Third Universal Definition of Myocardial Infarction

Prognostic value of a combination of cardiac biomarkers and risk indices for major adverse cardiovascular events following non-cardiac surgery in geriatric patients: a prospective cohort study

Major adverse cardiovascular events (MACEs) in geriatric patients are an important cause of increased mortality and morbidity. The results of current studies regarding the predictive value of the NT-proBNP, H-FABP, and AUB-HAS2 scales for cardiovascular complications are inconsistent, and there is no relevant large sample study. Therefore, this study aimed to investigate whether preoperative NT-proBNP, H-FABP, and AUB-HAS2 alone or in combination can effectively predict postoperative cardiovascular complications in geriatric patients. A total of 1736 geriatric patients (aged ≥ 65 years) who were scheduled for elective non-cardiac surgery under general anesthesia were enrolled. AUB-HAS2 risk assessment is required for each patient, and blood was collected 1 h before surgery for the measurement of NT-proBNP and H-FABP. The primary outcomes were MACEs within 30 days after surgery. The secondary outcomes were other complications. Its predictive value was analyzed by receiver operating characteristic (ROC) curves. Of the 1736 patients, 71 (4.1%) had MACEs. NT-proBNP was a predictor of MACEs (AUC = 0.763; 95% CI 0.695-0.832; P < 0.001). When H-FABP was combined with AUB-HAS2, AUB-HAS2 increased the predictive value of H-FABP (AUC = 0.736; 95% CI 0.673-0.799; P < 0.001). Multiple logistic regression analysis revealed increased predictive value of the modified AUB-HAS2 scale for MACEs (AUC = 0.794, 95% CI = 0.737-0.851, P < 0.001). Our study revealed the predictive efficacy and prognostic value of NT-proBNP, H-FABP and the AUB-HAS2 score alone or in combination for postoperative MACE risk assessment in geriatric patients undergoing non-cardiac surgery.This trial was registered at the Chinese Clinical Trial Registry (2019/09/27 ChiCTR1900026223, https://www.chictr.org.cn ).

Outcomes in patients with chronic heart failure undergoing non-cardiac surgery: a secondary analysis of the METREPAIR international cohort study

INTRODUCTION

Heart failure is a frequent comorbidity in patients undergoing non-cardiac surgery and an acknowledged risk factor for postoperative mortality. The associations between stable chronic heart failure and postoperative outcomes have not been explored extensively. The aim of this study was to determine associations between stable chronic heart failure and its peri-operative management and postoperative outcomes after major non-cardiac surgery.

METHODS

This is a secondary analysis of MET-REPAIR, an international prospective cohort study including patients undergoing non-cardiac surgery aged ≥ 45 y with increased cardiovascular risk. Main exposures were stable chronic heart failure and availability of a pre-operative transthoracic echocardiogram. The primary endpoint was the incidence of postoperative major adverse cardiovascular events at 30 days. Secondary endpoints included 30-day mortality and severe in-hospital complications. Multivariable logistic regression models were calculated.

RESULTS

Of 15,158 included patients, 3880 (25.6%) fulfilled the diagnostic criteria for stable chronic heart failure, of whom 1397 (36%) were female. Chronic heart failure was associated with increased risk of postoperative 30-day major adverse cardiovascular events (OR 2.04, 95%CI 1.59-2.60), 30-day mortality (OR 1.50, 95%CI 1.17-1.92) and in-hospital complications (OR 1.47, 95%CI 1.30-1.66). Transthoracic echocardiography was performed in 1267 (32.7%) patients with heart failure; 146 (11.5%) patients with heart failure presented with a left ventricular ejection fraction < 40%. Reduced ejection fraction was associated with major adverse cardiovascular events (OR 2.0, 95%CI 1.01-3.81).

DISCUSSION

Stable chronic heart failure is independently associated with major adverse cardiovascular events, mortality and severe postoperative complications when measured 30 days after non-cardiac surgery.

Variants in candidate genes and their interactions with smoking on the risk of acute coronary syndrome

INTRODUCTION

Multiple genetic and environmental factors interact with the development of acute coronary syndrome. Smoking is one of the environmental factors that might alter the metabolic pathways shared by genes associated with this condition.

OBJECTIVE

To investigate the association of acute coronary syndrome with genetic variants related to inflammation, lipid metabolism, and platelet aggregation among subjects from the northeastern region of Colombia. The effects of interactions between polymorphisms and smoking were also evaluated.

MATERIALS AND METHODS

We analyzed data from 330 acute coronary syndrome cases and 430 controls. Associations between 20 polymorphisms and acute coronary syndrome were evaluated using logistic regression, adjusting for confounders. Gene and smoking interaction terms were calculated, and variants were analyzed separately in smokers and non-smokers for their association with acute coronary syndrome.

RESULTS

Two variants were associated with acute coronary syndrome, rs10455872 in the LPA gene (OR = 2.69; 95% CI: 1.61-4.49) and rs429358 in the APOE gene (OR = 1.93; 95% CI: 1.30-2.87). We identified smoking interactions with the variants rs6511720 in the LDLR gene (p = 0.04) and rs2227631 in the SERPINE1 gene (p = 0.02), with significant effects in non-smokers (rs6511720: OR = 0.40; 95% CI: 0.19-0.88; and rs2227631: OR = 0.69; 95% CI: 0.48-1.00), but not in smokers (rs6511720: OR = 1.28; 95% CI: 0.66-2.46; and rs2227631: OR = 1.30; 95% CI: 0.91-1.87).

CONCLUSIONS

Variants in the candidate genes LPA and APOE are associated with an increased risk of acute coronary syndrome in a population from northeastern Colombia. The effects of rs6511720 in LDLR and rs2227631 in SERPINE1 differ according to smoking habits and are significant in non-smokers. These results are helpful for early risk screening of acute coronary syndrome, mainly in individuals without defined conventional risk factors.

Clinical risk prediction, coronary computed tomography angiography, and cardiovascular events in new-onset chest pain: the PROMISE and SCOT-HEART trials

BACKGROUND AND AIMS

Whether index testing using coronary computed tomography angiography (CTA) improves outcomes in stable chest pain is debated. The risk factor weighted clinical likelihood (RF-CL) model provides likelihood estimation of obstructive coronary artery disease. This study investigated the prognostic effect of coronary CTA vs. usual care by RF-CL estimates.

METHODS

Large-scale studies randomized patients (N = 13 748) with stable chest pain to coronary CTA as part of the initial work-up in addition to or instead of usual care including functional testing. Patients were stratified according to RF-CL estimates [RF-CL: very-low (≤5%), low (>5%-15%), and moderate/high (>15%)]. The primary endpoint was myocardial infarction or death at 3 years.

RESULTS

The primary endpoint occurred in 313 (2.3%) patients. Event rates were similar in patients allocated to coronary CTA vs. usual care [risk difference (RD) 0.3%, hazard ratio (HR) 0.84 (95% CI 0.67-1.05)]. Overall, 33%, 44%, and 23% patients had very-low, low, and moderate/high RF-CL. Risk was similar in patients with very low and moderate/high RF-CL allocated to coronary CTA vs. usual care [very low: RD 0.3%, HR 1.27 (0.74-2.16); moderate/high: RD 0.5%, HR 0.88 (0.63-1.23)]. Conversely, patients with low RF-CL undergoing coronary CTA had lower event rates [RD 0.7%, HR 0.67 (95% CI 0.47-0.97)]. The number needed to test using coronary CTA to prevent one event within 3 years was 143.

CONCLUSIONS

Despite an overall good prognosis, low RF-CL patients have reduced risk of myocardial infarction or death when allocated to coronary CTA vs. usual care. Risk is similar in patients with very-low and moderate/high likelihood.

SARS-CoV-2 Infection Association with Atherosclerotic Plaque Progression at Coronary CT Angiography and Adverse Cardiovascular Events

Background Patients with acute SARS-CoV-2 infection are reportedly at increased risk for future cardiovascular events; the mechanism underlying this risk remains unclear. Purpose To evaluate the impact of SARS-CoV-2 infection on coronary inflammation and plaques by using coronary CT angiography (CCTA) and the impact on clinical outcomes. Materials and Methods This retrospective analysis of a prospective study included consecutive patients who underwent serial CCTA between September 2018 and October 2023. The quantitative total and compositional percent atheroma volume (PAV) and annualized PAV change, presence of high-risk plaque, and attenuation of lesion-specific pericoronary adipose tissue (PCAT) at baseline and follow-up were compared between lesions in patients with and without SARS-CoV-2 infection. Relationships between SARS-CoV-2 infection and target lesion failure, which is a composite of cardiac death, target lesion myocardial infarction, and clinically driven target lesion revascularizations, were assessed with Cox models and log-rank tests. Results In 803 patients (mean age, 63.9 years ± 10.1 [SD]; 543 [67.6%] male patients), 2108 coronary artery lesions were evaluated in patients with SARS-CoV-2 infection (n = 690) and 480 coronary artery lesions were evaluated in patients without SARS-CoV-2 infection (n = 113). Compared with lesions in patients without SARS-CoV-2 infection, lesions in patients with SARS-CoV-2 infection demonstrated more rapid progression of overall PAV (0.90% per year ± 0.91 vs 0.62% per year ± 0.68, respectively; P < .001) and noncalcified PAV (0.78% per year ± 0.79 vs 0.42% per year ± 0.45, respectively; P < .001). The incidence of becoming high-risk plaque (21.0% [442 of 2108] vs 15.8% [76 of 480]; P = .03) and PCAT attenuation of -70.1 HU or higher (27.1% [571 of 2108] vs 19.8% [95 of 480]; P < .001) at follow-up was also greater in lesions in patients with SARS-CoV-2 infection (P < .001), despite similar prevalence at baseline. Lesions in patients with COVID-19 had a higher risk of target lesion failure (10.4% vs 3.1%, respectively; adjusted hazard ratio, 2.90; 95% CI: 1.68, 5.02; P < .001). Conclusion SARS-CoV-2 infection was associated with a more rapid progression of lesion-based plaque volume and an increase in incidence of becoming high-risk plaque. Coronary plaques among patients who experienced COVID-19 were more prone to having an elevated risk of target lesion failure. Clinical trial registration no. NCT05380622 © RSNA, 2025 Supplemental material is available for this article. See also the editorial by Weir-McCall and Bell in this issue.

Clinical Outcomes of Comparison Between Type III Coronary Artery Perforation (CAP) and non-CAP Acute Coronary Syndrome Patients During 3-Year Follow-up

Coronary artery perforation (CAP) is a potentially fatal complication of percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS). This study aimed to investigate in-hospital, 1-year, and 3-year clinical outcomes of type III CAP during PCI in patients with ACS. The study retrospectively evaluated 118 patients with CAP and 43,226 case-control patients. Clinical, angiographic, and procedural characteristics, management, and outcomes were analyzed retrospectively at 1-year and 3-year follow-ups. The mean age of the patients was 66.5 ± 11.9 years (61.8% males). There was no significant difference in hospital mortality between the type III CAP and non-CAP groups. The all-cause mortality was 33.3% in the CAP group vs 1.8% in the non-CAP group at 1 year, and 28.3% in CAP group vs 6.9% in non-CAP group at 3 years (p = .001 for both comparisons). The procedural, clinical, and 1 and 3-year outcomes of type III CAP showed a relatively high risk of myocardial infarction, coronary artery bypass graft, cerebrovascular event, stent thrombosis, and major bleeding at the 1 and 3-year follow-ups. In addition, non-CAP ACS patients had better survival (log-rank: p < .001, 34.29 months 95% Confidence Interval [33.58-35.00]) than type III CAP ACS patients (29.53 months 95% Confidence Interval [27.28-31.78]) at the 3-year follow-up visit.

Heparin and Bivalirudin in Percutaneous Coronary Intervention for Acute Coronary Syndromes: A Review Article

Acute coronary syndrome (ACS) is one of the most common leading global causes of mortality, encompassing ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA). Percutaneous coronary intervention (PCI) has become a pivotal therapeutic approach for ACS, underscoring the importance of anticoagulation strategies. Among the commonly employed anticoagulants in PCI, heparin and bivalirudin take precedence, with heparin serving as the archetypal choice. Nevertheless, the determination of an optimal anticoagulation regimen remains a point of contention in contemporary clinical practice. To address the differences in anticoagulants during PCI, we meticulously conducted a literature review through PubMed and Web of Science, employing search terms such as "heparin," "bivalirudin," "percutaneous coronary intervention," and "acute coronary syndrome." For patients with PIC brought on by STEMI, NSTEMI, and stable or UA pectoris, the review focused on randomized controlled trials to assess and compare the efficacy and safety of heparin and bivalirudin as anticoagulant options. This systematic review is aimed at furnishing valuable insights into the ongoing debate surrounding the choice of anticoagulation regimens in PCI. By scrutinizing clinical evidence derived from relevant trials, we seek to inform and guide healthcare practitioners in making informed decisions based on the unique requirements of patients with various ACS presentations.

Staged versus immediate complete revascularization for non-culprit arteries in acute myocardial infarction: a post-hoc analysis of FRAME-AMI

Background and objectives

The optimal timing for complete revascularization (CR) in patients with acute myocardial infarction (AMI) and multivessel disease (MVD) remain uncertain.

Methods

This post-hoc analysis of the FRAME-AMI trial included AMI patients with MVD (n = 549). They were classified into immediate (n = 329) and staged CR (n = 220) groups. All percutaneous coronary interventions were performed during inex hospitalization. The primary endpoint was a composite of all-cause death, acute myocardial infarction, and repeated revascularization. Secondary endpoints included each component of the primary endpoint. Additional comparisons for the outcomes in ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) were also performed.

Results

The incidence of the primary endpoint was not significantly different in any of the AMI patients [12.7% [immediate CR] vs. 17.4% [staged CR], p = 0.905, adjusted hazard ratio [HR] of staged CR = 0.81, 95% confidence interval = 0.43-1.53, p = 0.528]. Other secondary endpoints were also not significantly different. Analyses of STEMI and Neither the primary or secondary endpoints of NSTEMI patients were significantly different.

Conclusions

In this post-hoc analysis of the FRAME-AMI trial, no significant difference in clinical outcomes was observed between the immediate and staged CR strategies for AMI with MVD and the subgroups, such as STEMI or NSTEMI. However, the results should be interpreted carefully because of the many limitations, including a limited sample size and a lack of statistical power. Trial Registration: FRAME-AMI clinicaltrials.gov, identifier (NCT02715518).

Sirolimus-coated balloon versus drug-eluting stent for complex coronary lesions. A propensity matched comparison

INTRODUCTION

Percutaneous coronary intervention (PCI) with drug-eluting stents (DES) in complex coronary artery disease (CAD) has been established as the standard of care, but stent-related events are not uncommon. Sirolimus-Coated Balloon (SCB)-based angioplasty is an emerging technology, although it needs to be thoroughly evaluated compared with DES in the complex PCI setting. This study aimed to investigate the safety and efficacy of SCB-based angioplasty compared with new-generation DES in complex PCI.

METHODS

Net adverse cardiovascular events (NACE: all-cause death, target lesion revascularization, non-fatal myocardial infarction, and major bleedings according to BARC classification), as a primary study endpoint was compared between SCB and new-generation DES for complex coronary lesions.

RESULTS

Among 1782 patients with complex CAD, 1076 were treated with a sirolimus-coated balloon (EASTBOURNE Registry) and 706 with new-generation DES (COMPLEX Registry). After propensity score matching, a total of 512 patients in both groups were analyzed. NACE occurred more significantly in the DES group during the 1-year follow-up (10.5% vs. 3.9%, p = 0.003), mainly due to a higher risk of bleeding (6.6% vs. 0.4%, p = 0.001). The Cox model adjusted for lesion length showed a significantly lower hazard of NACE (HR: 0.23, CI [0.10, 0.52], p < 0.001) and all-cause mortality (HR: 0.07, CI [0.01, 0.66], p = 0.020) in SCB compared to DES group.

CONCLUSIONS

SCB angioplasty has an advantage over DES for the treatment of complex CAD regarding NACE, significantly reducing the incidence of major bleeding without increasing ischemic endpoints. SCB may be an alternative to DES in selected patients with complex coronary lesions.

ECG data analysis to determine ST-segment elevation myocardial infarction and infarction territory type: an integrative approach of artificial intelligence and clinical guidelines

Introduction

Acute coronary syndrome (ACS) is one of the leading causes of death from cardiovascular diseases worldwide, with ST-segment elevation myocardial infarction (STEMI) representing a severe form of ACS that exhibits high prevalence and mortality rates. This study proposes a new method for accurately diagnosing STEMI and categorizing the infarction area in detail, based on 12-lead electrocardiogram (ECG) data using a deep learning-based artificial intelligence (AI) algorithm.

Methods

Utilizing an ECG database consisting of 888 myocardial infarction (MI) patients, this study enhanced the generalization ability of the AI model through five-fold cross-validation. The developed ST-segment elevation (STE) detector accurately identified STE across all 12 leads, which is a crucial indicator for the clinical ECG diagnosis of STEMI. This detector was employed in the AI model to differentiate between STEMI and non-ST-segment elevation myocardial infarction (NSTEMI).

Results

In the process of distinguishing between STEMI and NSTEMI, the average area under the receiver operating characteristic curve (AUROC) was 0.939, and the area under the precision-recall curve (AUPRC) was 0.977, demonstrating significant results. Furthermore, this detector exhibited the ability to accurately differentiate between various infarction territories in the ECG, including anterior myocardial infarction (AMI), inferior myocardial infarction (IMI), lateral myocardial infarction (LMI), and suspected left main disease.

Discussion

These results suggest that integrating clinical domains into AI technology for ECG diagnosis can play a crucial role in the rapid treatment and improved prognosis of STEMI patients. This study provides an innovative approach for the diagnosis of cardiovascular diseases and contributes to enhancing the practical applicability of AI-based diagnostic tools in clinical settings.

Optimal timing of percutaneous coronary intervention for non-ST elevated myocardial infarction with congestive heart failure

OBJECTIVES

This study investigated the optimal timing for percutaneous coronary intervention (PCI) in patients with NSTEMI complicated by heart failure (HF).

METHODS

In total, 762 patients with NSTEMI and HF in a multicenter, prospective registry in South Korea were classified according to the Killip classification (Killip class 2, n = 414 and Killip class 3, n = 348) and underwent early (within 24 h) and delayed (after 24 h) PCI. The primary outcome was all-cause mortality which was further analyzed with landmark analysis with two months as a cut-off. Secondary outcomes were cardiovascular death, in-hospital cardiogenic shock (CS), readmission due to HF, and acute myocardial infarction during follow-up.

RESULTS

Delayed PCI was associated with lower rates of 2-month mortality (6.1 % vs. 15.8 %, p = 0.007) and in-hospital CS (4.3 % vs. 14.1 %, p = 0.003), along with lower risks of 2-month mortality (hazard ratio [HR] = 0.38, 95 % confidence interval [CI] = 0.18-0.83, p = 0.014), in-hospital CS (HR = 0.29, 95 % CI = 0.12-0.71, p = 0.006) in multivariate Cox models of Killip class 3 patients. There was no statistical difference of incidence and risk of all predefined outcomes according to varying timing of PCI in Killip 2 patients.

CONCLUSIONS

Based on these results, the timing of PCI in patients with NSTEMI complicated by HF should be determined based on HF severity. Delayed PCI should be considered in patients with NSTEMI and more severe HF.

Correlation analysis between the expression of serum microRNA-665 and the degree of coronary artery stenosis and major adverse cardiovascular events in patients with acute myocardial infarction

BACKGROUND

The purpose of this study was to explore the expression of miR-665 in acute myocardial infarction (AMI) and evaluate its significance in the diagnosis and prognosis of AMI.

METHODS

100 patients with AMI were selected as the study group and 80 healthy subjects were chosen as the control group. The levels of miR-665 were detected by reverse transcription quantitative polymerase chain reaction (RT-qPCR) in the two groups. The diagnostic value of miR-665 expression level in AMI was analyzed by the receiver operator characteristic (ROC) curve. Kaplan-Meier curve and Cox regression were used to evaluate the predictive value of miR-665 for major adverse cardiovascular events (MACEs) in patients with AMI within 30 days after percutaneous coronary intervention (PCI).

RESULTS

The serum miR-665 level of the study group was significantly lower than that of the control group. The level of miR-665 was significantly correlated with clinical indicators of patients with AMI. ROC curve showed that miR-665 has a high diagnostic value for AMI. Survival analysis showed that Gensini score and miR-665 were independent risk factors for the occurrence of MACEs within 30 days after PCI in patients with AMI.

CONCLUSIONS

Abnormal decrease of serum miR-665 expression level in patients with AMI may increase the risk of MACEs occurrence after PCI.

Dexmedetomidine administration is associated with improved outcomes in critically ill patients with acute myocardial infarction partly through its anti-inflammatory activity

Background

Dexmedetomidine (DEX) is a commonly used sedative in the intensive care unit and has demonstrated cardioprotective properties against ischemia-reperfusion injury in preclinical studies. However, the protective effects of early treatment of DEX in patients with acute myocardial infarction (AMI) and its underlying mechanism are still not fully understood. This study aims to investigate the association between early DEX treatment and in-hospital mortality in patients with AMI, and to explore the potential mediating role of white blood cell (WBC) reduction in this relationship.

Methods

A retrospective cohort analysis was conducted using the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Patients with AMI were divided into the DEX and non-DEX group, based on whether they received DEX treatment in the early stage of hospitalization. The primary outcome measured was in-hospital mortality. The study evaluated the association between DEX use and in-hospital mortality using the Kaplan-Meier (KM) method and Cox proportional hazards model. Additionally, 1:1 propensity score matching (PSM) was conducted to validate the results. Furthermore, causal mediation analysis (CMA) was utilized to explore potential causal pathways mediated by WBC reduction between early DEX use and the primary outcome.

Results

This study analyzed data from 2,781 patients, with 355 in the DEX group and 2,426 in the non-DEX group. KM survival analysis revealed a significantly lower in-hospital mortality rate in the DEX group compared to the non-DEX group. After adjusting for multiple confounding factors, the Cox regression model demonstrated a significant positive impact of DEX on the risk of in-hospital mortality in patients with AMI, with hazard ratios (HR) of 0.50 (95% confidence interval (CI): 0.35-0.71, p < 0.0001). PSM analysis confirmed these results, showing HR of 0.49 (95% CI: 0.31-0.77, p = 0.0022). Additionally, CMA indicated that 13.7% (95% CI: 1.8%-46.9%, p = 0.022) of the beneficial effect of DEX on reducing in-hospital mortality in patients with AMI was mediated by the reduction in WBC.

Conclusion

The treatment of DEX was associated with a lower risk of in-hospital mortality in patients with AMI, potentially due to its anti-inflammatory properties.

Effect of Patient's Symptom Interpretation on In-Hospital Mortality in Acute Coronary Syndrome

BACKGROUND

The association between symptom interpretation and prognosis has not been investigated well among patients with acute coronary syndrome (ACS). As such, the present study evaluated the effect of heart disease awareness among patients with ACS on in-hospital mortality.

METHODS AND RESULTS

We performed a post hoc analysis of 1,979 consecutive patients with ASC with confirmed symptom interpretation on admission between 2014 and 2018, focusing on patient characteristics, recanalization time, and clinical outcomes. Upon admission, 1,264 patients interpreted their condition as cardiac disease, whereas 715 did not interpret their condition as cardiac disease. Although no significant difference was observed in door-to-balloon time between the 2 groups, onset-to-balloon time was significantly shorter among those who interpreted their condition as cardiac disease (254 vs. 345 min; P<0.001). Moreover, the hazard ratio (HR) for in-hospital mortality was significantly higher among those who did not interpret their condition as cardiac disease based on the Cox regression model adjusted for established risk factors (HR 1.73; 95% confidence interval 1.08-2.76; P=0.022).

CONCLUSIONS

This study demonstrated that prehospital symptom interpretation was significantly associated with in-hospital clinical outcomes among patients with ACS. Moreover, the observed differences in clinical prognosis were not related to door-to-balloon time, but may be related to onset-to-balloon time.

Choline metabolites and incident cardiovascular disease in a prospective cohort of adults: Coronary Artery Risk Development in Young Adults (CARDIA) Study

BACKGROUND

The potential role for choline metabolite trimethylamine N-oxide (TMAO) in cardiovascular disease (CVD) has garnered much attention, but there have been limited data from diverse population-based cohorts. Furthermore, few studies have included circulating choline and betaine, which can serve as precursors to TMAO and may independently influence CVD.

OBJECTIVE

We quantified prospective associations between 3 choline metabolites and 19-y incident CVD in a population-based cohort and tested effect modification of metabolite-CVD associations by kidney function.

METHODS

Data were from the Coronary Artery Risk Development in Young Adults (CARDIA) Study, a prospective cohort with recruitment from 4 US urban centers (year 0: 1985-1986, n = 5115, ages 18-30). The analytic sample included 3444 White and Black males and females, aged 33 to 45, who attended the year 15 follow-up exam and did not have prevalent CVD. TMAO, choline, and betaine were quantitated from stored plasma (-70°C) using liquid-chromatography mass-spectrometry. Nineteen-year incident CVD events (n = 221), including coronary heart disease and stroke, were identified through adjudicated hospitalization records and linkage with the National Death Register.

RESULTS

Plasma choline was positively associated with CVD in Cox proportional hazards regression analysis adjusted for demographics, health behaviors, CVD risk factors, and metabolites (hazard ratio: 1.24; 95% CI: 1.09, 1.40 per standard deviation-unit choline). TMAO and betaine were not associated with CVD in an identically adjusted analysis. There was statistical evidence for effect modification by kidney function with CVD positively associated with TMAO and negatively associated with betaine at lower values of estimated glomerular filtration rate (interaction P values: 0.0046 and 0.020, respectively).

CONCLUSIONS

Our findings are consistent with a positive association between plasma choline and incident CVD. Among participants with lower kidney function, TMAO was positively, and betaine negatively, associated with CVD. These results further our understanding of the potential role for choline metabolism on CVD risk.

Implementation of the European Society of Cardiology 0/3-hour accelerated diagnostic protocol, using high sensitive troponin T: a clinical practice evaluation of safety and effectiveness involving 3003 patients with suspected acute coronary syndrome

BACKGROUND

There have been relatively few studies detailing the real-world effectiveness and safety of accelerated diagnostic protocols (ADP), using high sensitivity cardiac troponin (hs-cTn).

OBJECTIVE

To analyse the safety and effectiveness of early emergency department (ED) discharge following implementation of the European Society of Cardiology (ESC) 0/3-hour ADP for suspected acute coronary syndromes (ACS).

METHOD

We prospectively studied 2 cohorts of consecutive suspected ACS presentations to ED before (n=1642) and after (n=1376, 2 centres) implementation of the ESC 0/3-hour ADP incorporating limit of detection rule out. Safety was defined by MACE (major adverse cardiac events) inclusive of type 1 myocardial infarction (MI) in patients discharged from ED, and clinical effectiveness by percentage ED discharge. Continuous variables and categorical data were evaluated by independent t-test and χ2 test, respectively. Time-to-event data were analysed as survival data and converted to Kaplan-Meier curves for interpretation.

RESULTS

In the preimplementation period, there was a higher prevalence of MI. Discharge from ED increased by >100% (from 27.1% to 56.5% of the cohort) with no safety signal (MACE rate 4/444 (0.9%) vs 4/769 (0.52%), p=0.430 for the 2011 and 2018 cohort, respectively). This correlated with a marked reduction in length of stay overall but a more modest reduction for those discharged from ED (6 hours 10 min vs 5 hours 25 min, p<0.001) for the 2011 and 2018 cohort, respectively. There were improvements in presentation to blood draw (163-90 min, p<0.001). Time from presentation to first ECG actually increased (16.2 vs 31.2 min, p<0.001). Analysis of hs-cTn values and ECGs revealed a maximum ED discharge rate of 69%, by applying the 0/3-hour protocol, implying potential for increasing safe ED discharge.

CONCLUSIONS

Implementation of an ADP with hs-cTn is safe and effective for early rule-out and discharge of suspected ACS but require considerable resources and education to optimise maximal patient flow.

Higher troponin T serum concentrations in hospital patients without diagnosed cardiac diseases compared to a population-based cohort

OBJECTIVES

Upper reference limits of high-sensitivity cardiac troponin T (hs-cTnT) are derived from healthy, population-based cohorts, and are frequently exceeded in hospitalized patients. In this study we aim to systematically examine the differences between in-hospital patients with no diagnosed cardiac diseases and a population-based cohort.

METHODS

Retrospective analyses were performed in two independent cohorts. We included 5,652 participants of the prospective population-based LIFE cohort as well as 9,300 patients having been treated at our hospital between 2014 and 2021. In both cohorts, subjects with diagnosed or suspected cardiac diseases were excluded. We used Spearman's rank correlation for correlation analyses of hs-cTnT serum concentrations and age. Sex- and age-adjusted 99th percentiles for hs-cTnT in subjects with preserved renal function were obtained in both cohorts.

RESULTS

In both cohorts, hs-cTnT serum concentrations positively correlated with age. Male sex was associated with higher hs-cTnT serum concentrations. Persons treated in hospital showed significantly higher hs-cTnT concentrations in females and males aged above 50. While in the population-based cohort only 99th percentile hs-cTnT results of females aged above 70 and males aged above 60 years exceeded the assay's upper reference limit, the 99th percentiles of in-hospital females over 40 years and males of all age groups exceeded this threshold.

CONCLUSIONS

Besides age and sex, hospitalization per se is correlated with higher serum concentrations of hs-cTnT in most age groups. Our results indicate, that unconditionally applying current hs-cTnT cut-offs to inpatients might overestimate myocardial infarction and potentially lead to overdiagnosis.

Impact of clinical diagnosis of myocardial infarction in patients with elevated cardiac troponin

OBJECTIVE

Type 2 myocardial infarction (MI) and myocardial injury are common conditions associated with an adverse prognosis. Physicians experience uncertainty how to distinguish these conditions, as well as how to manage and treat them. Therefore, the objective of this study was to compare treatment and prognosis in patients with an adjudicated diagnosis of type 2 MI and myocardial injury, who were discharged with and without a clinical diagnosis of MI.

DESIGN

The study consisted of two cohorts, 964 and 281 consecutive patients with elevated cardiac troponin, discharged with and without a clinical diagnosis of MI, respectively. All cases were adjudicated into MI type 1-5 or myocardial injury and followed regarding all-cause death.

RESULTS

The adjudication identified 138 and 37 cases of type 2 MI, and 86 and 185 of myocardial injury, with and without a clinical MI diagnosis, respectively. In patients with type 2 MI, a clinical MI diagnosis was associated with more coronary angiography investigations (39.1% vs 5.4%, p<0.001) and an increased use of secondary prevention medications (all p<0.001). However, no difference was observed in adjusted 5-year mortality between patients with and without a clinical MI diagnosis (HR: 0.77 with 95% CI 0.43 to 1.38). The results were similar for adjudicated myocardial injury.

CONCLUSION

In both type 2 MI and myocardial injury, a clinical diagnosis of MI at discharge was associated with more investigations and treatments. However, no prognostic effect of receiving a clinical MI diagnosis was observed.

Association Between Obstructive Sleep Apnea and Cardiovascular Events in Acute Coronary Syndrome Patients With or Without Revascularization - A Prospective Cohort Study

BACKGROUND

The effects of obstructive sleep apnea (OSA) on the prognosis of acute coronary syndrome (ACS) without revascularization remain unclear, so the aim of the present study was to elucidate the association of OSA with subsequent cardiovascular events in ACS patients with and without revascularization.

METHODS AND RESULTS

We prospectively recruited hospitalized ACS patients undergoing sleep monitoring between June 2015 and January 2020. OSA was defined as an apnea-hypopnea index ≥15 events/h. The primary endpoint was a major adverse cardiovascular and cerebrovascular event (MACCE), including cardiovascular death, myocardial infarction, stroke, ischemia-driven revascularization, or hospitalization for unstable angina or heart failure. Among 1,927 patients, 52.6% had OSA and 69.4% underwent revascularization. During a 2.9-year follow-up (1.5-3.6 years), the risk of MACCE was similar in patients with or without revascularization. OSA was an independent predictor of MACCE in the non-revascularization group (22.6% vs. 14.6%; hazard ratio (HR) 1.861; 95% confidence interval (CI) 1.239-2.796; P=0.003) but not in revascularization group (22.3% vs. 19.3%; HR 1.135; 95% CI 0.882-1.460; P=0.324). The incremental risk in the non-revascularization group was attributable to more hospitalizations for unstable angina (14.2% vs. 8.6%; HR 1.896; 95% CI 1.124-3.199; P=0.016).

CONCLUSIONS

For patients with ACS, OSA was independently associated with higher risk of recurrent cardiovascular events among patients without revascularization but not among patients undergoing revascularization. The benefits of suitable OSA treatment for patients without revascularization need further investigation.

Impact of Intravascular Ultrasound-Guided Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction and Chronic Kidney Disease

BACKGROUND

In the setting of acute myocardial infarction (AMI), there are no data regarding the benefits of intravascular ultrasound (IVUS) for chronic kidney disease (CKD) patients.

METHODS AND RESULTS

This study used data from the Korea Acute Myocardial Infarction Registry, a large, multicenter prospective cohort. We evaluated 1,759 patients with AMI and CKD, defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, and patients were classified into 2 groups: with and without IVUS. The primary outcome was target lesion failure (TLF) at 3 years. The hazard ratio (HR) of TLF according to eGFR was also analyzed. A total of 1,759 patients with AMI and CKD who underwent IVUS-guided PCI (19.2%) had a significantly lower risk of TLF at 3 years (8.9% vs. 15.3%; HR 0.55; 95% confidence interval [CI]: 0.38 to 0.81; P=0.002) than those who underwent angiography-guided PCI, regardless of their eGFR and the presence of end-stage renal disease (ESRD). The results were consistent after confounder adjustment and inversed probability weighting.

CONCLUSIONS

In patients with CKD and AMI who underwent PCI with 2nd-generation DES implantation, the use of IVUS guidance was associated with a significant reduction in 3-year TLF and showed consistently favorable outcomes regardless of eGFR and ESRD.

Comparing In-Hospital Outcomes for Acute Myocardial Infarction Patients in High-Volume Hospitals Performing Primary Percutaneous Coronary Intervention vs. Regional General Hospitals

BACKGROUND

It has been reported that patients with acute myocardial infarction (AMI) transferred to low-volume primary percutaneous coronary intervention (PCI) hospitals (<115/year) in low population density areas experience higher in-hospital mortality rates. This study compared in-hospital outcomes of patients admitted to high-volume primary PCI hospitals (≥115/year) with those for other regional general hospitals.

METHODS AND RESULTS

Retrospective analysis was conducted on data obtained from 2,453 patients with AMI admitted to hospitals in Iwate Prefecture (2014-2018). Multivariate analysis revealed that the in-hospital mortality rate of AMI among patients in regional general hospitals was significantly higher than among patients in high-volume hospitals. However, no significant difference in mortality rate was observed among patients with ST-elevation myocardial infarction (STEMI) undergoing primary PCI. Although no significant difference was found in the in-hospital mortality rate of patients with Killip class I STEMI, significantly lower in-hospital mortality rates were observed in patients admitted in high-volume hospitals for Killip classes II, III, and IV.

CONCLUSIONS

Although in-hospital outcomes for patients with STEMI undergoing primary PCI were similar, patients with heart failure or cardiogenic shock exhibited better in-hospital outcomes in high-volume primary PCI hospitals than those in regional general hospitals.

Early prediction of ventricular fibrillation using electrocardiographic characteristics in prehospital suspected ST-segment elevation myocardial infarction: a case-control study

PURPOSE

Our objective was to determine characteristics of electrocardiograms (ECG) that predict ventricular fibrillation (VF) among prehospital patients with suspected ST-segment elevation myocardial infarction (STEMI) in Québec.

METHODS

We performed a matched case-control study of prehospital adult suspected with STEMI. Patients in case group (STEMI/VF+) were matched with controls (STEMI/VF-) for age and sex and then compared for ECG characteristics, including ST-segment elevations (STE) and depressions (STD), duration of interval complexes, general characteristics, and several calculated variables. Logistic regression was used to measure the association between ECG characteristics and VF development.

RESULTS

Overall, 310 prehospital patients with suspected STEMI were included in the analysis (case group, n = 155; control group, n = 155). We confirmed that the presence of TW-pattern complex (OR 7.0, 95% CI 1.55-31.58), premature ventricular contraction (PVC) (OR 5.5, 95% CI 2.04-14.82), and STE in V2-V6 (OR 3.8, 95% CI 1.21-11.74) were electrocardiographic predictors of VF. We also observed that STD in V3-V5 (OR 6.5, 95% CI 1.42-29.39), atrial fibrillation (AF) ≥ 100 beats per minute (bpm) (OR 6.3, 95% CI 1.80-21.90), the combination of STE in V4 and V5, and STD in II, III and aVF (OR 4.8, 95% CI 1.01-22.35), and the presence of STD in ≥ 6 leads (OR 4.2, 95% CI 1.33-13.13) were also associated with VF development. Finally, simultaneous association of 2 (OR 2.3, 95% CI 1.13-4.06) and 3 (OR 11.6, 95% CI 3.22-41.66) predictors showed significant association with VF.

CONCLUSIONS

In addition to some already known predictors, we have identified several ECG findings associated with the development of VF in patients with suspected STEMI. Early identification of patients with STEMI at increased risk of VF should help EMS providers anticipate adverse events and encourage use of defibrillation pads.

In-Hospital Mortality Outcomes of ST-Segment Elevation Myocardial Infarction: A Cross-Sectional Study from a Tertiary Academic Hospital in Johannesburg, South Africa

In sub-Saharan Africa, the burden of atherosclerotic cardiovascular disease (ASCVD) is increasing. This study aimed to describe the clinical characteristics of patients with ST-segment elevation myocardial infarction (STEMI) and estimate the in-hospital all-cause mortality rate. We conducted a cross-sectional retrospective single-centre study of STEMI patients who underwent diagnostic coronary angiography with or without percutaneous coronary intervention (PCI) between January 2015 and December 2019. We compared demographic and clinical parameters between survivors and non-survivors with descriptive statistics. Univariable and multivariable logistic regression analyses were performed to determine the predictors of all-cause mortality. The study population consisted of 677 patients with a mean age of 55.5 ± 11.3 years. The in-hospital all-cause mortality rate was 6.2% [95% confidence interval (CI): 4.5-8.3%]. Risk factors for ASCVD included smoking (56.1%), hypertension (52.8%), dyslipidemia (40.0%), and a family history of coronary artery disease (32.7%). A pharmaco-invasive management strategy (treatment with thrombolytic therapy and PCI) was implemented in 36.5% of patients and reduced all-cause mortality risk (OR: 0.16; CI: 0.04-0.71, p = 0.015). The in-hospital all-cause mortality rate in STEMI patients was 6.2%, and a pharmaco-invasive management strategy proved to be an effective approach.

High sensitivity troponin-I threshold to predict perioperative myocardial infarction

BACKGROUND

High-sensitivity Troponin I (hs-cTnI) has largely replaced conventional troponin assays in an effort to improve detection of myocardial infarction. However, the mean displacement of hs-cTnI following coronary artery bypass graft (CABG) and the optimal threshold to detect perioperative myocardial infarction (MI) is unclear. Our objective is to describe mean hs-cTnI values at 6-12 h post-CABG and to determine the highest specificity while maintaining 100% sensitivity hs-cTnI cut-off values for diagnosis of perioperative or type-5 MI.

METHODS

Between 2016 and 2018, 374 patients underwent non-emergent, isolated CABG. Pre-operative and 6 h post-operative hs-cTnI values were recorded as well as ECG, echocardiographic and angiographic data.

RESULTS

Of 374 patients, 151 (40.3%) had normal and 224 (59.7%) had elevated preoperative hs-cTnI. Patients with normal preoperative hs-cTnI had a mean 6 h hs-cTnI of 9193 ng/l or 270X the upper normal value. Eleven patients (7.3%) presented with post-operative MI with a mean 6 h hs-cTnI of 50,218 ng/l or 1477X the upper normal value. Patients with elevated preoperative hs-cTnI had a mean 6 h hs-cTnI of 9449 ng/l or 292X the upper normal value. Eleven patients (4.9%) who presented with post-operative MI had a mean 6 h hs-cTnI of 26,823 ng/l or 789X the upper normal value.

CONCLUSIONS

We suggest hs-cTnI threshold of 80-fold in patients with normal pre-operative hs-cTnI and 2.7-fold in patients with elevated pre-operative hs-cTnI. These results have important implications for perioperative care and for surgical trial reporting.

Role of ST-Segment Resolution Alone and in Combination With TIMI Flow After Primary Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction

Background To evaluate the role of ST-segment resolution (STR) alone and in combination with Thrombolysis in Myocardial Infarction (TIMI) flow in reperfusion evaluation after primary percutaneous coronary intervention (PPCI) for ST-segment-elevation myocardial infarction by investigating the long-term prognostic impact. Methods and Results From January 2013 through September 2014, we studied 5966 patients with ST-segment-elevation myocardial infarction enrolled in the CAMI (China Acute Myocardial Infarction) registry with available data of STR evaluated at 120 minutes after PPCI. Successful STR included STR ≥50% and complete STR (ST-segment back to the equipotential line). After PPCI, the TIMI flow was assessed. The primary outcome was 2-year all-cause mortality. STR < 50%, STR ≥50%, and complete STR occurred in 20.6%, 64.3%, and 15.1% of patients, respectively. By multivariable analysis, STR ≥50% (5.6%; adjusted hazard ratio [HR], 0.45 [95% CI, 0.36-0.56]) and complete STR (5.1%; adjusted HR, 0.48 [95% CI, 0.34-0.67]) were significantly associated with lower 2-year mortality than STR <50% (11.7%). Successful STR was an independent predictor of 2-year mortality across the spectrum of clinical variables. After combining TIMI flow with STR, different 2-year mortality was observed in subgroups, with the lowest in successful STR and TIMI 3 flow, intermediate when either of these measures was reduced, and highest when both were abnormal. Conclusions Post-PPCI STR is a robust long-term prognosticator for ST-segment-elevation myocardial infarction, whereas the integrated analysis of STR plus TIMI flow yields incremental prognostic information beyond either measure alone, supporting it as a convenient and reliable surrogate end point for defining successful PPCI. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01874691.

Sex Differences in Outcomes of ST Elevation Myocardial Infarction Patients Submitted to Primary Percutaneous Coronary Intervention

BACKGROUND

Several studies have shown that women are usually undertreated and have worse outcomes after ST-segment elevation myocardial infarction (STEMI), hence the need to investigate questions related to sex in Brazil to better deal with the problem.

OBJECTIVE

To determine whether female sex is still associated with adverse events in a contemporary cohort of patients with STEMI undergoing primary percutaneous coronary intervention (pPCI).

METHODS

This was a prospective cohort study of STEMI patients submitted to pPCI in a tertiary university hospital between March 2011 and December 2021. Patients were categorized into groups based on their sex at birth. The primary clinical outcome was long-term MACCE. Patients were followed-up for up to five years. All hypothesis tests had a two-sided significance level of 0.05.

RESULTS

Among 1457 patients admitted with STEMI in the study period, 1362 were included and 468 (34.4%) were women. Female patients had a higher prevalence of hypertension (73% vs. 60%, p <0.001), diabetes (32% vs. 25%, p=0.003) and Killip class 3-4 at hospital admission (17% vs. 12%, p=0.01); TIMI risk score was higher among women (4 [2, 6] vs. 3 [2, 5], p<0.001). In-hospital mortality was not different between groups (12.8% vs. 10.5%, p=0.20). In-hospital MACCE (16.0% vs. 12.6%, p=0.085) and long-term MACCE (28.7% vs. 24.4%, p=0.089) were numerically higher in women, with borderline significance. After multivariate analysis, female sex was not associated with MACCE (HR = 1.14; 95% CI 0.86 - 1.51; p = 0.36).

CONCLUSION

In a prospective cohort of STEMI patients submitted to pPCI, female patients were older and had more comorbidities at baseline, but no significant differences were found in terms of long-term adverse outcomes.

Prognostic Impact of Prehospital Simple Risk Index in Patients With ST-Elevation Myocardial Infarction

BACKGROUND

The simple risk index recorded in the emergency room (ER-SRI), which is calculated using the formula (heart rate × [age / 10]2) / systolic blood pressure, was shown to be able to stratify the prognosis in ST-elevation myocardial infarction (STEMI) patients. However, the prognostic impact of the prehospital simple risk index (Pre-SRI) remains unknown.

METHODS AND RESULTS

This study enrolled 2,047 STEMI patients from the Mie Acute Coronary Syndrome (ACS) registry. Pre-SRI was calculated using prehospital data and ER-SRI was calculated using emergency room data. The primary endpoint was 30-day all-cause mortality. The cut-off values of Pre-SRI and ER-SRI for predicting 30-day mortality were 34.8 and 34.1, with accuracies of 0.816 and 0.826 based on receiver operating characteristic analyses (P<0.001 for both). There was no difference in the accuracy of the 2 indices. Multivariate Cox regression analysis demonstrated that a High Pre-SRI (≥34) was a significant independent predictor of 30-day mortality. With combined Pre-SRI and ER-SRI assessment, patients with High Pre-SRI/High ER-SRI showed significantly higher mortality than those with High Pre-SRI/Low ER-SRI, Low Pre-SRI/High ER-SRI, and Low Pre-SRI/Low ER-SRI (P<0.001). The addition of High Pre-SRI to High ER-SRI showed incremental prognostic value of the Pre-SRI.

CONCLUSIONS

Pre-SRI can identify high-risk STEMI patients at an early stage and combined assessment with Pre-SRI and ER-SRI could be of incremental prognostic value for risk stratification in STEMI patients.

HbA1c is a predictive factor of severe coronary stenosis and major adverse cardiovascular events in patients with both type 2 diabetes and coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is not only a macrovascular complication of type 2 diabetes mellitus (T2DM). Cardiovascular disease (CVD) is one of the leading causes of mortality among individuals with T2DM. Reducing the risk of adverse cardiovascular events (MACE) is crucial for the management of patients with CHD. This study aimed to investigate the effect of glycemic control on CHD severity and 3-point MACE (3p-MACE) risk in patients with T2DM and CHD.

METHODS

681 patients with both T2DM and CHD throughout October 2017 and October 2021 who were hospitalized in the second affiliated hospital of Nanchang university were included. A total of 300 patients were eventually enrolled in this retrospective cohort research. The severity of CHD in these patients was assessed, and the primary outcome during follow-up was recorded, with the primary result being the 3-point major adverse cardiovascular event (3p-MACE). The correlation between baseline glycated hemoglobin A1c (b-HbA1c) and the severity of CHD was evaluated by logistic regression analysis. The effect of b-HbA1c and follow-up HbA1c (f-HbA1c) levels on the risk of 3p-MACE were investigated by cox regression analysis.

RESULTS

b-HbA1c was positively correlated with the severity of CHD (r = 0.207, p = 0.001), and patients with b-HbA1c > 9% were more likely to have severe CHD. The HRs for b-HbA1c and f-HbA1c on the risk of 3p-MACE were 1.24 (95% CI 0.94-1.64, p = 0.123) and 1.32 (95% CI 1.02-1.72, p = 0.036), respectively. Patients with f-HbA1c   ≥8.6% had a higher risk of 3p-MACE than f-HbA1c < 8.6% (HR = 1.79, 95% CI 1.16-2.79, p = 0.009).

CONCLUSION

In patients with both T2DM and CHD, b-HbA1c was an independent predictive factor of severe CHD. f-HbA1c was an independent predictive factor of 3p-MACE. Having the f-HbA1c below 8.6% significantly reduced the risk of 3p-MACE.

Predictors of increased risk of adverse cardiovascular outcomes among patients with myeloproliferative neoplasms and atrial fibrillation

BACKGROUND

Patients with myeloproliferative neoplasms (MPNs), essential thrombocythemia (ET), polycythemia vera (PV), and myelofibrosis (MF), have increased risk of cardiovascular (CV) disease. Atrial fibrillation (AF) is associated with adverse CV outcomes including arterial thrombosis, heart failure (HF), and CV death and coexists with MPN. Traditional risk scores (CHA2DS2-VASC and HAS-BLED) for estimating risks/benefits of anticoagulation to prevent thrombotic events in AF do not include MPN status. Therefore, we aimed to investigate CV outcomes in patients with MPN and AF and evaluate the predictive ability of traditional risk scores.

METHODS

We conducted a single-center, retrospective cohort study of patients with MPN and AF. Primary outcome was composite of CV death and arterial thromboembolism; secondary outcomes were bleeding requiring emergency department visit or hospitalization, hospitalization for HF, and all-cause death. Multivariable competing-risk and Cox proportional hazards regression models were used to estimate risk of outcomes. Receiver operating characteristic (ROC) curve used to evaluate predictive ability of CHA2DS2-VASC and HAS-BLED of composite outcome and bleeding, respectively.

RESULTS

A total 142 patients was included (62 ET, 54 PV, 26 MF). Composite outcome, bleeding, HF hospitalization and all-cause death occurred in 39 %, 30 %, 34 %, and 48 %, of patients respectively. After multivariable modeling, MF was associated with increased risk of composite outcome (SHR 2.70, 95 % CI 1.38-5.27) and all-cause mortality (HR 9.77, 95 % CI 4.88-19.54) but not bleeding (SHR 1.19, 95 % CI 0.51-2.80) or HF admissions (SHR 0.57, 95 % CI 0.19-1.72). CHA2DS2-VASC and HAS-BLED were poor predictors of composite outcome (C-statistic 0.52, 95 % CI 0.43-0.62) and bleeding (C-statistic 0.49, 95 % CI 0.40-0.58), respectively.

CONCLUSION

In patients with MPN and AF, MF is associated with increased risk of CV death and arterial thrombosis and traditional risk scores do not accurately predict outcomes in this patient population. Further investigation is needed to refine risk scores in this patient population.

Fibrinolytic therapy use for ST-segment elevation myocardial infarction and long-term outcomes in China: 2-year results from the China Acute Myocardial Infarction Registry

BACKGROUND

Data on fibrinolytic therapy use for ST-segment elevation myocardial infarction (STEMI) and long-term clinical outcomes in developing countries are limited. We aimed to investigate the management and 2-year mortality of fibrinolytic-treated patients in China.

METHODS

A total of 19,112 patients with STEMI from 108 hospitals participated in the China Acute Myocardial Infarction registry between January 2013 and September 2014. We investigated the 2-year all-cause mortality among patients treated with fibrinolysis. Non-invasive clinical indexes were used to diagnose successful fibrinolysis or not.

RESULTS

Only 1823 patients (9.5%) enrolled in the registry underwent fibrinolysis and 679 (37.2%) could be treated within 3 h after symptom onset. The overall use of rescue percutaneous coronary intervention was 8.9%. Successful fibrinolysis, which could be achieved in 1428 patients (78.3%), was related to types of fibrinolytic agents, symptom to needle time, infarction site, and Killip class. Follow-up data were available for 1745 patients (95.7%). After multivariate adjustment, successful fibrinolysis was strongly associated with a decreased risk of death compared with failed fibrinolysis at 2 years (8.5% vs. 29.0%, hazard ratio: 0.27, 95% confidence interval: 0.20-0.35).

CONCLUSION

Within a minority of STEMI patients in the CAMI registry underwent fibrinolysis, most of them could achieve successful clinical reperfusion, presenting a much benign 2-year survival outcome than those with failed fibrinolysis. Quality improvement initiatives focusing on fibrinolysis are warranted to achieve its promise fully.

TRIAL REGISTRATION

URL: https// www.

CLINICALTRIALS

gov . Unique identifier: NCT01874691. Registered 11/06/2013.

Clinical and organizational impact of the use of different cardiac troponin assays for the diagnosis of myocardial infarction without persistent elevation of the ST segment at presentation (NSTEMI) in 12 Italian emergency departments (EDs): the TROCAR study

The management of acute chest pain is one of the challenges for emergency departments (EDs) worldwide. This study aims to provide insights into clinical and organizational aspects related to the use of different cardiac troponin tests for the diagnosis of NSTEMI. A prospective observational study was conducted among 12 Italian EDs. Eligible participants had chest pain of suspected cardiac origin and accessed EDs from January 2017 to March 2019. A 30-day follow-up was performed to gather information about the main cardiac outcomes. Tests validity and performance were assessed by computing sensitivity, specificity, positive and negative predictive values and area under the ROC curve. The independent association between adverse event end point at 30 days and type of troponin was evaluated by multiple logistic regression models, using odds ratio and 95% confidence interval. 2913 patients were included. Almost 72% were affected by comorbidities and most of them stayed in the EDs for more than 3 h, with significant differences among the different troponin assays. The results of follow-up at 30 days for the outcomes considered for the patients who were ruled out in 3 h or less did not differ significantly compared to those ruled out after 3 h or more. After adjustment for confounders, patients admitted to an ED that used a high-sensitivity troponin were at a lower risk of having a MACE (OR = 0.53, 95%CI 0.35-0.90) and a non-significant lower risk of myocardial infarction (OR = 0.68, 95% CI 0.41-1.13, p = 0.1314) at 30 days compared to patients admitted to an ED that used a standard troponin. Appropriate troponin testing is extremely important for differential diagnosis and for addressing proper treatment and safe procedures for patients who are not admitted to the hospital.

Coronary Intervention in ST-Segment Elevation Myocardial Infarction Patients With Symptom Onset >12 Hours: Data from China Acute Myocardial Infarction Registry

To determine whether late percutaneous coronary intervention (PCI) of an infarct-related artery >12 h after ST-segment elevation myocardial infarction onset is beneficial, patients were included from the prospective, nationwide, multicenter China Acute Myocardial Infarction registry. The number of patients who underwent PCI or received drug therapy alone was 4791 and 1149, respectively. Hazard ratio (HR) and associated 95% confidence interval (CI) were calculated. Compared with drug therapy, PCI was associated with lower incidences of 2-year major adverse cardiac and cerebrovascular events (MACCE; 6.43 vs 20.19%; HR, .27; 95% CI, .23-.32; P < .001), all-cause death (4.13 vs 15.74%; HR, .24; 95% CI, .20-.30; P < .001), myocardial infarction (1.73 vs 3.31%; HR, .49; 95% CI, .33-.72; P = .0003), stroke (1.02 vs 2.00%; HR, .47; 95% CI, .28-.77; P = .0026), and revascularization (10.96 vs 27.56%; HR, .32; 95% CI, .26-.39; P < .001). Subgroup analysis consistently indicated that PCI was superior to drug therapy. Moreover, the left ventricular ejection fraction in the PCI group was increased after 2-year follow-up, whereas there was no significant increase in the drug therapy group. In conclusion, late PCI is common in Chinese clinical practice, and it is associated with significant improvements in cardiac function and survival compared with drug therapy alone.

Quantitation of cardiac troponin I in cancer patients treated with immune checkpoint inhibitors: a case-control study

OBJECTIVES

Immune checkpoint inhibitors (ICIs) cause a variety of toxicities, including immune-related adverse events (irAEs), but there are no biomarkers to predict their development. Guidelines recommend measuring circulating cardiac troponin I (cTnI) during ICI therapy to detect related cardiotoxicities. Moreover, elevated cTnI has also been associated with worse outcomes in non-cardiac patients, including cancer. Thus here, we investigated whether cTnI levels were higher in patients with irAEs.

METHODS

The study consisted of three groups; 21 cancer patients undergoing ICI immunotherapies who presented with irAEs, four patients without irAEs, and 20 healthy controls. Patient samples were assessed at baseline (n=25), during ICI treatment (n=25, median=6 weeks of treatment) and at toxicity (n=6, median=13 weeks of treatment). In addition to blood high sensitivity cardiac troponin I (hs-cTnI), anti-thyroglobulin (TG) and anti-thyroid peroxidase (TPO) antibodies were also quantitated to detect thyroid dysfunction, constituting the second leading toxicity (23.8%) after pneumonitis (28.6%).

RESULTS

Four patients with irAEs (n=4/21; 19%) and one without irAEs (n=1/4; 25%) showed higher hs-cTnI levels at any time-point; the remaining had physiological levels. None of these patients developed cardiotoxicity. Concurrent elevated levels of anti-thyroid antibodies and hs-cTnI were detected in one patient with thyroid dysfunction (n=1/5, 20%). However, these antibodies were also elevated in three patients (n=3/16, 19%) with non-thyroid irAEs and in up to 40% of healthy controls.

CONCLUSIONS

hs-cTnI was not elevated in patients with irAEs, but larger studies are needed to confirm these observations.

Predictive outcomes of APACHE II and expanded SAPS II mortality scoring systems in coronary care unit

OBJECTIVE

We investigated the predictive values of the expanded Simplified Acute Physiology Score (SAPS) II and Acute Physiologic Score and Chronic Health Evaluation (APACHE) II score in predicting in-hospital mortality in coronary care unit (CCU) patients.

METHODS

In this study, expanded SAPS II and APACHE II scores were calculated in the CCU of a single-center tertiary hospital. Patients admitted to CCU with any cardivascular indication were included in the study. Both scores were calculated according to previously determined criteria. Calibration and discrimination abilities of the scores in predicting in-hospital mortality were tested with Hosmer-Lemeshow goodness-of-fit C chi-square and receiver operating characteristics (ROC) curve analyses.

RESULTS

A total of 871 patients were included in the analysis. The goodness-of-fit C chi-square test showed that both scores have a good performance in predicting survivors and nonsurvivors in CCU. Expanded SAPS II score has a sensitivity of 80% and a specificity of 91.8% with the cut-off value of 5.55, while APACHE II has a sensitivity of 75.9% and a specificity of 87.4% with the cut-off value of 16.5 in predicting mortality.

CONCLUSION

Expanded SAPS II and APACHE II scores have good ability to predict in-hospital mortality in CCU patients. Therefore, they can be used as a tool to predict short-term mortality in cardiovascular emergencies.

Pulmonary hypertension is associated with poor cardiovascular and hematologic outcomes in patients with myeloproliferative neoplasms and cardiovascular disease

Cardiovascular events and hematologic progression to myelofibrosis or leukemia are leading causes of morbidity and mortality among patients with myeloproliferative neoplasms (MPN). Pulmonary hypertension (PH) is also associated with MPN and cardiovascular disease (CVD), though its prognostic significance in MPN is not well characterized. Our primary objective was to investigate the effect of PH, defined as right-ventricular systolic pressure (RVSP) ≥ 50 mmHg on echocardiogram or mean pulmonary artery pressure (mPAP) ≥ 20 on right heart catheterization, on cardiovascular and all-cause mortality and hematologic progression in patients with MPN and CVD (atrial fibrillation, heart failure hospitalization, and myocardial infarction after MPN diagnosis). Of the 197 patients included (86 ET, 80 PV, 31 PMF), 92 (47%) had PH and 98 (50%) were male. All-cause mortality (58 vs 37%, p = 0.004), cardiovascular death (35 vs 9%, p < 0.0001), and hematologic progression (23 vs 11%, p = 0.037) occurred more frequently in patients with PH. Multivariable competing-risk and proportional hazards regression showed that PH was associated with increased risk of all-cause death (adjusted hazard ratio [HR], 1.80, 95% CI 1.10-2.93), CV death (adjusted subdistribution HR 3.71, 95% CI 1.58-8.73), and hematologic progression (adjusted subdistribution HR 1.99, 95% CI 1.21-3.27).

Sex differences in quality of life of patients following percutaneous coronary intervention in Vietnam

PURPOSE

Data regarding the health-related quality of life (HRQoL) in men and women after percutaneous coronary intervention (PCI) in low-and-middle incomes countries remains scarce. To investigate sex difference in the HRQoL at 30 days and 12 months post PCI in Vietnam.

METHODS

We used data from a single percutaneous coronary registry established in the Vietnam National Heart Institute. The HRQoL was measured using the EQ-5D-3L instrument via telephone interviews, and information about demographics, clinical presentation and procedures was obtained through face-to-face interviews and medical records. The HRQoL between men and women were compared using independent samples t tests, the Mann-Whitney U test or univariate/multivariate logistic regression.

RESULTS

There were 866 patients included in this cohort, with the proportion of women being nearly half of men (32.1 vs 67.9%). Women were 3.5 years older, had lower income and educational levels but greater prevalence of cardiovascular risk factors. At 30 days, women significantly had more problems in mobility, personal care and pain/discomfort compared to men. At 12 months, women had more problem than men in usual activity. The geometric means of HRQoL was lower in women at 30 days, but not in 12 months. From 30 days to 12 months after discharge, women showed better recovery in mobility compared to men, but not in other dimensions.

CONCLUSIONS

In this first insight of sex differences in HRQoL following PCI in Vietnam, women appeared to have worse quality of life, especially at 30 days after discharge but they showed better recovery in mobility at 12 months compared to men.

Elastic and Conductive Melanin/Poly(Vinyl Alcohol) Composite Hydrogel for Enhancing Repair Effect on Myocardial Infarction

Heart failure caused by acute myocardial infarction (MI) still remains the main cause of death worldwide. Development of conductive hydrogels provided a promising approach for the treatment of myocardial infarction. However, the therapeutic potential of these hydrogels is still limited by material toxicity or low conductivity. The latter directly affects the coupling and the propagation of electrical signals between cells. Here, a functional conductive hydrogel by combining hydrophilic and biocompatible poly(vinyl alcohol) (PVA) with conductive melanin nanoparticles under physical crosslinking conditions is prepared. The composite hydrogels prepared by a facile fabrication process of five freeze/thaw cycles possessed satisfying mechanical properties and conductivity close to those of the natural heart. The physical properties and biocompatibility are evaluated in vitro experiments, showing that the introduction of melanin particles successfully improved the elasticity, conductivity, and cell adhesion of PVA hydrogel. In vivo, the composite hydrogels can enhance the cardiac repair effect by reducing MI area, slowing down ventricular wall thinning, and promoting the vascularization of infarct area in MI rat model. It is believed that the melanin/PVA composite hydrogel may be a suitable candidate material for MI repair.

Prognostic association of plasma NT-proBNP levels in patients with microvascular angina -A report from the international cohort study by COVADIS

BackgroudThe aim of this study was to assess the prognostic association of plasma levels of N-terminal prohormone of brain natriuretic peptide (NT-proBNP) with clinical outcomes of patients with microvascular angina (MVA).

Methods

In this international prospective cohort study of MVA by the Coronary Vasomotor Disorders International Study (COVADIS) group, we examined the association between plasma NT-proBNP levels and the incidence of major adverse cardiovascular events (MACE), including cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, and hospitalization due to heart failure or unstable angina.

Results

We examined a total of 226 MVA patients (M/F 66/160, 61.9 ± 10.2 [SD] yrs.) with both plasma NT-proBNP levels and echocardiography data available at the time of enrolment. The median level of NT-proBNP level was 94 pg/ml, while mean left ventricular ejection fraction was 69.2 ± 10.9 % and E/e' 10.7 ± 5.2. During follow-up period of a median of 365 days (IQR 365-482), 29 MACEs occurred. Receiver-operating characteristics curve analysis identified plasma NT-proBNP level of 78 pg/ml as the optimal cut-off value. Multivariable logistic regression analysis revealed that plasma NT-proBNP level ≥ 78 pg/ml significantly correlated with the incidence of MACE (odds ratio (OR) [95 % confidence interval (CI)] 3.11[1.14-8.49], P = 0.001). Accordingly, Kaplan-Meier survival analysis showed a significantly worse prognosis in the group with NT-proBNP ≥ 78 (log-rank test, P < 0.03). Finally, a significant positive correlation was observed between plasma NT-proBNP levels and E/e' (R = 0.445, P < 0.0001).

Conclusions

These results indicate that plasma NT-proBNP levels may represent a novel prognostic biomarker for MVA patients.

Outcomes of Elderly Patients With Acute Myocardial Infarction and Heart Failure Who Undergo Percutaneous Coronary Intervention

Background: As life expectancy rises, percutaneous coronary intervention (PCI) is being performed more frequently, even in elderly patients with acute myocardial infarction (AMI). This study evaluated outcomes of elderly patients with AMI complicated by heart failure (AMIHF), as defined by Killip Class ≥2 at admission, who undergo PCI. Methods and Results: We retrospectively analyzed 185 patients with AMIHF aged ≥80 years (median age 85 years) who underwent PCI between 2009 and 2019. The median follow-up period was 572 days. The rates of in-hospital major bleeding (Bleeding Academic Research Consortium Type 3 or 5) and in-hospital all-cause mortality were 20.5% and 25.9%, respectively. The proportion of frail patients increased during hospitalization, from 40.6% at admission to 59.2% at discharge (P<0.01). The cumulative incidence of all-cause mortality was 36.3% at 1 year and 44.1% at 2 years. After adjusting for confounders, advanced age, Killip Class 4, final Thrombolysis in Myocardial Infarction flow grade <3, and longer door-to-balloon time were associated with higher mortality, whereas higher left ventricular ejection fraction and cardiac rehabilitation were associated with lower mortality (all P<0.05). Progression of frailty during hospitalization was an independent risk factor for long-term mortality in hospital survivors (P<0.01). Conclusions: The management of patients with AMIHF aged ≥80 years who undergo PCI remains challenging, with high rates of in-hospital major bleeding, frailty progression, and mortality.

Plasma mannose as a novel marker of myocardial infarction across different glycaemic states: a case control study

BACKGROUND

Plasma mannose, an emerging novel biomarker of insulin resistance, is associated with both diabetes mellitus and coronary atherosclerosis, but the relationship between mannose concentrations and myocardial infarction (MI) across different glycaemic states remains to be elucidated. The aim of this study was to investigate the independent association between mannose and a first MI in a group of subjects characterized according to their glycaemic state.

METHODS

Fasting plasma mannose concentrations were analysed in 777 patients 6-10 weeks after a first myocardial infarction and in 770 matched controls by means of high-performance liquid chromatography coupled to tandem mass spectrometry. Participants without known diabetes mellitus were categorized by an oral glucose tolerance test (OGTT) as having normal glucose tolerance (NGT, n = 1045), impaired glucose tolerance (IGT, n = 246) or newly detected type 2 diabetes (T2DM, n = 112). The association between mannose and MI was investigated across these glycaemic states by logistic regression.

RESULTS

Mannose levels increased across the glycaemic states (p < 0.0001) and were significantly associated with a first MI in the whole study population (odds ratio, OR: 2.2; 95% CI 1.4 to - 3.5). Considering the different subgroups separately, the association persisted only in subjects with NGT (adjusted OR: 2.0; 95% CI 1.2-3.6), but not in subgroups with glucose perturbations (adjusted OR: 1.8, 95% CI 0.8-3.7).

CONCLUSIONS

Mannose concentrations increased across worsening levels of glucose perturbations but were independently associated with a first MI only in NGT individuals. Thus, mannose might be a novel, independent risk marker for MI, possibly targeted for the early management of previously unidentified patients at high cardiovascular risk.

Prognostic Impact of Peak Aortic Jet Velocity on Patients With Acute Myocardial Infarction

BACKGROUND

Aortic valve stenosis (AS) leads to increased cardiovascular mortality and morbidity, and recent studies reported that even mild-to-moderate AS was associated with poor prognosis in the general population. This study investigated the prognostic impact of mild or moderate AS, defined as 2.0 m/s ≤ peak aortic jet velocity (Vmax) ≤3.9 m/s using echocardiography in acute myocardial infarction (AMI) patients.

METHODS AND RESULTS

This study enrolled 3,049 AMI patients using data from the Mie ACS registry. Patients were divided into 2 groups according to Vmax: Group 1: Vmax <2.0 m/s and/or visually intact aortic valve in which all 3 leaflets are fully and evenly open; Group 2: 2.0 m/s ≤ Vmax ≤ 3.9 m/s. There were 2,976 patients in Group 1and 73 patients in Group 2. The Group 2 patients were older, had a higher percentage of males and had lower body mass index and Killip ≥2 than the Group 1 patients. Angiographic data, door-to-balloon time, and mechanical support were not different between the 2 groups. The Group 2 patients demonstrated a significantly higher all-cause mortality rate (P<0.01) and composite of cardiovascular death and heart failure hospitalization (P<0.01), and Kaplan-Meier analysis showed the same tendency in propensity score-matched patients.

CONCLUSIONS

The present study revealed that mild or moderate AS based on Vmax is associated with poor prognosis following AMI.

Prognostic significance of myocardial salvage assessed by cardiac magnetic resonance in reperfused ST-segment elevation myocardial infarction

Aims

Myocardial salvage index (MSI) is attracting increasing attention for predicting prognosis in acute myocardial infarction (AMI); however, the evaluation of MSI is mainly based on contrast agent-dependent cardiac magnetic resonance (CMR) scanning sequences. This study aims to investigate the prognostic value of MSI in reperfused ST-segment elevation myocardial infarction (STEMI) through the contrast agent-free CMR technique.

Methods and results

Nighty-two patients with acute STEMI, who underwent CMR after primary percutaneous coronary intervention (PPCI), were finally enrolled. Patients were subcategorized into two groups according to median MSI. T1 and T2 mapping were conducted for measuring infarct size (IS) and area at risk (AAR). IS was significantly larger in < median MSI group than ≥ median MSI group (P < 0.001). AAR between the two groups showed no obvious differences (P = 0.108). Left ventricular ejection fraction (LVEF) was lower in < median MSI group than ≥ median MSI group (P = 0.014). There was an obvious inverse correlation between MSI and reperfusion time (R = –0.440, P < 0.001) and a strong inverse correlation between MSI and IS (R = –0.716, P = 0.011). As for the relationship LVEF, MSI showed positive but weak correlation (R = 0.2265, P < 0.001). Over a median follow-up period of 263 (227–238) days, prevalence of MACEs was significantly higher in the < median MSI group [HR: 0.15 (0.04–0.62); Log-rank P = 0.008]. The univariate Cox regression analysis revealed that LVEF, IS, and MSI were significant predictors for major adverse cardiovascular events (MACEs) (all P < 0.05). In the stepwise multivariate Cox regression analysis, LVEF and MSI were identified as independent parameters for predicting MACEs (both P < 0.05). In the receiver-operating characteristic analysis, LVEF, IS, and MSI showed prognostic value in predicting MACEs with AUCs of 0.809, 0.779, and 0.896, respectively, all (P < 0.05). A combination of MSI with LVEF showed the strongest prognostic value of MACEs (AUC: 0.901, sensitivity: 77.78%, specificity: 98.80%, P < 0.001). Delong’s test showed that the combination of LVEF with MSI had an incremental value than LVEF itself in predicting MACEs (P = 0.026).

Conclusion

Contrast agent-free CMR technique provides a reliable evaluation of MSI, which contributes to assessing the efficacy of reperfusion therapy and predicting the occurrence of MACEs.

High-sensitivity troponin I with or without ultra-sensitive copeptin for the instant rule-out of acute myocardial infarction

Background

The instant, single-sampling rule-out of acute myocardial infarction (AMI) is still an unmet clinical need. We aimed at testing and comparing diagnostic performance and prognostic value of two different single-sampling biomarker strategies for the instant rule-out of AMI.

Methods

From the Biomarkers in Acute Cardiac Care (BACC) cohort, we recruited consecutive patients with acute chest pain and suspected AMI presenting to the Emergency Department of the University Medical Center Hamburg-Eppendorf, Hamburg, Germany. We compared safety, effectiveness and 12-month incidence of the composite endpoint of all-cause death and myocardial infarction between (i) a single-sampling, dual-marker pathway combining high-sensitivity cardiac troponin I (hs-cTnI) and ultra-sensitive copeptin (us-Cop) at presentation (hs-cTnI ≤ 27 ng/L, us-Cop < 10 pmol/L and low-risk ECG) and (ii) a single-sampling pathway based on one-off hs-cTnI determination at presentation (hs-cTnI < 5 ng/L and low-risk ECG). As a comparator, we used the European Society of Cardiology (ESC) 0/1-h dual-sampling algorithm.

Results

We enrolled 1,136 patients (male gender 65%) with median age of 64 years (interquartile range, 51–75). Overall, 228 (20%) patients received a final diagnosis of AMI. The two single-sampling instant rule-out pathways yielded similar negative predictive value (NPV): 97.4% (95%CI: 95.4–98.7) and 98.7% (95%CI: 96.9–99.6) for dual-marker and single hs-cTnI algorithms, respectively (P = 0.11). Both strategies were comparably safe as the ESC 0/1-h dual-sampling algorithm and this was consistent across subgroups of early-comers, low-intermediate risk (GRACE-score < 140) and renal dysfunction. Despite a numerically higher rate of false-negative results, the dual-marker strategy ruled-out a slightly but significantly higher percentage of patients compared with single hs-cTnI determination (37.4% versus 32.9%; P < 0.001). There were no significant between-group differences in 12-month composite outcome.

Conclusions

Instant rule-out pathways based on one-off determination of hs-cTnI alone or in combination with us-Cop are comparably safe as the ESC 0/1 h algorithm for the instant rule-out of AMI, yielding similar prognostic information. Instant rule-out strategies are safe alternatives to the ESC 0/1 h algorithm and allow the rapid and effective triage of suspected AMI in patients with low-risk ECG. However, adding copeptin to hs-cTn does not improve the safety of instant rule-out compared with the single rule-out hs-cTn at very low cut-off concentrations.

Citicoline Modifies the Expression of Specific miRNAs Related to Cardioprotection in Patients with ST-Segment Elevation Myocardial Infarction Subjected to Coronary Angioplasty

Extracellular vesicles are recognized as signaling mediators between cells both in physiological and pathological communication. In this work, we explored the potential effect of citicoline to modify relevant proteins or miRNAs for cardioprotection in the smallest population of such microvesicles; i.e., in exosomes from patients diagnosed with ST-segment elevation myocardial infarction (STEMI) undergoing coronary angioplasty. The plasma-exosome-enriched fraction from these patients was characterized. Their cellular origin was assessed by flow cytometry and Western blot, whereas miRNA expression was evaluated by real-time polymerase chain reaction (qRT-PCR). The content of caveolin-1, caveolin-3, and hnRNPA2B1, which play a relevant role in selective transport of miRNAs into microvesicles, along with the effect on cell viability of the exosomes obtained from citicoline-treated and untreated groups were also analyzed. Our results showed that hypoxic stress increases exosome release into the circulation. Moreover, we found that CD146+ increased in exosomes from citicoline-treated patients, while CD142+ decreased in these patients compared to the placebo group. No changes were detected in the protein levels of caveolin-1, caveolin-3, and hnRNPA2B1. Citicoline administration modified the expression of miR233-3p, miR92, and miR21-5p in exosomes. Cell viability decreased in the presence of exosomes from infarcted patients, while incubation of H9c2 cells with exosomes from patients reperfused with citicoline did not affect cell viability. In conclusion, citicoline administration modifies the expression of specific miRNAs related to cardioprotection in exosomes.

Central vs site outcome adjudication in the IRIS trial

BACKGROUND

Central adjudication of outcome events is the standard in clinical trial research. We examine the benefit of central adjudication in the Insulin Resistance Intervention after Stroke (IRIS) trial and show how the benefit is influenced by outcome definition and features of the adjudicated events.

METHODS

IRIS tested pioglitazone for prevention of stroke and myocardial infarction in patients with a recent transient ischemic attack or ischemic stroke. We compared the hazard ratios for study outcomes classified by site and central adjudication. We repeated the analysis for an updated stroke definition.

RESULTS

The hazard ratios for the primary outcome were identical (0.76) and statistically significant regardless of adjudicator. The hazard ratios for stroke alone were nearly identical with site and central adjudication, but only reached significance with site adjudication (HR, 0.80; p = 0.049 vs. HR, 0.82; p = 0.09). Using the updated stroke definition, all hazard ratios were lower than with the original IRIS definition and statistically significant regardless of adjudication method. Agreement was higher when stroke type was certain, subtype was large vessel or cardioembolic, signs or symptoms lasted > 24 h, imaging showed a stroke, and when NIHSS was ≥3.

DISCUSSION

Central stroke adjudication caused the hazard ratio for a main secondary outcome in IRIS (stroke alone) to be higher and lose statistical significant compared with site review. The estimate of treatment effects were larger with the updated stroke definition. There may be benefit of central adjudication for events with specific features, such as shorter symptom duration or normal brain imaging.

Patients with myeloproliferative neoplasms and COVID-19 have increased rates of arterial thrombosis

Background

Both coronavirus disease-2019 (COVID-19) and myeloproliferative neoplasms (MPNs) are associated with systemic inflammation and risk of thrombosis. Risk of thrombosis in patients with COVID with and without MPNs has not been extensively studied.

Methods

Retrospective cohort study of 44 patients with MPNs and 1114 patients without MPNs positive for SARS-COV-2. Outcomes were arterial thrombosis (AT), venous thromboembolism (VTE), bleeding, and death. Time-to-event analysis was performed using competing risk regression model and Cox proportional hazards.

Results

AT occurred more frequently in patients with MPN (7% vs. 1%, p = 0.03). Rates of VTE (7% vs. 5%, p = 0.73), bleeding (7% vs. 2%, p = 0.06), and death (9% vs. 6%, p = 0.32) were similar. MPN patients were older and had more cardiovascular comorbidities. After time-to-event competing-risk regression adjusting for age, MPN patients had higher risk of AT (subdivision hazards ratio 3.95, 95% CI 1.09-14.39) but not VTE, bleeding, or death.

Conclusions

Among patients with COVID-19, MPN patients had higher risk of arterial thrombosis but not VTE, bleeding, and death compared with non-MPN patients. Larger studies are needed to confirm our findings given the limited sample size.

S100A9 and SOCS3 as diagnostic biomarkers of acute myocardial infarction and their association with immune infiltration

Acute myocardial infarction (AMI) is one of the leading causes of death globally, with a mortality rate of over 20%. However, the diagnostic biomarkers frequently used in current clinical practice have limitations in both sensitivity and specificity, likely resulting in delayed diagnosis. This study aimed to identify potential diagnostic biomarkers for AMI and explored the possible mechanisms involved. Datasets were retrieved from the Gene Expression Omnibus. First, we identified differentially expressed genes (DEGs) and preserved modules, from which we identified candidate genes by LASSO (least absolute shrinkage and selection operator) regression and the SVM-RFE (support vector machine-recursive feature elimination) algorithm. Subsequently, we used ROC (receiver operating characteristic) analysis to evaluate the diagnostic accuracy of the candidate genes. Thereafter, functional enrichment analysis and an analysis of immune infiltration were implemented. Finally, we assessed the association between biomarkers and biological processes, infiltrated cells, clinical traits, tissues and time points. We identified nine preserved modules containing 1,016 DEGs and managed to construct a diagnostic model with high accuracy (GSE48060: AUC = 0.923; GSE66360: AUC = 0.973) incorporating two genes named S100A9 and SOCS3. Functional analysis revealed the pivotal role of inflammation; immune infiltration analysis indicated that eight cell types (monocytes, epithelial cells, neutrophils, CD8+ T cells, Th2 cells, NK cells, NKT cells and platelets) were likely involved in AMI. Furthermore, we observed that S100A9 and SOCS3 were correlated with inflammation, variably infiltrated cells, clinical traits of patients, sampling tissues and sampling time points. In conclusion, we suggested S100A9 and SOCS3 as diagnostic biomarkers of AMI and discovered their association with inflammation, infiltrated immune cells and other factors.

Long-term survival of Icelandic women following acute myocardial infarction

Objective. To evaluate the impact of sex on treatment and survival after acute myocardial infarction (AMI) in Iceland. Methods. A retrospective, nationwide cohort study of patients with STEMI (2008-2018) and NSTEMI (2013-2018) and obstructive coronary artery disease. Patient and procedural information were obtained from a registry and electronic health records. Survival was estimated with Kaplan-Meier method and Cox regression analysis used to identify risk factors for long-term mortality. Excess mortality from the AMI episode was estimated by comparing the survival with age- and sex-matched population in Iceland at 30-day interval. Results. A total of 1345 STEMI-patients (24% women) and 1249 NSTEMI-patients (24% women) were evaluated. Women with STEMI (mean age: 71 ± 11 vs. 67 ± 12) and NSTEMI (mean age: 69 ± 13 vs. 62 ± 12) were older and less likely to have previous cardiovascular disease. There was neither sex difference in the extent of coronary artery disease nor treatment. Although crude one-year post-STEMI survival was lower for women (88.7% vs. 93.4%, p = .006), female sex was not an independent risk factor after adjusting for age and co-morbidities after STEMI and was protective for NSTEMI (HR 0.67, 95% CI: 0.46-0.97). There was excess 30-day mortality in both STEMI and NSTEMI for women compared with sex-, age- and inclusion year-matched Icelandic population, but thereafter the mortality rate was similar. Conclusion. Women and men with AMI in Iceland receive comparable treatment including revascularization and long-term survival appears similar. Prognosis after NSTEMI is better in women, whereas higher early mortality after STEMI may be caused by delays in presentation and diagnosis.