patients at risk early.

How the brain impacts the heart: lessons from ischaemic stroke and other neurological disorders

Cardiovascular alterations are common in patients who had ischaemic stroke, haemorrhagic stroke and other acute brain disorders such as seizures. These cardiac complications are important drivers of morbidity and mortality and comprise blood-based detection of cardiomyocyte damage, ECG changes, heart failure and arrhythmia. Recently, the concept of a distinct 'stroke-heart syndrome' has been formulated as a pathophysiological framework for poststroke cardiac complications. The concept considers cardiac sequelae after stroke to be the result of a stroke-induced disturbance of the brain-heart axis. In this review, we describe the spectrum of cardiac changes secondary to ischaemic stroke and other acute brain disorders. Furthermore, we focus on Takotsubo syndrome secondary to acute brain disorders as a model disease of disturbed brain-heart interaction. Finally, we aim to provide an overview of the anatomical and functional links between the brain and the heart, with emphasis on the autonomic network and the role of inflammation. Given the clinical relevance of the deleterious impact of acute brain injury on the heart, we call for clinical awareness and for starting joint efforts combining expertise of neurology and cardiology to identify specific therapeutic interventions.

Myocardial Infarction-Associated Shock: A Comprehensive Analysis of Phenotypes, SCAI Classification, and Outcome Assessment

Background and Objectives: In-hospital mortality associated with myocardial infarction complicated by cardiogenic shock (MI-CS) remains critically high. A particularly challenging form, mixed shock (MS), combines features of cardiogenic shock (CS) with distributive elements such as vasodilation and reduced vascular resistance. MS is associated with elevated mortality rates and presents unique diagnostic and therapeutic challenges. This study aimed to analyze the clinical, historical, instrumental, and laboratory characteristics of the primary phenotypes of MI-CS, stratified according to the Society for Cardiovascular Angiography and Interventions (SCAI) shock severity scale. Materials and Methods: In this single-center, retrospective observational study, we reviewed the medical records of 1289 patients admitted to the emergency cardiology department from 1 January to 12 December 2020. Among them, 117 patients were identified as having MI-CS and were divided into two groups: MS (n = 48) and isolated CS (n = 69). The data were analyzed using the SCAI shock classification. Logistic regression analysis was employed to identify predictors of mortality and improved survival outcomes. Results: Patients with MS were older (80 years [71.0; 83.0] vs. 73 years [64.0; 81.0], p = 0.035). The overall mortality rate was significantly higher in the MS group (68% vs. 53%, RR = 1.438, 95% CI: 1.041-1.986, p = 0.03). Logistic regression identified mechanical ventilation (OR = 8.33, 95% CI: 2.54-22.80, p = 0.012), elevated lactate levels (OR = 1.20, 95% CI: 1.02-1.41, p = 0.026), and cardiopulmonary resuscitation (CPR) (OR = 7.97, 95% CI: 2.51-24.40, p < 0.0001) as independent predictors of mortality. Conversely, the use of an intra-aortic balloon pump (IABP) (OR = 0.22, 95% CI: 0.06-0.80, p = 0.021) and a higher body mass index (BMI) (OR = 0.91, 95% CI: 0.84-0.99, p = 0.038) were associated with reduced mortality risk. Conclusions: MS in the context of MI-CS represents a distinct clinical phenotype with specific hemodynamic features and significantly worsened outcomes. The identification of mortality predictors, such as mechanical ventilation, elevated lactate levels, and CPR, alongside protective factors like IABP use and a higher BMI, underscores the importance of early and tailored therapeutic interventions. These findings highlight the need for further studies to refine treatment protocols and improve outcomes in this high-risk population.

Triglyceride-glucose index: carotid intima-media thickness and cardiovascular risk in a European population

BACKGROUND

The triglyceride-glucose (TyG) index is now widely recognized as a marker of insulin resistance and has been linked to the development and prognosis of atherosclerotic cardiovascular diseases (ASCVD) in numerous populations, particularly in the Eastern world. Although there are fewer reports from the Western world, and they are sometimes contradictory, the absence of definitive data on the relationship between a raised TyG index and cardiovascular risk suggested the opportunity of testing this biochemical marker against a well-established vascular marker such as the carotid intima media thickness (c-IMT).

METHODS

Primary prevention patients were selected from a cohort of individuals who underwent c-IMT measurement between 1984 and 2018 at the Dyslipidemia Center at the ASST Grande Ospedale Metropolitano Niguarda in Milan, Italy. The TyG index was calculated as the Ln [fasting TG (mg/dL)×fasting glucose (mg/dL)/2]. Carotid ultrasonography was performed using echographic measurements of the far walls of the left and right common, internal carotids, and bifurcations. Patients were followed for up to 20 years with periodic evaluation of biochemical parameters. ASCVD events were monitored through hospital records, where all patients were regularly examined.

RESULTS

The analysis included 3108 individuals with a mean age of 54.9 ± 13.1 years. Participants were generally non-obese, with an average BMI of 24.6 ± 3.5 Kg/m2. Among the women, 83.1% were postmenopausal. The mean TyG index was 8.65 ± 0.59. There was a significant association between the TyG index and all c-IMT measurements. Those in the highest TyG index quartiles had significantly higher IMTmean and IMTmax compared to those in the lower quartiles. These associations were consistent across all vascular sites examined and remained significant after adjusting for all potential confounders. Kaplan-Meier survival analysis revealed an increased incidence of ASCVD events in the two highest TyG index quartiles.

CONCLUSIONS

TyG index is a sensitive marker of risk in a European population with moderate ASCVD risk, as assessed by c-IMT measurements, in a large cohort of Lipid Clinic patients.

Exposure to specific polyfluoroalkyl chemicals is associated with cardiovascular disease in US adults: a population-based study

Background

Polyfluoroalkyl chemicals (PFCs) present potential health risks due to their persistence and bioaccumulation. However, there is currently insufficient evidence regarding their impact on cardiovascular disease (CVD). Consequently, it is imperative to investigate the correlation between PFCs and CVD.

Methods

The data was collected from National Health and Nutrition Examination Survey in 2005-2012. Logistic regression models were employed to assess the association between single PFC and CVD. Generalized additive model (GAM) was used for evaluating nonlinear relationships. Subgroup analyses were conducted to explore interaction effects. Bayesian kernel machine regression (BKMR) and weighted quantile sum (WQS) models were used to evaluate the joint effect of PFC exposures on CVD.

Results

In logistic regression, PFDE, MPAH, and PFUA were positively associated with CVD. In the GAM, there was a significant nonlinear relationship between MPAH and CVD. Subgroup analysis revealed the interaction of gender and race in the effects of PFCs and CVD. PFUA was positively correlated with CVD in males but show no significant difference in females. PFDE was positively associated with CVD among non-Hispanic white individual. The results of BKMR indicated that the impact of mixed PFCs on CVD increased initially and then weakened, showing an overall positive trend. The results of WQS suggested that PFDO contributed most to the effect.

Conclusion

Our study showed that serum PFDE, MPAH, and PFUA levels were positively correlated with CVD. PUFA was found to interact with gender and race in relation to CVD. A general positive correlation exists between mixed exposure to PFCs and CVD, with PFDO being the most contributory PFC. Our study provided important evidence for probing the impact of PFCs on CVD and laid a foundation for further mechanism research.

Prognostic Implication of Computational Angiography-Derived Fractional Flow Reserve in Patients With Nonobstructive Coronary Artery Disease

BACKGROUND

Risk stratification of patients with symptomatic nonobstructive coronary artery disease remains uncertain. Our study assessed the clinical value of single-vessel, multivessel, and 3-vessel computational angiography-derived fractional flow reserve (caFFR) measurement in patients with nonobstructive coronary artery disease.

METHODS AND RESULTS

We enrolled patients with ≤50% stenosis with a caFFR value ≥0.8 in all 3 coronary arteries on coronary angiography. The sum of caFFR values in the 3 vessels was computed for each patient. Patient stratification was based on the median value of the following criteria: single-vessel analysis, multivessel analysis, and 3-vessel analysis. The primary end point of this study was major adverse cardiac events at 5 years, defined as a composite of cardiac death, myocardial infarction, and ischemia-driven revascularization. A total of 490 patients were included. The 5-year major adverse cardiac event rates in single-vessel analysis were statistically insignificant between low- and high-caFFR groups (left anterior descending artery [P=0.163]; left circumflex artery [P=0.797]; right coronary artery [P=0.127]). In multivessel analysis, patients in the multiple-vessel low-caFFR group (with 2-3 vessels lower than median value of all coronary arteries) showed an increased risk of 5-year major adverse cardiac events compared with patients in the single-vessel low-caFFR group (0-1 vessel) (hazard ratio [HR], 2.648 [95% CI, 1.141-6.145]; P=0.023). In 3-vessel analysis, patients in the low 3-vessel caFFR group demonstrated a greater 5-year major adverse cardiac event risk than the high 3-vessel caFFR group (HR, 2.43 [95% CI, 1.087-5.433]; P=0.031).

CONCLUSIONS

We demonstrated that both multiple-vessel and 3-vessel caFFR measurements serve as valuable prognostic indicators for risk assessment in patients with nonobstructive coronary artery disease.

Direct oral anticoagulants or warfarin in patients with left ventricular thrombus after ST-elevation myocardial infarction: a pilot trial and a prespecified meta-analysis of randomised trials

BACKGROUND

The role of direct oral anticoagulants (DOACs) in the treatment of left ventricular thrombus (LVT) after ST-elevation myocardial infarction (STEMI) remains uncertain.

AIMS

We aimed to compare the effect of rivaroxaban versus warfarin in patients with STEMI complicated by LVT.

METHODS

Adult patients with STEMI and two-dimensional transthoracic echocardiography showing LVT were assigned to rivaroxaban (15 mg once daily) or warfarin (international normalised ratio goal of 2.0-2.5) in an open-label, randomised clinical trial (RCT). A prospective pooled analysis was planned comparing DOAC- versus warfarin-based anticoagulation for the same indication. The main outcome of the RCT was complete LVT resolution at 3 months, determined by a blinded imaging core laboratory. Complete LVT resolution and bleeding were investigated in the pooled analysis.

RESULTS

A total of 50 patients (median age: 55 years, 18% females) were enrolled from June 2020 to November 2022. Three-month complete LVT resolution occurred in 19/25 (76.0%) patients assigned to rivaroxaban and 13/24 (54.2%) assigned to warfarin (relative risk [RR] 1.40, 95% confidence interval [CI]: 0.91-2.15; p=0.12) with no thrombotic or major bleeding events. Pooled analysis showed numerically better complete LVT resolution with DOACs (rivaroxaban and apixaban; 93/115 [80.8%] vs 79/112 [70.5%], RR 1.14, 95% CI: 0.98-1.32; p=0.08) and less major bleeding (2/116 [1.7%] and 9/112 [8.0%], risk difference -0.06, 95% CI: -0.12 to 0.00; p=0.05) than with warfarin.

CONCLUSIONS

Although the findings are limited by a small sample size, the results suggest that DOACs are safe with at least similar outcomes concerning LVT resolution and major bleeding compared with warfarin. (ClinicalTrials.gov: NCT05705089).

FTO rs1121980 polymorphism contributes to coronary artery disease susceptibility in a Chinese Han population

BACKGROUND

The fat mass and obesity-associated protein (FTO) has been showed to be involved in the pathogenesis and progression of coronary artery disease (CAD). However, the effects of FTO variants on CAD risk remain poorly understood. We herein genotyped three SNPs (rs1121980, rs72803657, and rs4783818) in FTO to investigate the influence of FTO polymorphisms on individual susceptibility to CAD.

METHODS

Genotyping for the three SNPs (rs1121980, rs72803657, and rs4783818) was conducted in a cohort of 712 CAD cases with 349 myocardial infarction (MI) cases and 701 control participants, utilizing the polymerase chain reaction-ligation detection reaction (PCR-LDR) technique. The associations of these SNPs with CAD were analyzed using multivariate logistic regression, and the associations with lipid profiles were assessed by the Kruskal-Wallis or Wilcoxon-Mann-Whitney tests.

RESULTS

The A allele (OR = 1.26, 95% CI = 1.01-1.57, and P = 0.044) and the AA genotype (OR = 3.13, 95% CI = 1.53-6.38, and P = 0.002) of FTO rs1121980 were significantly associated with an elevated risk of CAD. Similarly, the A allele (OR = 1.54, 95% CI = 1.18-2.02, and P = 0.002) and the AA genotype (OR = 5.61, 95% CI = 2.57-12.27, and P < 0.001) of rs1121980 exhibited increased MI risk. This SNP also showed significant associations under recessive genetic models for both CAD and MI (OR = 3.09, 95% CI = 1.52-6.27, P = 0.002 for CAD; OR = 5.40, 95% CI = 2.49-11.71, P < 0.001 for MI). However, the other two SNPs did not show significant associations with CAD or MI risks under any genetic model tested. Stratified analyses indicated a more pronounced association of the A allele with increased CAD/MI risk among younger participants, non-smokers, and non-drinkers. Interestingly, A allele carriers in younger subjects exhibited higher triglyceride (TG) levels and lower high-density lipoprotein cholesterol (HDL-C) levels compared to non-carriers (P < 0.05).

CONCLUSIONS

Our data provides the first evidence that the FTO rs1121980 polymorphism is associated with an increased risk of CAD in the Chinese population. This association is more significant in younger subjects, likely due to the elevated TG levels and reduced HDL-C levels.

Personalized perioperative blood pressure management in patients having major non-cardiac surgery: A bicentric pilot randomized trial

STUDY OBJECTIVE

We hypothesize that personalized perioperative blood pressure management maintaining intraoperative mean arterial pressure (MAP) above the preoperative mean nighttime MAP reduces perfusion-related organ injury compared to maintaining intraoperative MAP above 65 mmHg in patients having major non-cardiac surgery. Before testing this hypothesis in a large-scale trial, we performed this bicentric pilot trial to determine a) if performing preoperative automated nighttime blood pressure monitoring to calculate personalized intraoperative MAP targets is feasible; b) in what proportion of patients the preoperative mean nighttime MAP clinically meaningfully differs from a MAP of 65 mmHg; and c) if maintaining intraoperative MAP above the preoperative mean nighttime MAP is feasible in patients having major non-cardiac surgery.

DESIGN

Bicentric pilot randomized trial.

SETTING

University Medical Center Hamburg-Eppendorf, Hamburg, Germany, and RWTH Aachen University Hospital, Aachen, Germany.

PATIENTS

Patients ≥ 45 years old having major non-cardiac surgery.

INTERVENTIONS

Personalized blood pressure management.

MEASUREMENTS

Proportion of patients in whom preoperative automated nighttime blood pressure monitoring was possible; proportion of patients in whom the preoperative mean nighttime MAP clinically meaningfully differed from a MAP of 65 mmHg (difference > ±10 mmHg); intraoperative time-weighted average MAP below the preoperative mean nighttime MAP.

MAIN RESULTS

We enrolled 105 patients and randomized 98 patients. In 98 patients (93 %), preoperative automated nighttime blood pressure monitoring was possible. In 83 patients (85 %), the preoperative mean nighttime MAP clinically meaningfully differed from a MAP of 65 mmHg. The median time-weighted average MAP below the preoperative mean nighttime MAP was 3.29 (1.64, 6.82) mmHg in patients assigned to personalized blood pressure management.

CONCLUSIONS

It seems feasible to determine the effect of personalized perioperative blood pressure management maintaining intraoperative MAP above the preoperative mean nighttime MAP on postoperative complications in a large multicenter trial.

Sex and race disparities in emergency department patients with chest pain and a detectable or mildly elevated troponin

Background

Identifying and eliminating health disparities is a public health priority. The goal of this analysis is to determine whether cardiac testing or outcome disparities exist by race or sex in patients with detectable to mildly elevated serum troponin.

Methods

We conducted a secondary analysis of the CMR-IMPACT trial that randomized patients with symptoms suggestive of acute coronary syndrome and a detectable or mildly elevated troponin measure from 4 US hospitals to an early invasive angiography or cardiac MRI strategy. The primary endpoint was the composite of all-cause mortality, myocardial infarction, cardiac hospital readmission, and repeat cardiac ED. Secondary outcomes were components of the composite and revascularization.

Results

Participants (n = 312, mean age 61 ± 11 years) were 36.2 % non-white and 40.1 % female. The composite outcome occurred in 63.7 % of non-white vs. 49.8 % of white patients (aHR 1.50, 95 % CI 1.08-2.09) and 53.6 % of female vs. 55.6 % of male patients (aHR 0.93, 95 % CI 0.68-1.28). Non-white (aHR 0.57, 95 % CI 0.35-0.92) patients had lower rates of revascularization also less median stenosis (p < 0.001) and stenosis >70 % (p < 0.001) during index cardiac testing. Despite these findings, ACS after discharge was higher among non-white patients (aHR 1.84, 95 % CI 1.11-3.05). Females had lower rates of revascularization (aHR 0.52, 95 % CI 0.33-0.82), but no increase in ACS after discharge (aHR 0.90, 95 % CI 0.55-1.49).

Conclusion

Non-white patients had higher rates of ACS following discharge despite lower rates of obstructive CAD following standardization of index cardiac testing. Future disparity works should explore care following the index encounter.

Advanced Machine Learning to Predict Coronary Artery Disease Severity in Patients with Premature Myocardial Infarction

Background

Studies using machine learning to identify the target characteristics and develop predictive models for coronary artery disease severity in patients with premature myocardial infarction (PMI) are limited.

Methods

In this observational study, 1111 PMI patients (≤55 years) at Tianjin Chest Hospital from 2017 to 2022 were selected and divided according to their SYNTAX scores into a low-risk group (≤22) and medium-high-risk group (>22). These groups were further randomly assigned to a training or test set in a ratio of 7:3. Lasso-logistic was initially used to screen out target factors. Subsequently, Lasso-logistic, random forest (RF), k-nearest neighbor (KNN), support vector machine (SVM), and eXtreme Gradient Boosting (XGBoost) were used to establish prediction models based on the training set. After comparing prediction performance, the best model was chosen to build a prediction system for coronary artery severity in PMI patients.

Results

Glycosylated hemoglobin (HbA1c), angina, apolipoprotein B (ApoB), total bile acid (TBA), B-type natriuretic peptide (BNP), D-dimer, and fibrinogen (Fg) were associated with the severity of lesions. In the test set, the area under the curve (AUC) of Lasso-logistic, RF, KNN, SVM, and XGBoost were 0.792, 0.775, 0.739, 0.656, and 0.800, respectively. XGBoost showed the best prediction performance according to the AUC, accuracy, F1 score, and Brier score. In addition, we used decision curve analysis (DCA) to assess the clinical validity of the XGBoost prediction model. Finally, an online calculator based on the XGBoost was established to measure the severity of coronary artery lesions in PMI patients.

Conclusions

In summary, we established a novel and convenient prediction system for the severity of lesions in PMI patients. This system can swiftly identify PMI patients who also have severe coronary artery lesions before the coronary intervention, thus offering valuable guidance for clinical decision-making.

Accuracy of dynamic stress CT myocardial perfusion in patients with suspected non-ST elevation myocardial infarction

Coronary CT angiography (CCTA) and dynamic stress CT myocardial perfusion (CT-MPI) are established modalities in the analysis of patients with chronic coronary syndromes. Their role in patients with suspected non-ST elevation myocardial infarction (NSTEMI) is unknown. CCTA with CT-MPI might assist in the triage of NSTEMI patients to the Cath lab. We investigated the correlation of significant epicardial lesions by CT-MPI in addition to CCTA compared to invasive coronary angiography (ICA) with fractional flow reserve (FFR) in patients with NSTEMI. Twenty NSTEMI patients scheduled for ICA were enrolled in this study with planned ICA. CCTA and CT-MPI was performed pre-ICA. For each coronary artery, the presence or absence of significant lesions was interpreted by CCTA with CT-MPI, using an FFR of ≤ 0.8 or angiographic culprit (stenosis > 90%, suspected plaque rupture) as reference. The main outcome was the per-vessel correlation. Sixteen out of 20 patients had a culprit lesion that required immediate revascularization. CCTA with ≥ 50% stenosis demonstrated a per vessel sensitivity and specificity for the detection of significant stenosis of respectively 100% (95% CI: 86-100%) and 75% (95% CI: 58-88%). CCTA with CT-MPI showed a lower sensitivity 90% (95% CI: 70-99%) but higher specificity of 100% (95% CI: 90-100%). CCTA with CT-MPI exhibits a strong correlation for identifying significant CAD in patients with NSTEMI. Thereby, it might assist in the triage of ICA in NSTEMI patients.

Predictive Value of High-Sensitivity Troponin I for Left Ventricular Ejection Fraction in Patients with Non-ST-Elevation Myocardial Infarction

Background

According to the World Health Organization's 2021 statistics, cardiovascular diseases (CVDs), particularly coronary artery disease (CAD), remain among the leading causes of global morbidity and mortality, affecting both high-income and low-income countries like Vietnam.

Objective

Acute myocardial infarction (AMI) remains a major cause of mortality and cardiovascular complications, with a poor prognosis in patients with left ventricular systolic dysfunction (LVSD). High-sensitivity cardiac troponin I (hs-cTnI) is a specific biomarker of myocardial injury linked to infarct size and LVSD. However, its role in predicting left ventricular ejection fraction (LVEF) in non-ST-elevation myocardial infarction (NSTEMI) is underexplored. This study investigates the correlation between hs-cTnI and LVSD in NSTEMI patients.

Methods

A descriptive, cross-sectional study was conducted on 117 patients with first-time NSTEMI treated at Cho Ray Hospital from February 2024 to April 2024. Admission hs-cTnI levels were measured and correlated with LVEF, assessed via echocardiography. The predictive value and optimal cut-off points of hs-cTnI for LVSD (LVEF < 50% and ≤ 40%) were determined using receiver operating characteristic (ROC) curve analysis.

Results

Hs-cTnI levels showed a significant inverse correlation with LVEF (r = - 0.569, p < 0.001). Patients with moderate-to-severe LVSD (LVEF ≤ 40%) had the highest median hs-cTnI levels (25,000 pg/mL, p < 0.001). The area under the ROC curve (AUC) for predicting LVEF < 50% was 0.78, with a cut-off of 12,344 pg/mL (sensitivity 68.5%, specificity 82.5%). For LVEF ≤ 40%, the AUC was 0.82, with a cut-off of 20,979 pg/mL (sensitivity 73.3%, specificity 88.5%, accuracy 84.6%). These findings underscore hs-cTnI's utility in identifying LVSD.

Conclusion

Hs-cTnI is inversely correlated with LVEF and serves as a reliable biomarker for predicting LVSD in NSTEMI patients, facilitating risk stratification and early management decisions.

Association of Serum Gamma-Glutamyltransferase with In-hospital Heart Failure in Patients with ST-segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Background

To explore the association between gamma-glutamyltransferase (GGT) and in-hospital heart failure (HF) in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).

Methods

A total of 412 patients diagnosed with STEMI and treated with primary PCI were included in our study. Univariate and multivariate logistic regression models were used to evaluate the association between GGT and the risk of in-hospital HF in STEMI patients. The receiver operating characteristic (ROC) curve was used to assess the accuracy of GGT in predicting in-hospital HF.

Results

The incidence of HF after STEMI increased significantly with increasing GGT tertiles (the first, second, and third tertile groups were 7.97%, 14.49%, and 18.38%, respectively; p = 0.039). Multivariate logistic regression analysis revealed that the risk of HF in the second and third GGT tertile groups was 2.51 times greater (95% CI, 1.06-5.96) and 2.77 times greater (95% CI, 1.13-6.81), respectively, than that in the first GGT tertile group. Each 1-unit increase in the lnGGT level was related to a 1.88-fold increased risk of HF (odds ratio, OR, 1.88; 95% CI, 1.19-2.96; p = 0.007). Restricted cubic splines suggested a linear relationship between GGT and in-hospital HF (p for nonlinearity = 0.158). The area under the curve was 0.607 (95% CI, 0.558-0.654; p = 0.007) when GGT was used to predict in-hospital HF, with a sensitivity of 57.14% and a specificity of 64.04%. Moreover, the incidence of HF significantly increased in-hospital death risk (OR, 7.75; 95% CI, 1.87-32.12; p = 0.005).

Conclusions

GGT is positively associated with in-hospital HF and is an independent risk factor for in-hospital HF in STEMI patients.

Feasibility of fractal dimension analysis for left ventricular trabecular complexity using cardiac computed tomography

AIMS

To evaluate the consistency between fractal dimensions (FD) derived from cardiac computed tomography (CT-FD) and cardiac magnetic resonance (MR-FD) in assessing left ventricular trabecular complexity.

METHODS

This retrospective study included 170 patients who underwent CCT and CMR scans within two weeks. Five short-axis cine images were selected at end-diastole: one basal, three mid, and one apical slice. Short-axis CCT views were reconstructed and aligned with the cine images. CT-FD and MR-FD values were calculated for each slice, with mean values determined for each patient. Severe left ventricular hypertrophy (LVH) was defined as a maximum wall thickness > 15 mm in end-diastolic cine images.

RESULTS

The diastolic CT-FD and MR-FD values exhibited high consistency, with values of 1.253 ± 0.091 and 1.250 ± 0.102, respectively (n = 535, ICC = 0.882, 95 % CI: 0.861-0.899, P < 0.001). Similarly, the systolic CT-FD and MR-FD values demonstrated good consistency, with values of 1.268 ± 0.072 and 1.286 ± 0.093, respectively (n = 390, ICC = 0.720, 95 % CI: 0.669-0.765, P < 0.001). For subgroups of systolic NLVH and LVH, the ICCs were 0.773 (n = 305, CI: 0.723-0.814, P < 0.001) and 0.565 (n = 85, 95 % CI: 0.402-0.694, P < 0.001), respectively. The diagnostic efficacy of mean CT-FD aligned with that of mean MR-FD in distinguishing abnormal cardiac conditions from the CMR-negative group.

CONCLUSIONS

CCT is a feasible method for assessing left ventricular trabecular complexity, with good agreement with CMR, except in cases of severe left ventricular hypertrophy during systole.

Prognostic Value of Cardiac MRI Late Gadolinium Enhancement Granularity in Participants with Ischemic Cardiomyopathy

Background Ischemic late gadolinium enhancement (LGE) assessed with cardiac MRI is a well-established prognosticator in ischemic cardiomyopathy. However, the prognostic value of additional LGE parameters, such as extent, transmurality, location, and associated midwall LGE, remains unclear. Purpose To assess the prognostic value of ischemic LGE features to predict all-cause mortality in ischemic cardiomyopathy. Materials and Methods This study is a secondary analysis of a prospective dual-center trial of participants with ischemic cardiomyopathy and left ventricular ejection fraction (LVEF) under 50% referred for viability assessment using cardiac MRI between 2008 and 2022. The LGE granularity parameters (extent of ischemic LGE, transmurality, location, and associated midwall LGE) assessed by cardiac MRI experts were compared with traditional prognosticators of adverse events in ischemic cardiomyopathy (age, sex, body mass index, diabetes, smoking, dyslipidemia, heart failure hospitalization, atrial fibrillation, renal failure, known myocardial infarction, and LVEF). The primary outcome was all-cause mortality. Predictive value was evaluated using Cox regression analysis and assessed using time-dependent receiver operating characteristic curves at 10 years. The cardiac MRI LGE score was developed using LGE granularity parameters. Results Among 6082 participants (mean age, 64.5 years ± 11.8 [SD]; 4419 men), 3591 had ischemic LGE. During a median follow-up of 9.0 years (IQR, 6.6-11.5 years), 652 participants died. The presence of ischemic LGE was strongly associated with mortality (hazard ratio, 3.45 [99.5% CI: 2.55, 4.67]; P < .001). In the group with ischemic LGE, the LGE granularity model combining these LGE features showed the best predictive value above traditional prognosticators and ischemic LGE extent to predict all-cause mortality (area under the receiving operating characteristic curve [AUC] at 10 years, 0.89 [99.5% CI: 0.89, 0.90] vs 0.83 [99.5% CI: 0.83, 0.84]; P < .001). The cardiac MRI LGE score performed well in participants with ischemic LGE (AUC at 10 years, 0.87 [99.5% CI: 0.85, 0.90]). Conclusion In a large cohort of participants with ischemic cardiomyopathy, an LGE granularity model had a higher prognostic value over traditional prognosticators to predict mortality. © RSNA, 2025 Supplemental material is available for this article. See also the editorial by Lima and Ebrahimihoor in this issue.

A Machine Learning Model Using Cardiac CT and MRI Data Predicts Cardiovascular Events in Obstructive Coronary Artery Disease

Background Multimodality imaging is essential for personalized prognostic stratification in suspected coronary artery disease (CAD). Machine learning (ML) methods can help address this complexity by incorporating a broader spectrum of variables. Purpose To investigate the performance of an ML model that uses both stress cardiac MRI and coronary CT angiography (CCTA) data to predict major adverse cardiovascular events (MACE) in patients with newly diagnosed CAD. Materials and Methods This retrospective study included consecutive symptomatic patients without known CAD referred for CCTA between December 2008 and January 2020. Patients with obstructive CAD (at least one ≥50% stenosis at CCTA) underwent stress cardiac MRI for functional assessment. Eighteen clinical, two electrocardiogram, nine CCTA, and 12 cardiac MRI parameters were evaluated as inputs for the ML model, which involved automated feature selection with the least absolute shrinkage and selection operator algorithm and model building with an XGBoost algorithm. The primary outcome was MACE, defined as a composite of cardiovascular death and nonfatal myocardial infarction. External testing was performed using two independent datasets. Performance was compared between the ML model and existing scores and other approaches using the area under the receiver operating characteristic curve (AUC). Results Of 2210 patients who completed cardiac MRI, 2038 (mean age, 70 years ± 12 [SD]; 1091 [53.5%] female participants) completed follow-up (median duration, 7 years [IQR, 6-9 years]); 281 experienced MACE (13.8%). The ML model exhibited a higher AUC (0.86) for MACE prediction than the European Society of Cardiology score (0.55), QRISK3 score (0.60), Framingham Risk Score (0.50), segment involvement score (0.71), CCTA data alone (0.76), or stress cardiac MRI data alone (0.83) (P value range, <.001 to .004). The ML model also exhibited good performance in the two external validation datasets (AUC, 0.84 and 0.92). Conclusion An ML model including both CCTA and stress cardiac MRI data demonstrated better performance in predicting MACE than traditional methods and existing scores in patients with newly diagnosed CAD. © RSNA, 2025 Supplemental material is available for this article.

The kinetics of cardiac troponin T release during and after 1- and 6-h maximal cycling trials

OBJECTIVES

In this study, the effects of short-duration high-intensity exercise and long-duration exercise on high-sensitivity cardiac troponin T (hs-cTnT) levels were compared.

METHODS

Twelve male amateur cyclists performed 1- and 6-h cycling trials. In both exercise trials, hs-cTnT was assessed at rest, immediately postexercise and at 1, 3, 6, 12, and 24 h postexercise. Additionally, hs-cTnT levels were assessed every hour during the 6-h trial.

RESULTS

Exercise resulted in an increase in hs-cTnT levels in all subjects. Circulating hs-cTnT levels increased in both exercise trials (p < 0.001), with higher peak values occurring after the 1-h trial compared with those of the 6-h trial (p = 0.023). The upper reference limit (URL) exceeded 83 % of the participants in the 1-h trial and 42 % of the participants in the 6-h trial. There was substantial individual variability in peak hs-cTnT in both trials. Values of hs-cTnT were greater after exercise than during exercise for the 6-h trial. For both exercise trials, the maximum postexercise hs-cTnT values correlated with the %HRMAX (r = 0.906 for the 1-h trial, r = 0.735 for the 6-h trial). For the 1-h trial, the maximum postexercise hs-cTnT values were observed at 3 h in all subjects. No significant difference in the hs-cTnT values was observed for the 6-h trial during the first 12 h postexercise.

CONCLUSIONS

Our results demonstrated greater hs-cTnT levels in young male participants after a 1-h cycling trial than after a 6-h cycling trial, despite a substantially greater energy expenditure and total external work completed in the 6-h trial. Postexercise hs-cTnT values are associated with relative exercise intensity.

Long-term outcomes and operators' experience in primary percutaneous coronary intervention for ST-segment elevation myocardial infarction

Primary percutaneous coronary intervention (pPCI) for ST-segment elevation myocardial infarction (STEMI) is typically performed by experienced operators. Therefore, the safety of pPCI for STEMI performed by less experienced operators with the support of experienced operators remains unknown. We aimed to investigate the long-term outcomes of pPCI for STEMI performed by less experienced operators with the support of experienced operators. In total, 775 STEMI patients were enrolled and divided into groups according to operator experience in PCI: less experienced (n = 384) and experienced (n = 391) operator groups. Experienced operators were defined as those who had performed > 50 elective PCI procedures per year as the first operator or instructional assistant, whereas less experienced operators were defined as others. When less experienced operators performed the pPCI, experienced operators supported them. The primary endpoint was any cardiovascular event, defined as a composite of cardiovascular death, nonfatal myocardial infarction, and unplanned hospitalization for heart failure. In the propensity score-matched analysis, 324 patients were included in each group. The cumulative incidence of the primary endpoint over a median of 5 years in the less experienced operator group was similar to that in the experienced operator group (15% vs. 18%, P = 0.209). In the multivariate Cox proportional hazards model, there was no excess risk for patients operated upon by less experienced operators for the primary endpoint (adjusted hazard ratio, 0.85; 95% confidence interval, 0.58-1.25; P = 0.417). pPCI for STEMI by less experienced operators did not increase the risk of in-hospital mortality or 5-year long-term cardiovascular events if supported by experienced operators.

Sex-Specific Troponin and Creatine Kinase Thresholds After Coronary Bypass Surgery

BACKGROUND

The impact of sex-differences on the release of cardiac biomarkers after coronary artery bypass grafting (CABG) remains unknown. The aim of our study was to (1) investigate the impact of sex-differences in cardiac biomarker release after CABG and (2) determine sex-specific thresholds for high-sensitivity cardiac troponin (hs-cTn) and creatine kinase-myocardial band (CK-MB) associated with 30-day major adverse cardiovascular events (MACE) and mortality.

METHODS

A consecutive cohort of 3687 patients, comprising 643 women (17.4%) and 3044 men (82.6%), undergoing CABG from 2008 to 2021 in 2 tertiary university centers with serial postoperative cTn and CK-MB measurement was analyzed. The composite primary outcome was MACE at 30 days. Secondary end points were 30-day mortality and 5-year mortality and MACE. Sex-specific thresholds for cTn and CK-MB were determined.

RESULTS

Lower levels of cTn were found in women after CABG (69.18 vs 77.57 times the upper reference limit [URL]; P < .001). The optimal threshold value for cTn was calculated at 94.36 times the URL for female patients and 206.07 times the URL for male patients to predict 30-day MACE. Female patients missed by a general threshold had increased risk for MACE or death within 30 days (cTn: MACE: odds ratio [OR], 3.78; 95% CI, 1.03-13.08; P = .035; death: OR, 4.98; 95% CI, 1.20-20.61; P = .027; CK-MB: MACE: OR, 10.04; 95% CI, 2.07-48.75; P < .001; death: OR 13.59; 95% CI, 2.66-69.47; P = .002).

CONCLUSIONS

We provide evidence for sex-specific differences in the outcome and biomarker release after CABG. Sex-specific cutoffs are necessary for the diagnosis of perioperative myocardial injury to improve outcomes of women after CABG.

Biomarkers to Predict Abnormal Technetium-99m Pyrophosphate Scans in Patients With Suspected Transthyretin Amyloidosis

Background

Technetium Tc 99m pyrophosphate scintigraphy (99mTc PYP imaging) is a diagnostic tool for transthyretin amyloid cardiomyopathy (ATTR-CM). Cardiac biomarkers, particularly high-sensitivity cardiac troponin (hs-cTn) and N-terminal pro-B-type natriuretic peptide (NT-proBNP), may help identify patients at low or high risk for ATTR-CM.

Objectives

The authors sought to evaluate the predictive value of hs-cTnT and NT-proBNP in patients undergoing 99mTc PYP imaging for suspected ATTR-CM in a large U.S. cohort.

Methods

This was a retrospective study of patients who underwent 99mTc PYP imaging between May 2013 and September 2022, including those with at least 1 hs-cTnT measurement within 6 months of the scan.

Results

ATTR-CM was diagnosed in 427 of 1,442 patients (29.6%). A hs-cTnT level <6 ng/L (n = 50, 3.5%) showed a negative predictive value of 100% (95% CI: 93%-100%) and sensitivity of 100% (95% CI: 99%-100%) for ruling out ATTR-CM. As the hs-cTnT threshold increased, the number of patients who could be ruled out also increased, but false negatives emerged. The positive predictive value for ruling in ATTR-CM remained low. NT-proBNP showed similar results (n = 1,378). The combination of hs-cTnT <14 ng/L and NT-proBNP <60 ng/L identified 45 patients (3.3%) without ATTR-CM.

Conclusions

In patients undergoing 99mTc PYP imaging for suspected ATTR-CM, very low hs-cTnT levels can effectively rule out the diagnosis, although in a small subset of patients. Higher thresholds increase the risk of false negatives. NT-proBNP and combined biomarker strategies showed similar trends, the utility of hs-cTnT and NT-proBNP for ruling in the disease is limited.

4-Factor prothrombin complex concentrates and factor VIII inhibitor bypass activity use in cardiac surgery

OBJECTIVES

The objective of this study was to compare total thromboembolic complications between 4-factor prothrombin complex concentrate (4F-PCC) with factor VIII inhibitor bypassing activity (FEIBA) when utilized during cardiac surgery.

DESIGN

A quasi-experimental analysis of retrospective data from consecutive patients.

SETTING

A tertiary care university hospital.

PARTICIPANTS

Patients undergoing cardiac surgery with cardiopulmonary bypass.

INTERVENTIONS

Patients received either 4F-PCC or FEIBA after discontinuation of cardiopulmonary bypass and reversal of heparin with protamine.

MEASUREMENTS AND MAIN RESULTS

Medical records were reviewed for thromboembolic events (stroke, arterial or venous thrombosis, pulmonary embolism, myocardial infarction), acute kidney injury, ischemic bowel, death, duration of intensive care unit and hospital stay, clinical and surgical characteristics and blood product utilization. A comparison of the clinical and surgical variables demonstrated a mean effect size of 0.33 imbalance between groups that was reduced to 0.18 after propensity score weighting. The propensity scores weighted analysis found an incidence of composite thromboembolic events of 39% in the 4F-PCC ( n  = 90) and 47% in the FEIBA ( n  = 50) group, difference -8 (-24% to 12%), P  = 0.13. Individual thromboembolic events, acute kidney injury, ischemic bowel, mortality, and length of intensive care unit or hospital stay was not different among groups. Patients who received FEIBA had greater chest tube drainage and received more cryoprecipitate intraoperatively. Patients who received 4F-PCC received more fresh frozen plasma transfusions postoperatively.

CONCLUSIONS

Among cardiac surgery patients, there was no difference in thromboembolic events between patients who received 4F-PCC or FEIBA when used as an adjunct to blood product administration.

Knockdown of KLF6 ameliorates myocardial infarction by regulating autophagy via transcriptional regulation of PTTG1

Krüppel-like factor 6 (KLF6) knockdown provides protection against kidney ischemia/reperfusion injury and ischemic stroke. However, it is unclear whether it plays a role in myocardial infarction (MI). Here, the expression of KLF6 was analyzed using the Gene Expression Omnibus (GEO) database and determined in patients with MI. The impact of KLF6 knockdown was further confirmed in in vivo and in vitro models of MI. The interaction between KLF6 and pituitary tumor-transforming gene 1 (PTTG1) was also evaluated. According to the GEO database, KLF6 expression was found to be upregulated in mouse hearts after MI compared to sham-operated mice. The upregulation of KLF6 in hearts from mice post-MI and in patients with MI was confirmed. KLF6 knockdown was found to alleviate myocardial injury, diminish infarct size, and suppress apoptosis and autophagy in mice with MI. In addition, inactivation of the AMP-activated protein kinase (AMPK)/mammalian target of rapamycin (mTOR) signaling was observed after KLF6 knockdown in mice with MI. In an in vitro model of MI, the knockdown of KLF6 increased cell survival and inhibited autophagy through the AMPK/mTOR pathway. In addition, KLF6 interacted with the promoter of PTTG1 and negatively regulated its expression. Knockdown of PTTG1 abolished the function of KLF6 knockdown in vitro. This study demonstrates the protective effect of KLF6 knockdown against MI, which is attributed to the elevation of PTTG1 expression and inhibition of the AMPK/mTOR pathway. These findings provide a novel insight into MI treatment.NEW & NOTEWORTHY Our study demonstrates for the first time the role of Krüppel-like factor 6 (KLF6)/PTTG1 axis in myocardial infarction (MI). This study demonstrates the protective effect of KLF6 knockdown against MI, which is attributed to the elevation of PTTG1 expression and inhibition of the AMPK/mTOR pathway. These findings provide a novel insight into MI treatment.

Serial secretoneurin measurement and risk of ventricular arrhythmias and death in patients with left ventricular systolic dysfunction

BACKGROUND

Secretoneurin, a member of the granin protein family, is associated with the risk of mortality in patients with acute and chronic heart failure. Secretoneurin may play an important role in cardiomyocyte calcium handling, suggesting that it may influence cardiac arrhythmia risk. We hypothesized that baseline and serial measurements of circulating secretoneurin are associated with the risk of incident ventricular tachyarrhythmias (VA) and death, and that serial measurement would provide prognostic information beyond baseline values.

METHODS

We measured circulating secretoneurin concentrations in blood samples obtained at 3-month intervals for one year in a prospectively enrolled cohort of ambulatory patients with left ventricular ejection fraction (LVEF) ≤ 35 % and a primary-prevention implanted cardioverter defibrillator (ICD). Associations between secretoneurin modeled as a time-dependent variable and the incidences of VA and death were assessed.

RESULTS

154 patients (66 ± 14 years, LVEF 23 ± 8 %) were included in the analysis. During one-year follow-up, 26 (17 %) patients experienced VA, and 16 (10 %) died. Adjusting for age, sex, eGFR, and LVEF, baseline secretoneurin concentration was associated with the risk of death (hazard ratio (HR) per 10 pmol/L increase: 1.14 (95 % CI: 1.02-1.27), p = 0.020) but not VA (HR: 0.98 (0.81-1.19), p = 0.856). Using serial measurements at 3-month intervals, time-varying secretoneurin was associated with a similarly higher risk of death (HR: 1.14 (1.02-1.27), p = 0.017) but not of VA (HR: 0.97 (0.81-1.17), p = 0.776).

CONCLUSION

In stable ambulatory patients with reduced LV systolic function and a primary prevention indication for ICD, secretoneurin concentration was associated with the risk of death but not ventricular tachyarrhythmia.

Characteristics of Atherosclerotic Plaques Left after Percutaneous Coronary Intervention in Patients with Acute Coronary Syndrome. Assessment According to Computed Tomographic Angiography of the Coronary Arteries

AIM

To evaluate characteristics of atherosclerotic plaques (ASP) remaining after percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) by coronary computed tomography angiography (CCTA).

MATERIAL AND METHODS

Among 249 patients (193 men) with ACS aged 58±10 years, 183 (73.5%) had myocardial infarction, 66 (26.5%) had unstable angina. CCTA was performed after PCI at 3-7 days after the onset of ACS according to the standard protocol: in 41 patients, on a 64-slice tomograph (Aquilion 64, Toshiba, Japan) and in 208 patients, on a 640-slice tomograph with 320 rows of detectors (Aquilion ONE Vision Edition, Toshiba, Japan). CCTA of all patients was performed on a Vitrea workstation. Patients with at least one non-calcified ASP were included.

RESULTS

Among all ASPs, non-calcified ASPs predominated, 609 of 785 (77.6%), including 400 soft and 209 combined ones. Signs of obstruction (stenosis ≥50%) were noted in 72.2% of non-calcified ASPs. ASPs were characterized by a pronounced burden, 69 [61.4; 74.2]%, and a low minimum density, 31 [23; 37] HU, which was consistent with mature plaques with a lipid core. Various signs of ASP instability were observed in 6-35.3% of cases. There were 2 [2;3] (1 to 6) affected coronary arteries (CAs) and 3 [2;4] (1 to 7) ASPs, including calcified ones, per patient. 77.7% of ASPs were located in the CA proximal and middle segments. Obstructive stenosis was detected in 92% of patients. The number of ASPs with obstructive stenosis ranged from 0 to 7 per patient, with a median of 2 [1;3]. In 44% of patients, stenosis was 70% or more. The maximum burden of non-calcified ASPs was high, 74.3±12.1%; their maximum and total length were 13.8±10.4 mm and 26.5±19.7 mm, respectively; and the ASP minimum density was low, 25 [17;32] HU. ASPs with a low-density area of ≤46 HU and ≤30 HU were detected in 24.9% and 14.8% of patients, respectively. Other CCTA signs of instability were quite common: punctate calcifications in 52.2% of patients, coronary positive remodeling in 37%, the presence of "ring-like enhancement" in 16.1%, an uneven plaque contour in 26.7%, and at least one sign of ASP instability in 73% of patients.

CONCLUSION

After PCI, patients with ACS still have rather many ASPs, including those with CCTA signs of instability, with stenosis >50%; more than a third of the plaques had stenosis >70%; the plaques were extended and localized mainly in the proximal and middle sections of the main CAs.

Prognostic potential of inflammatory markers in chronic kidney disease patients combined with acute myocardial infarction

Background

Inflammation significantly impacts chronic kidney disease (CKD) and acute myocardial infarction (AMI). This study investigates the prognostic value of inflammatory markers in predicting outcomes for CKD patients with AMI.

Methods

We enrolled patients diagnosed with CKD concomitant with AMI, choosing five inflammatory markers related to both diseases. Patients were categorized into elevated inflammatory markers group and control group based on inflammatory markers cut-off values for predicting in-hospital major adverse cardiac and cerebrovascular events (MACCE). Using univariate and multivariate logistic regression, we identified inflammation-related risk factors for MACCE. We adjusted covariates stepwise to explore the relationship between independent risk factors and adverse outcomes. We also evaluated the predictive value of these markers for MACCE by receiver operating characteristic (ROC) curves.

Results

In the multivariate logistic regression analysis, higher levels of neutrophil-to-lymphocyte ratio (NLR), and platelet to lymphocyte ratio (PLR) significantly increased risk of MACCE (all P < 0.05). After adjusting above two indicators, NLR was independently associated with in-hospital MACCE in CKD patients with AMI (OR = 10.764, 95% CI: 1.887-61.406, P = 0.007). Furthermore, compared to other inflammatory markers, NLR had the highest predictive value for MACCE in patients with AMI and CKD [Area Under the Curve (AUC): 0.748, 95% Confidence Interval (CI): 0.634-0.861, P < 0.001].

Conclusion

In CKD patients combined with AMI, elevated levels of inflammation markers could increase the risk of MACCE. NLR may provide superior predictive value compared to other markers.

Adjustment of the ACEF score by the triglyceride glucose index improves the prediction of clinical outcomes in patients undergoing percutaneous coronary intervention

BACKGROUND

The ACEF score (age, creatinine, and left ventricular ejection fraction) and the triglyceride-glucose (TyG) index have been identified as robust risk prediction models for adverse outcomes post-percutaneous coronary intervention (PCI) in coronary atherosclerotic heart disease (CHD) patients. This study aimed to assess whether incorporating the TyG index enhances the predictive ability of the ACEF score and enhances risk stratification for CHD patients undergoing PCI.

METHODS

This observational cohort study enrolled 1248 patients diagnosed with CHD who underwent PCI at the Third People's Hospital of Chengdu, China, between May 2018 and December 2022. Receiver operating characteristic (ROC) curves were employed to establish the optimal cutoff values for the TyG index and ACEF score. The primary endpoint event was defined as major adverse cardiac and cerebrovascular events (MACCEs). Cumulative survival curves were plotted using the Kaplan-Meier method. Univariable and multivariable Cox regression analyses were conducted to identify predictors of MACCEs. The predictive ability of the ACEF score and the TyG index was assessed using the area under the ROC curve, net reclassification improvement (NRI), and integrated discrimination improvement (IDI).

RESULTS

Over a median follow-up period of 30.60 months, 214 patients experienced MACCEs. Kaplan-Meier survival analysis demonstrated a significant association between elevated ACEF score (> 1.27) and TyG index levels (> 8.82) with a heightened incidence of MACCEs (HR = 2.018, 95%CI 1.593-2.789; HR = 2.057, 95%CI 1.572-2.691; Log-Rank test, both P < 0.001). Multivariable Cox regression analysis revealed that even after adjusting for multiple confounders, both the ACEF score and TyG index remained as predictors of MACCEs (HR = 1.702, 95%CI 1.210-2.394, P = 0.002; HR = 1.575, 95%CI 1.296-1.916, P < 0.001). Additionally, the addition of the ACEF score and TyG index into the conventional risk model significantly improved the ability to predict MACCEs, as evidenced by the increase in the C-statistic value from 0.664 to 0.703, along with notable improvements in continuous NRI (0.391), categorical NRI (0.107), and IDI (0.033) (all P < 0.001).

CONCLUSION

The combination of the TyG index and the ACEF score enhances the predictive ability for long-term MACCEs in patients with CHD undergoing PCI.

Metabonomic Biomarkers of Plaque Burden and Instability in Patients With Coronary Atherosclerotic Disease After Moderate Lipid-Lowering Therapy

BACKGROUND

Contemporary risk assessment in patients with coronary atherosclerotic disease (CAD) often relies on invasive angiography. However, we aimed to explore the potential of metabolomic biomarkers in reflecting residual risk in patients with CAD after moderate lipid-lowering therapy.

METHODS AND RESULTS

We analyzed serum metabolomic profile among 2560 patients with newly diagnosed CAD undergoing moderate lipid-lowering therapy, through nuclear magnetic resonance spectroscopy and quantified 175 metabolites, predominantly lipoproteins and their components. CAD severity was evaluated using Gensini score for plaque burden and circulating cardiac troponin T levels for plaque instability. The association of metabolites with CAD severity was examined using multivariate linear regression, and the underlying potential causality was explored using a 2-sample Mendelian randomization approach. Two composite metabolomic indices were constructed to reflect CAD severity using least absolute shrinkage and selection operator linear regression, and their associations with risk of major adverse cardiac events during a median follow-up of 3.8 years were evaluated using Cox models. Our investigation revealed that triglycerides and apolipoprotein B in low-density lipoprotein particles displayed stronger associations with CAD severity compared with the clinically used low-density lipoprotein cholesterol marker. In large high-density lipoprotein, components like cholesterol, cholesterol esters, triglyceride, apolipoprotein A1/A2 showed inverse associations with CAD severity. Certain metabolites, including apolipoprotein B and dihydrothymine, showed a putative causal link with Gensini score. Notably, per standard deviation increase in Gensini score-based metabolomic index was associated with 14.8% higher major adverse cardiac event risk (hazard ratio, 1.148 [95% CI, 1.018-1.295]) independent of demographic factors, medication use, and disease status.

CONCLUSIONS

Our findings highlight the potential of nuclear magnetic resonance-based metabolomics in identifying novel biomarkers of plaque burden and instability. Metabolites related to plaque burden may facilitate noninvasive assessment of CAD prognosis.

Phaeochromocytoma mimicking acute ST-elevation myocardial infarction

Phaeochromocytomas are rare catecholamine-secreting tumours, usually benign, originating from chromaffin cells of the adrenal glands. Their typical presentation includes the triad of headaches, sweating and tachycardia due to excessive catecholamine release. However, many patients do not exhibit all three symptoms, making diagnosis challenging. A significant proportion of cases (around 40%) are linked to genetic disorders. Cardiac complications, including life-threatening events, are common.This report details the case of a 43-year-old woman presenting with chest pain, headaches and diaphoresis. Initial ECG showed an anterolateral ST-elevation myocardial infarction pattern, but coronary angiography revealed no arterial disease. The left ventricular angiogram indicated apical ballooning. Elevated blood pressure prompted suspicion of phaeochromocytoma, which was confirmed through positive metanephrine tests.The tumour, located in the right adrenal gland, was successfully removed laparoscopically, and pathological examination confirmed the diagnosis.Phaeochromocytoma should be suspected in patients with unexplained myocardial infarction, labile hypertension and normal coronary arteries, as beta-blockers can be harmful if used in untreated cases.