Fourth Universal Definition of Myocardial Infarction (2018)

When Cardiac Magnetic Resonance Changed the Diagnosis of a Young Patient With Spontaneous Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a significant cause of acute coronary syndrome, myocardial infarction, arrhythmia, and sudden death, particularly in young women and individuals with few conventional atherosclerotic risk factors, necessitating a high degree of suspicion. The most common risk factors for SCAD include atherosclerosis, females in the peripartum period, autoimmune inflammatory diseases, and connective tissue diseases. We present an unusual case of a young man who was initially suspected of having myocarditis, but cardiac magnetic resonance (CMR) revealed an ischemic pattern in late gadolinium enhancement. A coronary angiography (CA) led to the diagnosis of SCAD. We report a case of a 28-year-old male who presented with typical chest pain on and off for the past three months. Since the patient had no medical or cardiac history, the previous computed tomography CA (CTCA) revealed normal coronaries, raising the suspicion of myocarditis. Consequently, we performed a CMR, which revealed subendocardial delayed enhancement in the apical anterior and mid-anteroseptal segments, thereby ruling out myocarditis. The decision was made here to perform a coronary angiogram, which led to the diagnosis of SCAD.

Liberal versus restrictive transfusion strategies in acute myocardial infarction: a systematic review and comparative frequentist and Bayesian meta-analysis of randomized controlled trials

BACKGROUND

The transfusion strategy in the acute phase of myocardial infarction (AMI) remains a debated topic with non-standardized guidelines. This study aimed to evaluate the impact of liberal versus restrictive transfusion strategies on mortality during AMI.

METHODS

A systematic search was conducted across MEDLINE, EMBASE, and the COCHRANE library databases, focusing on randomized controlled trials (RCTs). The primary endpoint was the latest measured mortality within 90 days following myocardial infarction (MI). Secondary endpoints included recurrence of MI, cardiovascular mortality, stroke occurrence, unplanned revascularization, and a composite endpoint of death or recurrent MI. Mixed and random-effects models were employed to estimate relative risks. Sensitivity analyses were conducted using two approaches: one incorporating only studies assessed as low risk of bias according to the Rob2 tool, and another employing a Bayesian analysis.

RESULTS

Four RCTs including a total of 4324 participants were analyzed. Neither the fixed-effect nor random-effects models demonstrated a significant reduction in mortality, with risk ratios (RR) of 1.16 (95% CI 0.95-1.40) for the fixed-effect model and 1.13 (95% CI 0.67-1.91) for the random-effects model (GRADE: low certainty of evidence). Sensitivity analyses, including the exclusion of two high-risk-of-bias studies and a Bayesian analysis, were consistent with the primary analysis. For the composite outcome death or MI both fixed-effect and random-effects models showed a statistically significant RR of 1.18 (95% CI 1.01-1.37) with negligible heterogeneity (I2 = 0%, p = 0.46), indicating results unfavorable to restrictive transfusion (GRADE: very low certainty of evidence). However, this result was primarily driven by a single study. For cardiac mortality, the fixed-effects model indicated a significant RR of 1.42 (95% CI 1.07-1.88), whereas the random-effects model showed non-significant RR of 1.05 (95% CI 0.36-3.80). Analyses of other secondary endpoints did not show statistically significant results.

CONCLUSIONS

Our analysis did not demonstrate a significant benefit in early mortality with a liberal transfusion strategy compared to a restrictive strategy for AMI, low certainty of evidence. Liberal transfusion may reduce the risk of the composite outcome death or MI, with very low certainty of evidence. These findings should be interpreted with caution in critically ill patients.

Prognostic value of global coronary flow reserve before and after elective percutaneous coronary intervention in patients with chronic coronary syndrome

BACKGROUND

Impaired global coronary flow reserve (G-CFR), evaluated through phase-contrast cine cardiovascular magnetic resonance (PC-CMR), has been linked to worse outcomes in patients with cardiovascular disease. This study aimed to investigate the prognostic value of G-CFR improvement, as evaluated using PC-CMR imaging pre- and post-percutaneous coronary intervention (PCI).

METHODS

In this single-center study, 320 patients with chronic coronary syndrome (CCS) who underwent pre- and post-PCI PC-CMR measurements were followed up to determine major adverse cardiac or cerebrovascular events (MACCE) predictors. MACCE was defined as a composite of cardiac death, nonfatal myocardial infarction, hospitalization due to heart failure, or ischemic stroke. The association between CMR parameters, including baseline data, G-CFR changes post-PCI, and MACCE, was investigated.

RESULTS

G-CFR improvement was observed in 51.6% (165/320) patients, while MACCE occurred in 8.1% (26/320) during a median follow-up period of 2.5 years. G-CFR improvement was significantly associated with a lower pre-PCI G-CFR. The log-rank test revealed a significant association between patients without G-CFR improvement post-PCI and a poor prognosis. Patients with lower pre-PCI G-CFR and lack of G-CFR improvement exhibited the highest incidence of MACCE. The multivariable Cox proportional hazard model revealed that lack of G-CFR improvement was an independently significant MACCE predictor from pre-PCI G-CFR and SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) score.

CONCLUSION

Besides the association between pre- and post-PCI lower G-CFR and worse prognosis, the presence or absence of G-CFR improvement post-PCI may provide novel insights into the prognosis following elective PCI in patients with CCS.

Reference intervals of circulating secretoneurin concentrations determined in a large cohort of community dwellers: the HUNT study

OBJECTIVES

Secretoneurin (SN) is a novel cardiac biomarker that associates with the risk of mortality and dysfunctional cardiomyocyte Ca2+ handling in heart failure patients. Reference intervals for SN are unknown.

METHODS

SN was measured with a CE-marked ELISA in healthy community dwellers from the fourth wave of the Trøndelag Health Study (HUNT4) conducted in 2017-2019. The common, sex and age specific 90th, 95th, 97.5th and 99th percentiles were calculated using the non-parametric method and outlier exclusion according to the Reed test. The applicability of sex and age specific reference intervals were investigated using Harris and Boyd test. We also estimated the percentiles in a subset with normal findings on echocardiographic screening.

RESULTS

The total cohort included 887 persons (56.4 % women). After echocardiographic screening 122 persons were excluded, leaving a total of 765 persons (57.8 % women). The 97.5th percentile (95 % CI in brackets) of SN was 59.7 (57.5-62.1) pmol/L in the total population and 58.6 (57.1-62.1) pmol/L after echocardiography screening. In general, slightly higher percentiles were found in women and elderly participants, but less than 4 % in these subgroups had concentrations deviating from the common 97.5th percentile. Low BMI or eGFR was also associated with higher concentrations of SN.

CONCLUSIONS

Upper reference limits for SN were similar amongst healthy adult community dwellers regardless of prescreening including cardiac echocardiography or not. Women and elderly showed higher concentrations of SN, but the differences were not sufficiently large to justify age and sex stratified upper reference limits.

Effect of impaired kidney function on outcomes and treatment effects of oral anticoagulant regimes in patients with atrial fibrillation in a real-world registry

BACKGROUND

The impact of impaired kidney function on outcomes and treatment benefits of vitamin-K antagonists (VKA) versus direct oral anticoagulants (DOAC) in patients with atrial fibrillation (AF) has insufficiently been investigated in randomized controlled studies (RCTs). Most studies and registries are either biased due to incomplete enrolment of consecutive patients in large pharma industry sponsored registries, or due to short recruitment periods or incomplete assessment of important variables in national registries.

METHODS

This study uses data from the Heidelberg Registry of Atrial Fibrillation (HERA-FIB), a retrospective single-center registry of 10,222 consecutive patients with AF presenting to the emergency department of University Hospital of Heidelberg from June 2009 until March 2020. Rates of all-cause mortality, stroke, major bleeding and myocardial infarction (MI) were related to the presence and severity of impaired presenting kidney function, as well as to assigned treatment with VKA vs. DOAC.

RESULTS

The risks for all-cause mortality (HR: 3.26, p<0.001), stroke (HR: 1.58, p<0.001), major bleeding (HR: 2.28, p<0.001) and MI (HR: 2.48, p<0.001) were significantly higher in patients with an eGFR<60 ml/min at admission and increased with decreasing eGFR. After adjustment for variables of CHA2DS2VASc-score, presence of eGFR <60 ml/min remained as an independent predictor for all-cause mortality, major bleeding and MI. The hazard ratio (HR) for all-cause mortality, major bleedings and MI was significantly lower in patients receiving DOAC compared to VKA.

CONCLUSION

Findings from our large real-life registry confirm the data from RCTs and extend our knowledge on the effectiveness and safety of DOACs to subjects that were underrepresented in RCTs.

Two-year clinical outcome of patients with mildly reduced ejection fraction after acute myocardial infarction: insights from the prospective KAMIR-NIH Registry

Background

Left ventricular ejection fraction (LVEF) is a crucial prognostic indicator of acute myocardial infarction (AMI). However, there is a lack of studies on the clinical characteristics and prognosis of patients with mildly reduced ejection fraction (EF) after AMI.

Methods

We categorized 6,553 patients with AMI from the Korea Acute Myocardial Infarction Registry-National Institutes of Health (KAMIR-NIH) between November 2011 and December 2015 into three groups based on their EF, as assessed by echocardiography during index hospitalization: reduced EF (LVEF ≤40%), mildly reduced EF (LVEF 41%-49%), and preserved EF (LVEF ≥50%). The primary outcome was all-cause death within 2 years. The secondary outcomes included myocardial infarction (MI), revascularization, and patient-oriented composite endpoint (POCE), which was defined as a composite of all-cause death, any MI, or revascularization.

Results

Of the total 6,553 patients, 884 (13.5%) were classified into the reduced EF group, 1,749 (26.7%) into the mildly reduced EF group, and 3,920 (59.8%) into the preserved EF group. Patients with mildly reduced EF exhibited intermediate mortality (reduced EF, 24.7%; mildly reduced EF, 8.3%; preserved EF, 4.6%; p < 0.0001), MI (3.9% vs. 2.7% vs. 2.6%; p < 0.0046), and POCE (33.0% vs. 15.6% vs. 12.4%; p < 0.0001) rates, albeit closer to those of the preserved EF. After adjustment for demographics, risk factors, admission status, and discharge medications, patients with mildly reduced EF showed a lower risk of all-cause death than those with reduced EF (mildly reduced EF group as a reference: HR, 1.74; 95% CI, 1.40-2.18; p < 0.001), but it did not differ significantly from those with preserved EF (HR, 0.94; 95% CI, 0.75-1.18; p = 0.999).

Conclusions

Over a 2-year follow-up period, patients with AMI and mildly reduced EF demonstrated better prognoses than those with reduced EF, but did not differ significantly from those with preserved EF.

Clinical Trial Registration

cris.nih.go.kr, identifier: KCT-0000863.

A novel vital sign pattern predicts sepsis-related myocardial injury mortality

Non-invasive, real-time monitorable indicators for early assessment of sepsis-associated myocardial injury (SMI) are still lacking. We aimed to develop non-invasive, real-time indicators for early assessment of SMI using bedside heart rate (HR) and diastolic arterial pressure (DAP) monitors. In this multi-center cohort study, piece-wise exponential additive mixed models were used to estimate the exposure window and time fraction of the hazardous exposure proportion, and secondarily to analyze the exposure characterization on this basis to identify high-risk exposure pattern. In total, 20,043 patients were finally included; we found that SMI patients had the highest survival rate when HR was <90 bpm or DAP was between 50 and 70 mmHg. Further investigation revealed that the SMI high-risk exposure pattern was the H1D-1 (HR ≥ 90 bpm and DAP ≤ 50 mmHg, exposure proportion > 0.3 and 0.2, respectively, and exposure window on admission day 1). H1D-1 exposure pattern using glucocorticoids significantly increased the risk of mortality in H1D-1. Validation against various methodologies and data sources demonstrated acceptable consistency.

Serum Klotho Is Elevated in Patients with Acute Myocardial Infarction and Could Predict Poor In-Hospital Prognosis

INTRODUCTION

Klotho has emerged as a potential protective factor for cardiovascular diseases recently. Nevertheless, the levels of serum Klotho in acute coronary syndrome (ACS) have not been reported. Hence, we undertook a study to investigate the potential correlation between serum Klotho and ACS patients.

METHOD

This observational cohort study was conducted at Peking University People's Hospital between May 2016 and April 2020. Upon admission, we collected the patients' clinical data and conducted ELISA tests to measure their serum Klotho levels.

RESULT

A total of 349 patients were enrolled in this study, including 14 patients with UA and 335 patients with AMI. We observed that serum Klotho levels were obviously higher in the AMI group compared to the UA group (median 479.8 vs. 233.8 pg/mL, p = 0.035). In addition, serum Klotho levels were positively correlated with cardiac function and more pronounced in patients who died in the hospital (median 721.1 vs. 468.3 pg/mL, p < 0.001). A logistic regression analysis indicated that age ≥ 78 years old, HR ≥ 90 bpm, Killip classification ≥ 3 grade, and serum Klotho > 645.0 pg/mL were risk factors for poor prognosis.

CONCLUSIONS

Serum Klotho is obviously increased in patients with AMI and with a positive correlation with cardiac function, and its elevation could serve as a predictor of poor prognosis in ACS patients.

Identifying heterogeneous subgroups of systemic autoimmune diseases by applying a joint dimension reduction and clustering approach to immunomarkers

BACKGROUND

The high complexity of systemic autoimmune diseases (SADs) has hindered precise management. This study aims to investigate heterogeneity in SADs.

METHODS

We applied a joint cluster analysis, which jointed multiple correspondence analysis and k-means, to immunomarkers and measured the heterogeneity of clusters by examining differences in immunomarkers and clinical manifestations. The electronic health records of patients who received an antinuclear antibody test and were diagnosed with SADs, namely systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and Sjögren's syndrome (SS), were retrieved between 2001 and 2016 from hospitals in Taiwan.

RESULTS

With distinctive patterns of immunomarkers, a total of 11,923 patients with the three SADs were grouped into six clusters. None of the clusters was composed only of a single SAD, and these clusters demonstrated considerable differences in clinical manifestation. Both patients with SLE and SS had a more dispersed distribution in the six clusters. Among patients with SLE, the occurrence of renal compromise was higher in Clusters 3 and 6 (52% and 51%) than in the other clusters (p < 0.001). Cluster 3 also had a high proportion of patients with discoid lupus (60%) than did Cluster 6 (39%; p < 0.001). Patients with SS in Cluster 3 were the most distinctive because of the high occurrence of immunity disorders (63%) and other and unspecified benign neoplasm (58%) with statistical significance compared with the other clusters (all p < 0.05).

CONCLUSIONS

The immunomarker-driven clustering method could recognise more clinically relevant subgroups of the SADs and would provide a more precise diagnosis basis.

Analysis of Compliance with Proper Nutrition Principles in Patients with a History of Myocardial Infarction

Adherence to dietary recommendations and the implementation of appropriate dietary habits after myocardial infarction (MI) can significantly improve health and reduce mortality from cardiac causes. The aim of this study was to analyse the adherence of patients with a history of MI to a healthy diet, which is one of the primary methods of cardiovascular disease (CVD) prevention. Following a proper diet involves limiting the consumption of saturated fats, salt, alcohol, and simple sugars. It is recommended to follow the Mediterranean diet, which is based on whole grains, fruits, vegetables, and fish. This study involved 120 patients hospitalised in the Invasive Cardiology and Cardiac Intensive Care Unit at the Independent Public Voivodship Hospital in Szczecin from August to December 2019. A self-designed questionnaire and the Questionnaire of Eating Behaviour (QEB) were used. The majority of respondents were hospitalised for a first-time MI (88.33%), and 65% of them reported adherence to the recommendations. The vast majority (78.33%) considered their diet good, with 50.83% of the respondents eating four meals a day and never eating fast food (49.17%). The analysis showed that although the respondents' diets did not contain many unhealthy foods, they did not consume enough vegetables, fruits, fish, nuts, or fibre, which have a protective effect, lowering the risk of cardiovascular diseases and death. Furthermore, patients with a better education had a higher level of knowledge. Respondents' knowledge of proper post-MI nutrition was sufficient, and their index of unhealthy diets was low, but they still made dietary mistakes and did not consume enough health-protective foods. These results indicate a need for further education.

Duration of Dual Antiplatelet Therapy after Percutaneous Coronary Intervention of Unprotected Left Main Coronary Artery Stenosis: 6 versus 12 Months

Background/Objectives: For patients with percutaneous coronary intervention (PCI) of an unprotected left main coronary artery (uLMCA) stenosis, the optimal duration of dual antiplatelet therapy (DAPT) remains a matter of debate. The purpose of this study was to compare clinical outcomes of 6- versus 12-month DAPT duration in patients with PCI of an uLMCA and stable angina. Methods: In this retrospective analysis, we included consecutive patients of our centre who underwent PCI of uLMCA stenosis for stable angina and who received DAPT with acetylsalicylic acid and clopidogrel for either 6 or 12 months. The primary endpoint was the composite of all-cause mortality, myocardial infarction, and target lesion revascularization at one year. Secondary endpoints included individual components of the primary endpoint, definite/probable stent thrombosis, and bleeding. Clinical outcomes were assessed by unadjusted analysis and by inverse probability of treatment weighting (IPTW). Results: Out of 984 included patients, 339 (34.5%) received DAPT for 6 months and 645 (65.5%) for 12 months. The primary endpoint occurred in 51 patients (15.2%) in the 6-month group and in 104 (16.3%) in the 12-month group (p = 0.674). Incidences of stent thrombosis (0.9% versus 0.3%, p = 0.224) and BARC 3,4,5 bleeding (6% versus 5.8%, p = 0.808) were also comparable in both groups. We found no significant differences in the primary endpoint and its components or BARC 3,4,5 bleeding between 6 and 12 months. Conclusions: Our findings do not support the extension of DAPT beyond 6 months after PCI for uLMCA in patients with stable angina.

Heart Rate Variability and Global Longitudinal Strain for Prognostic Evaluation and Recovery Assessment in Conservatively Managed Post-Myocardial Infarction Patients

Background: Heart rate variability (HRV) is the fluctuation in the time intervals between adjacent heartbeats. HRV is a measure of neurocardiac function that is produced by dynamic autonomic nervous system (ANS) processes and is a simple measure that estimates cardiac autonomic modulation. Methods: The study included 108 patients admitted to the Coronary Intensive Care Unit with acute myocardial infarction (AMI) who did not undergo primary percutaneous transluminal coronary angioplasty (PTCA) or systemic thrombolysis and followed conservative management. All patients underwent detailed clinical, biological, and paraclinical assessments, including evaluation of HRV parameters and echocardiographic measurements. The analysis of RR variability in both time and frequency domains indicates that the negative prognosis of patients with AMI is associated with an overall imbalance in the neuro-vegetative system. The HRV parameters were acquired using continuous 24 h electrocardiogram (ECG) monitoring at a baseline, after 1 month, and 6 months. Results: Our analysis reveals correlations between alterations in HRV parameters and the increased risk of adverse events and mortality after AMI. The study found a significant improvement in HRV parameters over time, indicating better autonomic regulation post-AMI. The standard deviation of all RR intervals (SDNN) increased significantly from baseline (median 75.3 ms, IQR 48.2-100) to 1 month (median 87 ms, IQR 55.7-111) and further to 6 months (median 94.2 ms, IQR 67.6-118) (p < 0.001 for both comparisons). The root mean square of successive difference of RR (RMSSD) also showed significant increases at each time point, from baseline (median 27 ms, IQR 22-33) to 1 month (median 30.5 ms, IQR 27-38) and from 1 month to 6 months (median 35 ms, IQR 30-42) (p < 0.001 for all comparisons), indicating enhanced parasympathetic activity. Moreover, changes in HRV parameters have been associated with impaired left ventricle ejection fraction (LVEF) and global longitudinal strain (GLS), indicating a relationship between autonomic dysfunction and myocardial deformation. GLS values improved from a baseline median of -11% (IQR 5%) to -13% (IQR 4%) at 6 months (p < 0.001), reflecting better myocardial function. Conclusions: HRV parameters and cardiac performance analysis, especially using GLS, offer a solid framework for evaluating recovery and predicting adverse outcomes post-MI.

Surface-enhanced Raman spectroscopy (SERS) for the diagnosis of acute myocardial infarction (AMI) using blood serum samples

Acute myocardial infarction (AMI) is a serious medical condition generally known as heart attack, which is caused by the decreased or completely blocked blood flow to a part of the heart muscle. It is a significant cause of both mortality and morbidity throughout the world. Cardiac troponin-I (cTnI) is an important biomarker at different stages of AMI and is one of the most specific and widely used cardiac skeletal muscle proteins. Delays in medical treatment and inaccurate diagnosis might be the main cause of death of AMI patients. To overcome the death rate of AMI patients, early diagnosis of this disease is crucial. In the current study, surface-enhanced Raman spectroscopy (SERS) is employed for the characterization and diagnosis of this disease using blood serum samples from 49 clinically confirmed acute myocardial infarction (AMI) patients and 17 healthy persons. Silver nanoparticles (AgNPs) are used as the SERS substrate for the recognition of characteristic SERS spectral features, differentiating between healthy and AMI-positive samples. The acute myocardial infarction-positive blood serum samples reveal remarkable differences in spectral intensities at 534, 697, 744, 835, 927, 941, 988, 1221, 1303, 1403, 1481, 1541, 1588 and 1694 cm-1. For the differentiation and quantitative analysis of the SERS spectra, multivariate chemometric tools (including principal component analysis (PCA) and partial least squares regression (PLSR)) are employed. A PLSR model established on the basis of differentiating the SERS spectral features is found to be helpful in the prediction of the levels of cardiac troponin-I (cTnI) in the blood serum samples with the root mean square error of calibration (RMSEC) value of 2.98 ng mL-1 and root mean square errors of prediction (RMSEP) value of 3.98 ng mL-1 for S7.

Examining the influence of anxiety and depression on medication adherence among patients diagnosed with acute myocardial infarction

BACKGROUND

Effective medication adherence is vital for managing acute myocardial infarction (AMI) and enhancing patient well-being. This study aimed to evaluate medication adherence levels and associated factors among AMI patients using standardized assessment tools.

METHODS

Employing a cross-sectional descriptive design, the study involved 210 patients diagnosed with acute myocardial infarction. Participants completed the General Medication Adherence Scale (GMAS), Hospital Anxiety and Depression Scale (HADS), and provided socio-demographic details.

RESULTS

The study revealed partial adherence to medications among AMI patients, with mean scores of 24.89 (± 3.64) out of 33. Notably, good adherence was observed in non-adherence due to patient behavior (mean ± SD = 11.8 ± 2.3 out of 15) and additional disease burden (mean ± SD = 8.65 ± 2.21 out of 12), while partial adherence was noted in non-adherence due to financial constraints (mean ± SD = 4.44 ± 1.34 out of 6). Patients reported mild anxiety (mean ± SD = 8.38 ± 2.81) and no depressive symptoms (mean ± SD = 7.43 ± 2.42). Multiple linear regression analysis indicated that employed status, younger age, shorter duration of MI, lower anxiety, and depression levels were associated with higher medication adherence. However, factors such as monthly income, gender, educational level, and marital status did not predict medication adherence.

CONCLUSION

The study highlights the significance of addressing anxiety and depression levels and considering socio-demographic factors when designing interventions to enhance medication adherence among AMI patients. Further research is needed to explore additional determinants of medication adherence and develop tailored interventions to improve patient outcomes post-AMI.

Acute Myocardial Injury in Spontaneous Intracerebral Hemorrhage: A Secondary Observational Analysis of the FAST Trial

BACKGROUND

Acute myocardial injury is associated with poor outcomes in patients with acute ischemic stroke, but its prognostic significance in patients with spontaneous intracerebral hemorrhage remains unclear. We investigated whether acute myocardial injury and the direction of the cardiac troponin I (cTnI) change (rising versus falling) affect post-intracerebral hemorrhage outcomes.

METHODS AND RESULTS

We re-analyzed the FAST (Factor-Seven-for-Acute-Hemorrhagic-Stroke) trial. Acute myocardial injury was defined as at least 1 cTnI value above the upper reference limit with a rise/fall of >20%. Logistic regression tested for associations (1) between acute myocardial injury (presence versus absence) and poor outcome (modified Rankin Scale 4-6) and mortality at 15 and 90 days; (2) among 3 groups (rising versus falling versus no acute myocardial injury) and outcomes. Among the 841 FAST participants, 785 patients were included. Acute myocardial injury was detected in 29% (n=227); 170 had rising cTnI. At 15 and 90 days, respectively, those with acute myocardial injury had higher odds of poor outcome (adjusted odds ratio) ([aOR] 2.3 [95% CI, 1.3-3.9]); and adjusted odds ratio 2.5 [95% CI, 1.6-3.9];, and higher odds of mortality (adjusted odds ratio 2.4 [95% CI, 1.4-4.3]; and adjusted odds ratio 2.2 [CI, 1.3-3.6]) than patients without. There was no interaction between FAST group assignment and myocardial injury, and associations between myocardial injury and outcomes were consistent across group assignments. Rising cTnI was associated with the highest risk of poor outcomes and mortality.

CONCLUSIONS

In this secondary analysis of the FAST trial, acute myocardial injury was common and associated with poor outcomes. The direction of the cTnI change might provide additional risk stratification after intracerebral hemorrhage.

Evaluation of the analytical and clinical performance of a high-sensitivity troponin I point-of-care assay in the Mersey Acute Coronary Syndrome Rule Out Study (MACROS-2)

OBJECTIVES

The objective of this study is to evaluate the analytical and diagnostic performance of a high-sensitivity point-of-care (POC) cardiac troponin I assay, the Quidel TriageTrue™ (QuidelOrtho Inc, San Diego, USA), compared to central laboratory testing (CLT) in accelerated diagnostic protocols (ADP) in real time in a clinical environment.

METHODS

In a nested sub-study of a pragmatic randomised control trial, consecutive patients with suspected acute coronary syndrome (ACS) and chest pain <12 h duration were randomised to the ESC 0/1 and 0/3-h ADP. Subjects underwent sampling for Quidel TriageTrue POC hs-TnI whole blood and plasma, CLT hs-TnT Roche Elecsys and a validated, NICE approved CLT High sensitivity cardiac troponin I (hs-TnI) (Siemens Attellica) at each time point. Assay imprecision was assessed by repeat analysis of whole blood samples at three levels (low, near 10 % CV 5-10 ng/L, medium, approximating 99th percentile 15-25 ng/L and high, 3-5 times the 99th percentile, 60-100 ng/L). Final diagnosis was adjudicated at 6 weeks by Roche hs-TnT using the 4th universal definition of myocardial infarction (MI).

RESULTS

A total of 1,157 patients consented and had both investigational POC whole blood and plasma and central lab hs-cTn available. The median age was 59, 47.2 % were female and 15 % had suffered a previous MI. Assay imprecision of whole blood POC TriageTrue revealed 10 % CV at 8.6 ng/L (>50 % lower than 99th percentile [20.5 ng/L]) and a 20 % CV at 1.2 ng/L. Receiver operator characteristics (ROC) curves were computed for each assay against adjudicated index type 1 MI to study clinical performance. At all-time points there were excellent performance for whole blood POC TriageTrue: area under the curve (AUC) 0.97 [95 % CI 0.94-098], 0.98 [95 % CI 0.97-1.00] and 0.95 [95 % CI 0.92-0.98] at time 0, 1 and 3 h respectively. There was statistical equivalence for performance of whole blood and plasma POC TriageTrue hs-TnI and laboratory Siemens Atellica hs-TnI.

CONCLUSIONS

The whole blood POC TriageTrue hs-TnI assay demonstrates imprecision levels consistent with high sensitivity characteristics and has a clinical performance equivalent to an established, validated and NICE approved laboratory Siemens Atellica hs-TnI.

Clinical Analysis of Myocardial Injury in Highlanders with Pulmonary Hypertension

Background: Pulmonary hypertension (PH) is a prevalent adverse cardiovascular event at high-altitude environments. Prolonged exposure to high altitudes may result in myocardial injury, which is associated with poor clinical outcomes. This study aims to investigate the clinical characteristics of myocardial injury in patients with PH at high altitude. Methods: Consecutive patients admitted to a general tertiary hospital at the altitude of 3,650 m were selected into this retrospective study. Clinical and biochemical data were collected, as well as based on cardiac troponin I (cTnI) and echocardiography, patients were divided into myocardial injury group and non-myocardial injury group. Results: A total of 231 patients were enrolled, among whom 29 (12.6%) had myocardial injury. We found that body mass index, left ventricular end-diastolic dimension, and serum level of creatine kinase-MB (CK-MB) in myocardial injury group were significantly higher than non-myocardial injury group. Spearman correlation analysis revealed that cTnI has a significant positive correlation with CK-MB and lactic dehydrogenase instead of aspartate aminotransferase. A receiver operating characteristic curve was drawn to demonstrate that CK-MB could significantly predict the occurrence of myocardial injury with an area under the curve of 0.749, and a level of 3.035 (sensitivity = 59.3%, specificity = 90.5%) was optimal cutoff value. Conclusion: The incidence of myocardial injury in highlanders with PH is significant. CK-MB, as a convenient and efficient marker, has been found to be closely associated with cTnI and plays a predictive role in the occurrence of myocardial injury with PH in individuals exposed to high altitude.

Coronary sodium [18F]fluoride activity predicts outcomes post-CABG: a comparative evaluation with conventional metrics

PURPOSE

The value of preoperative multidisciplinary approach remains inadequately delineated in forecasting postoperative outcomes of patients undergoing coronary artery bypass grafting (CABG). Herein, we aimed to ascertain the efficacy of multi-modality cardiac imaging in predicting post-CABG cardiovascular outcomes.

METHODS

Patients with triple coronary artery disease underwent cardiac sodium [18F]fluoride ([18F]NaF) positron emission tomography/computed tomography (PET/CT), coronary angiography, and CT-based coronary artery calcium scoring before CABG. The maximum coronary [18F]NaF activity (target-to-blood ratio [TBR]max) and the global coronary [18F]NaF activity (TBRglobal) was determined. The primary endpoint was perioperative myocardial infarction (PMI) within 7-day post-CABG. Secondary endpoint included major adverse cardiac and cerebrovascular events (MACCEs) and recurrent angina.

RESULTS

This prospective observational study examined 101 patients for a median of 40 months (interquartile range: 19-47 months). Both TBRmax (odds ratio [OR] = 1.445; p = 0.011) and TBRglobal (OR = 1.797; P = 0.018) were significant predictors of PMI. TBRmax>3.0 (area under the curve [AUC], 0.65; sensitivity, 75.0%; specificity, 56.8%; p = 0.036) increased PMI risk by 3.661-fold, independent of external confounders. Kaplan-Meier test revealed a decrease in MACCE survival rate concomitant with an escalating TBRmax. TBRmax>3.6 (AUC, 0.70; sensitivity, 76.9%; specificity, 73.9%; p = 0.017) increased MACCEs risk by 5.520-fold. Both TBRmax (hazard ratio [HR], 1.298; p = 0.004) and TBRglobal (HR = 1.335; p = 0.011) were significantly correlated with recurrent angina. No significant associations were found between CAC and SYNTAX scores and between PMI occurrence and long-term MACCEs.

CONCLUSION

Quantification of coronary microcalcification activity via [18F]NaF PET displayed a strong ability to predict early and long-term post-CABG cardiovascular outcomes, thereby outperforming conventional metrics of coronary macrocalcification burden and stenosis severity.

TRIAL REGISTRATION

The trial was registered with the Chinese Clinical Trial Committee (number: ChiCTR1900022527; URL: www.chictr.org.cn/showproj.html?proj=37933 ).

High-sensitivity troponin T for detection of culprit lesions in patients with out-of-hospital cardiac arrest

BACKGROUND

Patients with an out-of-hospital cardiac arrest (OHCA) often undergo coronary angiography, although a culprit lesion is found in only 30%-40% of patients. The aim of this study was to investigate high-sensitivity troponin T (hsTnT) levels in post cardiac arrest patients with and without coronary culprit lesions; factors affecting hsTnT levels after return of spontaneous circulation (ROSC); and the diagnostic ability of hsTnT in identifying patients with culprit lesions. We hypothesized that peak hsTnT levels were higher during the initial 48 h after cardiac arrest in patients with a coronary culprit lesion.

METHODS

This was a retrospective observational study, which included patients admitted to the Intensive Care Unit after an OHCA and who received a coronary angiography. Peak values and dynamic changes in hsTnT were analyzed in relation to the presence of a culprit lesion at coronary angiography.

RESULTS

A total of 238 patients were studied, of whom 140 had a culprit lesion. HsTnT levels during the initial 48 h were higher in patients with culprit lesions, longer time to ROSC and an unwitnessed cardiac arrest. At 6 to 12 h after ROSC, a hsTnT cut-off level of 1690 ng/L had a sensitivity of 64% and specificity of 84% to identify a culprit lesion. In patients without ST-elevations, hsTnT measured between 6 and 12 h after ROSC had a specificity above 90%, with a sensitivity of 46%.

CONCLUSION

HsTnT levels after cardiac arrest are higher in patients with coronary culprit lesions. Presence of a culprit lesion, witnessed status and the duration of CPR are important factors affecting hsTnT levels. Repeated measurement of hsTnT within the first 12 h after admission improved diagnostic accuracy but the value of hsTnT as a predictor of culprit lesions early after OHCA is limited.

Association of Cardiac Troponin T With Coronary Atherosclerosis in Asymptomatic Primary Prevention People With HIV

Background

Coronary plaque is common among people with HIV (PWH) with low-to-moderate traditional atherosclerotic cardiovascular disease (ASCVD) risk.

Objectives

The purpose of this study was to determine the association of high-sensitivity cardiac troponin T (hs-cTnT) levels with coronary plaque characteristics and evaluate if hs-cTnT improves identification of these features beyond traditional ASCVD risk factors among PWH.

Methods

Among PWH receiving stable antiretroviral therapy with low-to-moderate ASCVD risk and no known history of ASCVD, hs-cTnT levels and measures of plaque by coronary computed tomography angiography were assessed. Primary outcomes included the association of hs-cTnT level with the presence of any plaque, vulnerable plaque, coronary artery calcium (CAC) score, and Leaman score. Assessment of model discrimination of hs-cTnT for plaque characteristics was also performed.

Results

The cohort included 708 U.S. participants with a mean age of 51 ± 6 years, 119 (17%) females, a median ASCVD risk score of 4.4% (Q1-Q3: 2.5%-6.6%), and a median hs-cTnT level of 6.7 ng/L (detectable level ≥6 ng/L in 61%). Any plaque was present in 341 (48%), vulnerable plaque in 155 (22%), CAC>100 in 68 (10%), and a Leaman score >5 in 105 (15%). After adjustment for ASCVD risk score, participants with hs-cTnT >9.6 ng/L (highest category) versus an undetectable level (<6 ng/L) had a greater relative risk for any plaque (1.37, 95% CI: 1.12-1.67), vulnerable plaque (1.47, 95% CI: 1.16-1.87), CAC>100 (2.58, 95% CI: 1.37-4.83), and Leaman score >5 (2.13, 95% CI: 1.32-3.46). The addition of hs-cTnT level modestly improved the discrimination of ASCVD risk score to identify critical plaque features.

Conclusions

In PWH without known ASCVD, hs-cTnT levels were strongly associated with and improved prediction of subclinical coronary plaque. (Evaluating the Use of Pitavastatin to Reduce the Risk of Cardiovascular Disease in HIV-Infected Adults [REPRIEVE]; NCT02344290).

IL-4-Induced Gene 1: A Potential Player in Myocardial Infarction

Myocardial infarction (MI), a severe outcome of cardiovascular disease, poses a serious threat to human health. Uncontrolled inflammation and excessive cardiomyocyte death, following an infarction event, significantly contribute to both the mortality rate and complications associated with MI. The protein IL-4-induced gene 1 (IL4I1 or FIG1) serves as a natural inhibitor of innate and adaptive immunity, playing a crucial role in CD4+ T cell differentiation, macrophage polarization, and ferroptosis inhibition. Previous studies have linked IL4I1 to acute MI. This review summarizes evidence from both basic and clinical research, highlighting IL4I1 as a critical immunoregulatory enzyme that not only regulates inflammatory responses, but also potentially mitigates MI-induced damage.

The association between myocardial early systolic lengthening and high risk angiographic territory involvement in patients with non-ST-segment elevation myocardial infarction

BACKGROUND

Non-ST-segment elevation myocardial infarction (NSTEMI) is more common than ST-segment elevation myocardial infarction (STEMI), consisting of 60-70% of myocardial infarctions. When left ventricular (LV) pressure increases during early systole, regionally ischaemic myocardium with a reduced active force exhibit stretching. The aim of this study was to evaluate the role of this parameter in determining high risk angiographic territory involvement in NSTEMI patients.

RESULTS

This study was a descriptive correlational research that was conducted on 96 patients with NSTEMI and a left ventricular ejection fraction ≥ 50% who underwent coronary angiography (CAG). Patients were divided into two groups based on having or not having high risk angiographic territory involvement in CAG. All patients underwent a transthoracic echocardiography during the first day of hospitalization and early systolic lengthening (ESL), duration of ESL (DESL), left ventricular global longitudinal strain (LVGLS), pulsed-wave Doppler-derived transmitral early (E wave) and late (A wave) diastolic velocities, and tissue-Doppler-derived mitral annular early diastolic (e') and peak systolic (s') velocities were determined. The results of this study showed DESL, DESLLAD, and DESLLCX were longer in high risk angiographic territory group than other one (P value 0.016, 0.044, and 0.04, respectively). The logistic regression analysis showed among different variables, only age and ESLLAD had an independent association with high risk angiographic territory involvement (P = 0.01, odds ratio [OR] 1.09, 95% CI 1.021-1.164, and P = 0.024, odds ratio [OR] 1.243, 95% CI 1.029-1.50, respectively).

CONCLUSIONS

Assessment of myocardial ESLLAD by speckle-tracking echocardiography may be helpful in predicting high risk angiographic territory involvement in patients with NSTEMI. Indeed, a higher value can be considered as a high risk parameter which may show benefit of an early invasive strategy versus a conservative approach.

OCT-based comparative evaluation of culprit lesion morphology in very young versus older adult patients with STEMI

Background

The clinical and pathophysiological characteristics of coronary artery disease in very young adults are poorly described.

Aims

Using optical coherence tomography (OCT), we compared culprit lesion morphology in very young adult patients (≤35 years) versus older adult patients (>60 years) with ST-segment elevation myocardial infarction (STEMI).

Methods

Culprit lesion morphology was classified as plaque rupture, plaque erosion, or calcified nodule. Thrombus age was subclassified into acute (intraluminal thrombus with surface irregularity) or subacute (mostly mural thrombus with a smooth surface).

Results

A total of 61 patients who underwent thrombolysis within 24 hours from symptom onset were included, with 38 (59.7%) subjects ≤35 years and 23 (40.3%) subjects >60 years of age. As an underlying mechanism of STEMI thrombosis, plaque erosion was more common in very young patients (52.6% vs 21.7%; p=0.02) while plaque rupture was more common in elderly patients (65.2% vs 36.8%; p=0.03). Acute or subacute thrombus was identified in 68.9% (42/61) of patients, with red thrombus being more frequent in very young patients. In the entire patient cohort, acute thrombus was more frequent in plaque rupture compared with plaque erosion (62.0% vs 28.0%; p=0.01), whereas subacute thrombus was more common in plaque erosion versus plaque rupture (52.0% vs 10.3%; p=0.0008).

Conclusions

OCT showed that plaque erosion and plaque rupture were the most common underlying STEMI mechanisms in very young patients and older patients, respectively, and that subjects with plaque erosion had greater evidence of subacute thrombus.

Coronary Microvascular Disease Registry (CMDR): Study design and rationale

BACKGROUND

Coronary microvascular dysfunction (CMD) is a prevalent condition among patients with cardiovascular risk factors, leading to a reduced quality of life and an increased risk of major adverse cardiovascular events. Novel invasive techniques have emerged to more accurately diagnose CMD. However, CMD's natural history remains poorly understood due to limited data. To address this knowledge gap, the Coronary Microvascular Disease Registry (CMDR) was established with the primary aim of standardizing comprehensive coronary functional testing and understanding of CMD.

DESIGN

CMDR is a prospective, multicenter registry enrolling an unlimited number of consecutive subjects who undergo comprehensive invasive hemodynamic assessment of the entire coronary arterial vasculature. Patients undergoing acetylcholine provocation test for coronary vasospasm will also be included. Follow-up assessments will be conducted at 30 days and annually for up to 5 years. The primary endpoint is Canadian Cardiovascular Society angina grade over time. Secondary endpoints, including all-cause mortality, cardiovascular death, acute myocardial infarction, stroke, hospitalizations, medication changes, and subsequent coronary interventions, will be analyzed to establish long-term safety and clinical outcomes in patients undergoing invasive CMD assessment.

SUMMARY

CMDR aims to characterize the clinical and physiologic profile of patients undergoing comprehensive invasive coronary functional testing, simultaneously providing crucial longitudinal information on the natural history and outcomes of these patients. This will shed light on CMD's course and clinical implications, which, in turn, holds the potential to significantly improve diagnostic and treatment strategies for CMD patients, ultimately leading to the enhancement of their overall prognosis and quality of life.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov, NCT05960474.

Kidney function-specific cut-off values of high-sensitivity cardiac troponin T for the diagnosis of acute myocardial infarction

Background

The diagnosis of acute myocardial infarction (AMI) using high-sensitivity cardiac troponin T (hs-cTnT) remains challenging in patients with kidney dysfunction.

Methods

In this large, multicenter cohort study, a total of 20 912 adults who underwent coronary angiography were included. Kidney function-specific cut-off values of hs-cTnT were determined to improve the specificity without sacrificing sensitivity, as compared with that using traditional cut-off value (14 ng/L) in the normal kidney function group. The diagnostic accuracy of the novel cut-off values was validated in an independent validation cohort.

Results

In the derivation cohort (n = 12 900), 3247 patients had an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. Even in the absence of AMI, 50.2% of participants with eGFR <60 mL/min/1.73 m2 had a hs-cTnT concentration ≥14 ng/L. Using 14 ng/L as the threshold of hs-cTnT for diagnosing AMI led to a significantly reduced specificity and positive predictive value in patients with kidney dysfunction, as compared with that in patients with normal kidney function. The kidney function-specific cut-off values were determined as 14, 18 and 48 ng/L for patients with eGFR >60, 60-30 and <30 mL/min/1.73 m2, respectively. Using the novel cut-off values, the specificities for diagnosing AMI in participants with different levels of kidney dysfunction were remarkably improved (from 9.1%-52.7% to 52.8-63.0%), without compromising sensitivity (96.6%-97.9%). Similar improvement of diagnostic accuracy was observed in the validation cohort (n = 8012).

Conclusions

The kidney function-specific cut-off values of hs-cTnT may help clinicians to accurately diagnose AMI in patients with kidney dysfunction and avoid the potential overtreatment in practice.

High-sensitive troponin T, suPAR and Beta-2-microglobulin changes in concentration during hemodialysis

Hemodialysis (HD) patients are at high risk of cardiovascular disease and death. Reliable biomarkers for risk stratification and detection of acute myocardial infarction (AMI) are therefore pivotal. Cardiac troponins (cTn) are the preferred biomarkers for AMI. It remains unclear, if cTn concentrations changes as a consequence of HD treatment itself during dialysis. In this study, cTn was compared with soluble urokinase plasminogen activator receptor (suPAR) and Beta-2-microglobulin (B2M). We performed a prospective study including 17 HD patients measuring high-sensitive cardiac troponin t (hs-cTnT), suPAR and B2M before and after a dialysis session and verified the results in a random subgroup of eight patients from the group by repeating their measurements before and after a dialysis session 15 weeks later. Biomarker concentrations after dialysis were adjusted according to hemodilution or concentration according to the hemoglobin concentration. The average hs-cTnT concentration decreased significantly by -9.9% after dialysis (95% CI: -13.6% to -6.2%). The average (paired) difference were - 6.7 ng/L (p = 0.0104) after dialysis comparing 25 HD treatment occasions. SuPAR was not significantly influenced by dialysis. B2M decreased by -58% after HD as an expected result from the molecular size of the biomarker. The hs-cTnT in average decreased by -9.9% after dialysis. This is a diagnostic challenge since the current guidelines suggest a 20% change in hs-cTnT in patients with acute myocardial infarction. Larger prospective studies investigating the different factors influencing hs-cTnT after HD are warranted. Adjusting biomarker concentrations according to hemodilution or concentration using the hemoglobin concentration, should be considered in future studies to determine more exact changes in concentrations of cTnT and other relevant biomarkers.

Establishment and validation of a nomogram model containing a triglyceride-glucose index and neutrophil-to-high-density lipoprotein ratio for predicting major adverse cardiac events in patients with ST-segment elevation myocardial infarction

OBJECTIVE

To analyze the predictive value of the triglyceride-glucose (TyG) index and neutrophil-to-high-density lipoprotein ratio (NHR) for in-hospital major adverse cardiac events (MACE) after percutaneous coronary intervention (PCI) in patients with acute ST-segment elevation myocardial infarction (STEMI), and to establish an associated nomogram model.

METHODS

In this retrospective study, we collected data from consecutive STEMI patients who underwent PCI from October 2019 to June 2023 at the Second People's Hospital of Hefei and the Second Affiliated Hospital of Anhui Medical University, as training and validation sets. Stepwise regression and multivariate logistic regression analysis were performed to screen independent risk factors, and a nomogram model was constructed and evaluated for its predictive efficacy.

RESULTS

The TyG index, NHR, urea, diastolic blood pressure, hypertension, and left ventricular ejection fraction were independent risk factors for in-hospital MACE after PCI, and were used to construct the nomogram model. The C-index of the training and validation sets were 0.799 and 0.753, respectively, suggesting that the model discriminated well. Calibration and clinical decision curves also demonstrated that the nomogram model had good predictive power.

CONCLUSION

In STEMI patients, increased TyG index and NHR were closely related to the occurrence of in-hospital MACE after PCI. Our constructed nomogram model has some value for predicting the occurrence of in-hospital MACE in STEMI patients.

Translational molecular imaging: Thrombosis imaging with positron emission tomography

A key focus of cardiovascular medicine is the detection, treatment, and prevention of disease, with a move towards more personalized and patient-centred treatments. To achieve this goal, novel imaging approaches that allow for early and accurate detection of disease and risk stratification are needed. At present, the diagnosis, monitoring, and prognostication of thrombotic cardiovascular diseases are based on imaging techniques that measure changes in structural anatomy and biological function. Molecular imaging is emerging as a new tool for the non-invasive detection of biological processes, such as thrombosis, that can improve identification of these events above and beyond current imaging modalities. At the forefront of these evolving techniques is the use of high-sensitivity radiotracers in conjunction with positron emission tomography imaging that could revolutionise current diagnostic paradigms by improving our understanding of the role and origin of thrombosis in a range of cardiovascular diseases.

Predictability of noninvasive liver fibrosis score for cardiac events in patients with nonalcoholic fatty liver disease

BACKGROUND AND AIMS

Patients with nonalcoholic fatty liver disease (NAFLD) have a higher risk of cardiac events. However, although the severity of liver fibrosis is related to worsening prognosis in patients with NAFLD, it is unclear whether the noninvasive liver fibrosis score has a predictive value for cardiac events.

METHODS AND RESULTS

We evaluated 4071 patients with NAFLD diagnosed using ultrasonography. Liver fibrosis was assessed and divided into three groups based on the Fibrosis-4 (FIB4) index and NAFLD fibrosis score (NFS). The primary outcome of this study was major adverse cardiac events (MACE), including cardiac death, nonfatal myocardial infarction, and revascularization due to coronary artery disease. The median age of the evaluated patients was 61 (52-69) years, and 2201 (54.1%) were male. During the median follow-up period of 6.6 years, 179 (4.4%) patients experienced MACE. Kaplan-Meier survival analysis demonstrated that MACE increased progressively with the FIB4 index (log-rank, p < 0.001) and NFS (log-rank, p < 0.001). Multivariable analysis showed that the higher the FIB4 index, the higher the risk for MACE (low group as reference vs. intermediate group, hazard ratio [HR]: 1.860 [95% confidence interval (CI), 1.326-2.610; p < 0.001]; vs. high group, HR:3.325 [95% CI, 2.017-5.479; p < 0.001]), as well as NFS (low NFS group as reference vs. intermediate group, HR: 1.938 [95% CI, 1.391-2.699; p < 0.001]; vs. high group, HR: 3.492 [95% CI, 1.997-6.105; p < 0.001]).

CONCLUSIONS

The FIB4 index and NFS are associated with the probability of MACE in patients with NAFLD.

CLINICAL TRIALS

The study design was approved by the ethics review board of Ogaki Municipal Hospital (approval number: 20221124-12, registration date: November 28th, 2022). https://www.ogaki-mh.jp/chiken/kenkyu.html.

The Impact of Body Mass Index on the Mortality of Myocardial Infarction Patients With Nonobstructive Coronary Arteries

OBJECTIVES

Myocardial infarction without significant stenosis or occlusion of the coronary arteries carries a high risk of recurrent major adverse cardiovascular events and poor prognosis. This study aimed to investigate the association between body mass index and outcomes in patients with a suspected myocardial infarction with nonobstructive coronary artery disease (MINOCA).

METHODS

Patients were recruited at Bergmannsheil University Hospital from January 2010 to April 2021. The primary outcomes were in-hospital and long-term mortality. Secondary outcomes consisted of adverse events during hospitalization and during follow-up.

RESULTS

A total of 373 patients were included in the study, with a mean follow-up time of 6.2 years. The patients were divided into different BMI groups: < 25 kg/m² (n = 121), 25-30 kg/m² (n = 140), and > 30 kg/m² (n = 112). In-hospital mortality was 1.7% versus 2.1% versus 4.5% (p = 0.368). However, long-term mortality tended to be higher in the < 25 kg/m² group compared to the 25-30 and > 30 kg/m² groups (log-rank p = 0.067). Subgroup analysis using Kaplan-Meier analysis showed a higher rate of cardiac cause of death in the < 25 kg/m² group compared to the 25-30 and > 30 kg/m² groups: 5.7% versus 1.1% versus 0.0% (log-rank p = 0.042). No significant differences were observed in other adverse events between the different BMI groups during hospitalization and long-term follow-up.

CONCLUSIONS

Patients with a BMI < 25 kg/m² who experience a suspected myocardial infarction without significant coronary artery disease may have higher all-cause mortality and cardiovascular cause of death. However, further data are needed to confirm these findings.

Prognostic Implications of Coronary Artery Sclerosis in Troponin-Positive Patients with Non-Obstructive Coronary Arteries

INTRODUCTION

Coronary sclerosis is a risk factor for the progression to obstructive coronary artery disease (CAD). However, understanding its impact on the outcomes of patients with myocardial infarction and non-obstructive coronary arteries is limited. This study aimed to explore the prognostic influence of coronary sclerosis on in- and out-of-hospital events in troponin-positive patients with non-obstructive coronary arteries.

METHODS

This study was a retrospective cohort analysis based on prospectively collected data. A total of 24,775 patients who underwent coronary angiography from 2010 to 2021 in a German university hospital were screened, resulting in a final study cohort of 373 troponin-positive patients with non-obstructive coronary arteries and a follow-up period of 6.2 ± 3.1 years. Coronary sclerosis was defined as coronary plaques without angiographically detectable stenotic lesions of 50% or more in the large epicardial coronary arteries. The primary study endpoint was the occurrence of in-hospital events. Secondary endpoints included events during follow-up.

RESULTS

Patients with coronary sclerosis were significantly older (70 ± 12 vs. 58 ± 16 years, p < 0.001), had ST-segment elevation less frequently on electrocardiogram (9.4% vs. 18.7%, p = 0.013), and suffered more often from diabetes mellitus (23.3% vs. 13.1%, p = 0.009), arterial hypertension (79.6% vs. 59.8%, p < 0.001), chronic obstructive pulmonary disease (17.1% vs. 9.4%, p = 0.028), chronic kidney disease (22.2% vs. 8.4%, p < 0.001), atrial fibrillation (19.8% vs. 12.2%, p = 0.045), and valvular diseases than patients without CAD. Patients with coronary sclerosis were more likely to receive medication for primary/secondary prevention on admission and at discharge. The incidence of in- and out-of-hospital events was significantly higher in patients with coronary sclerosis (in-hospital: 42.8% vs. 29.9%, p = 0.010; out-of-hospital: 46.0% vs. 26.1%, p < 0.001). Mortality rates tended to be higher in the coronary sclerosis group (29.4% vs. 20.0%, p = 0.066).

CONCLUSION

Patients diagnosed with coronary sclerosis presented a higher incidence of comorbidities and increased medication use, and experienced higher rates of both in-hospital and out-of-hospital events, primarily due to the clustering of cardiovascular risk factors.

Prognostic Value of PRECİSE DAPT Score on Short- and Long-Term Outcomes in MINOCA Patients with Acute Coronary Syndrome

BACKGROUND

Myocardial infarction with non-obstructive coronary arteries (MINOCA) constitutes a significant subset of acute myocardial infarctions (AMI) with uncertain prognostic markers. Early risk assessment is crucial to identify MINOCA patients at risk of adverse outcomes.

OBJECTIVES

This study aimed to evaluate the predictive capacity of the PRECISE-DAPT score in assessing short- and long-term prognoses in MINOCA patients presenting with ST-segment elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (NSTEMI).

METHODS

Among 741 MINOCA patients, the PRECISE-DAPT score was computed to analyze its association with in-hospital and follow-up major adverse cardiovascular events (MACE). Parameters showing significance in MACE (+) groups underwent statistical analysis: univariate logistic regression for in-hospital events and univariate Cox regression for follow-up events. For statistical significance, a predefined level of α = 0.05 was adopted. Parameters demonstrating significance proceeded to multiple logistic regression for in-hospital events and multivariate Cox regression for follow-up events.

RESULTS

In-hospital MACE occurred in 4.1% of patients, while 58% experienced follow-up MACE. Hemoglobin levels and the PRECISE-DAPT Score were identified as independent parameters for in-hospital MACE. Furthermore, ejection fraction (EF%) and the PRECISE-DAPT Score emerged as independent predictors of follow-up MACE.

CONCLUSIONS

The study revealed that a higher PRECISE-DAPT score was significantly associated with increased risks of both in-hospital and long-term major adverse cardiovascular events in MINOCA patients presenting with acute coronary syndrome (ACS), underscoring the score's potential in risk stratification for this patient cohort.

BACKGROUND

_ PRECISE-DAPT score predicts MACE risk in MINOCA patients.

BACKGROUND

_ Hemoglobin level and PRECISE-DAPT score predict in-hospital MACE.

BACKGROUND

_ Ejection fraction and PRECISE-DAPT score predict long-term MACE.

Long-term outcomes of cardiogenic shock and cardiac arrest complicating ST-elevation myocardial infarction according to timing of occurrence

Aims

Cardiogenic shock (CS) and cardiac arrest (CA) are serious complications in ST-elevation myocardial infarction (STEMI) patients, with lack of long-term data according to their timing of occurrence. This study sought to determine the incidence and relationship between the timing of occurrence and prognostic impact of CS and CA complicating STEMI in the long-term follow-up.

Methods and results

We conducted a retrospective analysis of consecutive STEMI patients treated between 2004 and 2017. Patients were divided into four groups based on the occurrence of neither CA nor CS, CA only, CS only, and both CA and CS (CA-CS-, CA+, CS+, and CA+CS+, respectively). Adjusted Cox regression analysis was used to assess the independent association between the CS and CA categories and mortality. A total of 1603 STEMI patients were followed for a median of 3.6 years. CA and CS occurred in the 12.2% and 15.9% of patients, and both impacted long-term mortality [adjusted hazard ratio (HR) = 2.59, 95% confidence interval (CI): 1.53-4.41, P < 0.001; HR = 3.16, 95% CI: 2.21-4.53, P < 0.001, respectively). CA+CS+ occurred in 7.3%, with the strongest association with higher mortality (adjusted HR = 5.36; 95% CI: 3.80-7.55, P < 0.001). Using flexible parametric models with B-splines, the increased mortality was restricted to the first ∼10 months. In addition, overall mortality rates were higher at all timings (all with P < 0.001), except for CA during initial cardiac catheterization (P < 0.183).

Conclusion

CS and CA complicating patients presenting with STEMI were associated with higher long-term mortality rate, especially in the first 10 months. Both CS+ and CA+ at any timeframe impacted outcomes, except for CA+ during the initial cardiac catheterization, although this will have to be confirmed in larger future studies, given the relatively small number of patients.

Coronary artery thromboembolism as a cause of myocardial infarction with non-obstructive coronary arteries (MINOCA)

Acute myocardial infarction (AMI) usually represents the clinical manifestation of atherothrombotic coronary artery disease (CAD) resulting from atherosclerotic plaque rupture. However, there are cases in which coronary angiography or coronary computed tomography angiography reveals patients with acute coronary syndrome with non-obstructive CAD. This clinical entity is defined as myocardial infarction with non-obstructive coronary arteries (MINOCA) and often considered as a clinical dynamic working diagnosis that needs further investigations for the establishment of a final etiologic diagnosis. The main causes of a MINOCA working diagnosis include atherosclerotic, non-atherosclerotic (vessel-related and non-vessel-related), and thromboembolic causes This literature review aimed to investigate the major thromboembolic causes in patients presenting with MINOCA regarding their etiology and pathophysiologic mechanisms, as well as diagnostic and treatment methods.

Discontinuation of β-blocker therapy in stabilised patients after acute myocardial infarction (SMART-DECISION): rationale and design of the randomised controlled trial

INTRODUCTION

There is a lack of evidence to support the effectiveness of prolonged β-blocker therapy after stabilisation of patients with acute myocardial infarction (AMI) without heart failure (HF) or left ventricular systolic dysfunction.

METHODS AND ANALYSIS

The SMart Angioplasty Research Team: DEcision on Medical Therapy in Patients with Coronary Artery DIsease or Structural Heart Disease Undergoing InterventiON (SMART-DECISION) trial is a multicentre, prospective, open-label, randomised, non-inferiority trial designed to determine whether discontinuing β-blocker therapy after ≥1 year of maintenance in stabilised patients after AMI is non-inferior to continuing it. Patients eligible for participation are those without HF or left ventricular systolic dysfunction (ejection fraction >40%) who have been continuing β-blocker therapy for ≥1 year after AMI. A total of 2540 patients will be randomised 1:1 to continuation of β-blocker therapy or not. Randomisation will be stratified according to the type of AMI (ie, ST-segment-elevation MI or non-ST-segment-elevation MI), type of β-blocker (carvedilol, bisoprolol, nebivolol or other) and participating centre. The primary study endpoint is a composite of all-cause death, MI and hospitalisation for HF over a median follow-up period of 3.5 years (minimum, 2.5 years; maximum, 4.5 years). Adverse effects related to β-blocker therapy, the occurrence of atrial fibrillation, medical costs and Patient-reported Outcomes Measurement Information system-29 questionnaire responses will also be collected as secondary endpoints.

ETHICS AND DISSEMINATION

Ethics approval for this study was granted by the Institutional Review Board of Samsung Medical Center (no. 2020-10-176). Informed consent is obtained from every participant before randomisation. The results of this study will be submitted for publication in international peer-reviewed journals and the key findings will be presented at international scientific conferences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov, NCT04769362.

Comparison of angiography-guided vs. intra-vascular imaging-guiding percutaneous coronary intervention of acute myocardial infarction: a real world clinical practice

Background

The role of routine intravascular imaging in percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) remains unclear. This study evaluated the clinical outcomes of PCI guided by different imaging modalities in AMI patients.

Materials and methods

Data from AMI patients who had undergone PCI between 2012 and 2022 were analyzed. The mean follow-up was 12.9 ± 1.73 months. The imaging modality-either intravascular ultrasound (IVUS), optical coherence tomography (OCT), or angiography alone-was selected at the operator's discretion. The primary endpoint was major adverse cardiac events (MACEs), including cardiovascular (CV) death, myocardial infarction (MI), target vessel revascularization.

Results

Of the 1,304 PCIs performed, 47.5% (n = 620) were guided by angiography alone, 37.0% (n = 483) by IVUS, and 15.4% (n = 201) by OCT. PCI guided by intravascular imaging modalities was associated with lower 1-year rates of MI (1.3%, P = 0.001) and MACE (5.2%, P = 0.036). OCT-guided PCI was linked to lower rates of 1-year CV death (IVUS vs. OCT: 6.2% vs. 1.5%, P = 0.016) and MACE (IVUS vs. OCT: 6.4% vs. 2.5%, P = 0.032). Intravascular imaging modalities and diabetes were identified as predictors of better and worse 1-year MACE outcomes, respectively.

Conclusion

PCI guided by intravascular imaging modalities resulted in improved 1-year clinical outcomes compared to angiography-guided PCI alone in AMI patients. OCT-guided PCI was associated with lower 1-year MACE rates compared to IVUS-guided PCI. Therefore, intravascular imaging should be recommended for PCI in AMI, with OCT being particularly considered when appropriate.

Prehospital tirofiban increases the rate of disrupted myocardial infarction in patients with ST-segment elevation myocardial infarction: insights from the On-TIME 2 trial

AIMS

In patients with ST-segment elevation myocardial infarction (STEMI), prehospital tirofiban significantly improved myocardial reperfusion. However, its impact on the rate of disrupted myocardial infarction (MI), particularly in the context of high-sensitivity cardiac troponin (hs-cTn) assays, is still unclear.

METHODS AND RESULTS

The On-TIME 2 (Ongoing Tirofiban In Myocardial infarction Evaluation 2) trial randomly assigned STEMI patients to prehospital tirofiban or placebo before transportation to a percutaneous coronary intervention (PCI) centre. In this post hoc analysis, we evaluated STEMI patients that underwent primary PCI and had measured hs-cTn levels. Troponin T levels were collected at 18-24 and 72-96 h after PCI. Disrupted MI was defined as peak hs-cTn T levels ≤ 10 times the upper limit of normal (≤140 ng/L). Out of 786 STEMI patients, 47 (6%) had a disrupted MI. Disrupted MI occurred in 31 of 386 patients (8.0%) in the tirofiban arm and in 16 of 400 patients (4.0%) in the placebo arm (P = 0.026). After multivariate adjustment, prehospital tirofiban remained independently associated with disrupted MI (odds ratio 2.03; 95% confidence interval 1.10-3.87; P = 0.027). None of the patients with disrupted MI died during the 1-year follow-up, compared with a mortality rate of 2.6% among those without disrupted MI.

CONCLUSION

Among STEMI patients undergoing primary PCI, the use of prehospital tirofiban was independently associated with a higher rate of disrupted MI. These results, highlighting a potential benefit, underscore the need for future research focusing on innovative pre-treatment approaches that may increase the rate of disrupted MI.

Coronary bifurcation lesion treatment with the BioMime™ Branch sirolimus-eluting coronary side-branch stent system: A single-center experience

BACKGROUND

Coronary bifurcation lesions (CBL) comprise 15 %-20 % of percutaneous coronary procedures and remain a challenge despite advances in stent and interventional techniques. The BioMime™ Branch sirolimus-eluting coronary side-branch stent (BBSES) is specifically designed for CBL treatment in conjunction with a standard drug-eluting stent (DES). We report the first single-center experience of treating complex CBL with the novel BBSES.

METHODS

This is a retrospective, single-center study involving consecutive prospectively identified patients who underwent treatment of true CBL with the BBSES. The protocol included BBSES+DES implantation in the CBL and simultaneous final kissing balloon inflation.

RESULTS

Fifty-eight CBL were treated in 58 consecutive patients (89.6 % men, mean age 69.0 ± 9.5 years) presenting primarily with stable angina (84.4 %) and true (Medina 1,1,1,) CBL. Procedural success was 100 % without major adverse cardiac events (MACE). At a median follow-up of 18 months, one sudden death was reported that was accounted as possible late stent thrombosis. One patient had spontaneous myocardial infarction due to subacute thrombosis of a DES implanted in the main vessel proximally to the BBSES before the index procedure. Another patient was hospitalized for atrial fibrillation.

CONCLUSIONS

This is the first clinical experience to date of true CBL treatment with the BBSES demonstrating high procedural success, no in-hospital MACE and sustained clinical results at a median follow-up of 18 months.

Exploring the impact of metabolites function on heart failure and coronary heart disease: insights from a Mendelian randomization (MR) study

BACKGROUND

Heart failure (HF) and coronary heart disease (CHD) are major causes of morbidity and mortality worldwide. While traditional risk factors such as hypertension, diabetes, and smoking have been extensively studied, the role of metabolite functions in the development of these cardiovascular conditions has been less explored. This study employed a Mendelian randomization (MR) approach to investigate the impact of metabolite functions on HF and CHD.

METHODS

To assess the causal impacts of specific metabolite risk factors on HF and CHD, this study utilized genetic variants associated with these factors as instrumental variables. Comprehensive genetic and phenotypic data from diverse cohorts, including genome-wide association studies (GWAS) and cardiovascular disease registries, were incorporated into the research.

RESULTS

Our results encompass 61 metabolic cell phenotypes, with ten providing strong evidence of the influence of metabolite functions on the occurrence of HF and CHD. We found that elevated levels of erucate (22:1n9), lower levels of α-tocopherol, an imbalanced citrulline-to-ornithine ratio, elevated γ-glutamyl glycine levels, and elevated 7-methylguanine levels independently increased the risk of these cardiovascular conditions. These findings were consistent across different populations and robust to sensitivity analyses.

CONCLUSION

This MR study provides valuable insights into the influence of metabolite functions on HF and CHD. However, further investigation is needed to fully understand the precise mechanisms by which these metabolite factors contribute to the onset of these conditions. Such research could pave the way for the development of targeted therapeutic strategies.

Clinical, electrocardiographic, echocardiographic, and angiographic predictors for the final infarct size assessed by cardiac magnetic resonance in acute STEMI patients after primary percutaneous coronary intervention

BACKGROUND

Final infarct size (IS) after ST segment elevation myocardial infarction (STEMI) is a major predictor of mortality. Seeking early predictors for final IS can guide individualized therapeutic strategies for those recognized to be at higher risk.

RESULTS

Eighty STEMI patients successfully treated with primary percutaneous coronary intervention (pPCI) underwent baseline (within 48 h) 2D, 3D echocardiography with speckle tracking and then underwent cardiac magnetic resonance (CMR) at 3 months to assess the final IS. After recruitment, 4 patients were excluded for uncontainable claustrophobia while 76 patients completed the final analysis. The mean ± standard deviation age was 54.1 ± 10.9 years, 84% were males, 25% had diabetes, 26% were hypertensives, 71% were current smokers, 82% had dyslipidemia, and 18% had a family history of premature coronary artery disease. By 3 months, CMR was performed to accurately evaluate the final IS. In univariate regression analysis, the admission heart rate, baseline and post-pPCI ST elevation, STEMI location (anterior vs. inferior), highest peri-procedural troponin, large thrombus burden, baseline thrombolysis in myocardial infarction flow grade, the final myocardial blush grade, the 2D and 3D left ventricular ejection fraction (LVEF), and the 2D and 3D global longitudinal strain (GLS) parameters were significant predictors for the final IS. In the multivariate regression analysis, four models were constructed and recognized the residual post-PCI ST segment elevation, the highest peri-procedural troponin, the 2D-LVEF, 3D-LVEF, and 2D-GLS as significant independent predictors for final IS.

CONCLUSIONS

In STEMI patients who underwent successful pPCI, early predictors for the final IS are vital to guide therapeutic decisions. The residual post-pPCI ST elevation, the highest peri-procedural troponin, and the baseline 2D-LVEF, 3D-LVEF, and 2D-GLS can be excellent and timely tools to predict the final IS.

Epidemiological and Prognostic Importance of New-Onset Cancer as a Net Adverse Clinical Outcome after ST-Elevation Myocardial Infarction

The study assessed the epidemiological frequency and prognostic impact of new-onset cancer as an additional net adverse clinical outcome in patients after ST-elevation myocardial infarction (STEMI), considering its potential clinical significance alongside classical endpoints. This study was designed as a single-center observational study, including 1285 consecutive patients who were diagnosed as STEMI patients as the subject, and the frequency and prognosis of new-onset cancer after STEMI onset were assessed. The incidence of all-cause death, nonfatal myocardial infarction (MI), stroke, and bleeding were analyzed as classical endpoints. Throughout an average of a 1241.4 days observation period, cancers were observed in 7.0% of patients (n = 90), showing development at a constant rate throughout this period (incidence rate, 0.06/1000 person-years). The average duration from STEMI onset to cancer diagnosis was 1371.4 days. Death, MI, or stroke were observed in 21.3%, 4.0%, 6.5%, and 12.8%, giving incidence rates of 0.18, 0.03, 0.06, and 0.11/1000 person-years, respectively. Long-term mortality was higher in patients with newly diagnosed cancer than in patients without cancer (36.7% vs. 20.1%, p < 0.01). Cancer after STEMI should be considered as an additional major adverse clinical event because of its high incidence, constant development, and high mortality in comparison to classical endpoints.

High sensitivity troponins and mortality in the population with metabolic dysfunction-associated steatotic liver disease

Given the global high prevalence of MASLD and its poor CVD prognosis, it is essential to perform risk stratification for MASLD patients. The specific impact of High Sensitivity Troponins (hs-cTn ) on mortality in MASLD patients remains unexplored.  The NHANES databases from 1999 to 2004, which include data on high-sensitivity cardiac troponin (hs-cTn) levels and comorbidities, were linked with the most recent mortality dataset. Myocardial injury was determined using the 99th upper reference limits (URL) for hs-cTn.  Our study included 3460 MASLD patients. The mean follow-up duration was 192 months, during which 1074 (23%) MASLD participants died from all-cause mortality, and 363 (7.3%) died from CVD mortality. Our findings indicate that MASLD patients with elevated levels of hs-cTnT (> 99th URL) exhibit increased risks of all-cause mortality [adjusted hazard ratio (aHR) = 1.93] and CVD mortality (aHR = 2.4). Similar results were observed for hs-cTnI, where the aHRs for all-cause mortality and CVD mortality were 2.03 and 2.97, respectively. Furthermore, we identified a nonlinear dose-response relationship between hs-cTn levels and the risk of mortality (P for nonlinearity < 0.001).  Our findings suggest that hs-cTn can predict mortality risk in MASLD, aiding clinicians in risk-stratifying this population. Therefore, we recommend considering hs-cTn detection in individuals with MASLD to effectively assess their future mortality risk.

Heart Rate Variability in Acute Myocardial Infarction: Results of the HeaRt-V-AMI Single-Center Cohort Study

(1) Background: Heart rate variability (HRV) has been investigated in the context of ST-segment elevation myocardial infarction (STEMI). This study contributes to the field by assessing short-term HRV during primary percutaneous coronary intervention (PCI) using wearable technology, providing real-time insights into autonomic function. (2) Methods: This single-center, observational cohort study included 104 STEMI patients undergoing primary percutaneous coronary intervention (PCI). HRV parameters (including SDNN, RMSSD, pNN50, HF, SD1, and SD2/SD1 ratio) were measured using a wearable device (Empatica E4 wristband, CE certified). Measurements were taken throughout the entire duration of the primary PCI, as well as specifically during the initial 5 min and the final 5 min of the procedure. The association between HRV parameters and adverse outcomes, including in-hospital mortality and in-hospital major adverse cardiovascular events (MACE), were assessed. (3) Results: HRV parameters significantly decreased after myocardial revascularization, particularly SDNN, RMSSD, pNN50, HF, SD1, and SD2/SD1 ratio. Significant associations were found between reduced SD2/SD1 ratio, approximate entropy, and adverse outcomes, including increased in-hospital mortality and in-hospital MACE (respectively, p = 0.007, p = 0.017 and p = 0.006 and p = 0.005). The SD2/SD1 ratio was significantly lower in patients who died during the hospital stay (p = 0.008) compared to survivors. Approximate entropy was also significantly lower in deceased patients (p = 0.019). (4) Conclusions: Real-time HRV monitoring using wearable technology offers valuable data regarding dynamic physiological changes during primary PCI. Further studies are required to validate these preliminary results and to explore their potential implications for clinical practice.

Exceptionally rare MINOCA: a case of acute myocardial infarction following surgery for Stanford type A aortic dissection

BACKGROUND

Aortic dissection is a severe cardiovascular condition associated with high mortality rates, particularly in cases of Stanford type A aortic dissection (TAAD). Myocardial infarction with non-obstructive coronary arteries (MINOCA) following surgery for TAAD is rare but potentially fatal.

CASE PRESENTATION

A 69-year-old woman presented with sudden chest pain and was diagnosed with acute TAAD. Emergency surgery was performed, during which complications arose, including significant hemodynamic instability. Despite efforts to manage the patient's condition postoperatively, she developed hemodynamic instability and myocardial infarction, leading to cardiogenic shock. MINOCA was diagnosed based on clinical presentation, echocardiographic findings, and coronary angiography ruling out significant stenosis or occlusion. The patient's condition deteriorated despite aggressive treatment, ultimately resulting in death.

CONCLUSION

MINOCA following surgery for TAAD is a rare but serious complication. Vigilant postoperative monitoring and timely intervention are essential for identifying and managing acute cardiac dysfunction in these patients. Further research is required to improve outcomes in this challenging clinical scenario.

Technological Advances Are Associated With Better Clinical Outcomes of Percutaneous Coronary Intervention in Patients With Unprotected Left Main Disease

BACKGROUND

Few large-scale studies have evaluated the effectiveness of percutaneous coronary intervention (PCI) technological advances in the treatment of patients with unprotected left main coronary artery disease (LM-CAD). We aim to identify independent factors that affect the prognosis of PCI in patients with unprotected LM-CAD and to assess the impact of PCI technological advances on long-term clinical outcomes.

METHODS AND RESULTS

A total of 4512 consecutive patients who underwent unprotected LM-CAD PCI at Fuwai Hospital from 2004 to 2016 were enrolled. Multivariable Cox proportional hazards model was used to identify which techniques can independently affect the incidence of major adverse cardiac events (MACEs; a composite of cardiac death, myocardial infarction, or target vessel revascularization). The incidence of 3-year MACEs was 9.0% (406/4512). Four new PCI techniques were identified as the independent protective factors of MACEs, including second-generation drug-eluting stents (hazard ratio [HR], 0.61 [95% CI, 0.37-0.99]), postdilatation (HR, 0.75 [95% CI, 0.59-0.94]), final kissing balloon inflation (HR, 0.78 [95% CI, 0.62-0.99]), and using intravascular ultrasound (HR, 0.78 [95% CI, 0.63-0.97]). The relative hazard of 3-year MACEs was reduced by ≈50% with use of all 4 techniques compared with no technique use (HR, 0.53 [95% CI, 0.32-0.87]).

CONCLUSIONS

PCI technological advances including postdilatation, second-generation drug-eluting stent, final kissing balloon inflation, and intravascular ultrasound guidance were associated with improved clinical outcomes in patients who underwent unprotected LM-CAD PCI.

Association between coronary artery stenosis and myocardial injury in patients with acute pulmonary embolism: A case-control study

BACKGROUND

The potential impact of pre-existing coronary artery stenosis (CAS) on acute pulmonary embolism (PE) episodes remains underexplored. This study aimed to investigate the association between pre-existing CAS and the elevation of high-sensitivity cardiac troponin I (hs-cTnI) levels in patients with PE.

METHODS

In this multicenter, prospective case-control study, 88 cases and 163 controls matched for age, sex, and study center were enrolled. Cases were patients with PE with elevated hs-cTnI. Controls were patients with PE with normal hs-cTnI. Coronary artery assessment utilized coronary computed tomographic angiography or invasive coronary angiography. CAS was defined as ≥50% stenosis of the lumen diameter in any coronary vessel >2.0 mm in diameter. Conditional logistic regression was used to evaluate the association between CAS and hs-cTnI elevation.

RESULTS

The percentage of CAS was higher in the case group compared to the control group (44.3% [39/88] vs. 30.1% [49/163]; P  = 0.024). In multivariable conditional logistic regression model 1, CAS (adjusted odds ratio [OR], 2.680; 95% confidence interval [CI], 1.243-5.779), heart rate >75 beats/min (OR, 2.306; 95% CI, 1.056-5.036) and N-terminal pro-B type natriuretic peptide (NT-proBNP) >420 pg/mL (OR, 12.169; 95% CI, 4.792-30.900) were independently associated with elevated hs-cTnI. In model 2, right CAS (OR, 3.615; 95% CI, 1.467-8.909) and NT-proBNP >420 pg/mL (OR, 13.890; 95% CI, 5.288-36.484) were independently associated with elevated hs-cTnI.

CONCLUSIONS

CAS was independently associated with myocardial injury in patients with PE. Vigilance towards CAS is warranted in patients with PE with elevated cardiac troponin levels.

Evaluation of preprocedural statin loading on clinical outcomes in patients undergoing elective percutaneous coronary intervention

Background and aim

High-dose statin therapy before percutaneous coronary intervention (PCI) is thought to reduce the occurrence of Peri-procedural Myocardial Infarction (PPMI), which is associated with increased mortality and prolonged hospitalization, especially in statin naïve patients. This study aims to investigate the effect of rosuvastatin loading dose on PPMI and major adverse cardiac and cerebrovascular events (MACCE) in patients undergoing elective PCI, considering their statin use.

Methods

One hundred sixty-five patients with stable coronary artery disease (CAD) without heart failure (HF) or chronic kidney disease (CKD) were included in the study. They were divided into two groups: patients already on statin treatment (n:126) and statin naive patients (n:39). Both groups were randomly assigned to high-dose (40 mg) rosuvastatin (n:86) or a non- loading dose group (n:79). The primary endpoint was the incidence of PPMI, and the secondary endpoint was MACCE.

Results

The mean age of study population was 59 ± 9.4 years with 77% being male (n = 127). The median follow-up (FU) time was 368 day. Thirty patients were diagnosed with PPMI after PCI (19 in the high-dose group and 11 in the no-loading-dose group). Meanwhile, less than half of study population (77 patients, 46.7%) had complex lesion type (B2, C) and 88 of those (53.3%) had simple lesion type (A, B1). PPMI was observed more frequently in statin-naive patients (23%) than in statin users (17%), although the difference was not statistically significant. Only two patients (1.2%) experienced MACCE during the FU period. One of these patients, who had a type C lesion, belonged to group A2 and underwent Target Vessel Revascularization (TVR) on the 391st day. The other patient, with a type B1 lesion, was in group A1 and was hospitalized due to Acute Coronary Syndrome (ACS) on the 40th day of FU.

Conclusions

Pre-procedural administration of high dose rosuvastatin in patients with stable coronary artery disease did not decrease PPMI, independent of chronic statin use.