2023 ESC Guidelines for the management of acute coronary syndromes

Can apelins guide the diagnosis of coronary artery disease in COPD patients?

BACKGROUND

Apelins are adipokines known for their anti-inflammatory, vasodilator, and antiatherosclerotic effects. They are involved in the pathogenesis of chronic diseases like chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD).

OBJECTIVES

This study aims to investigate apelin as a potential biomarker for early diagnosis and management of CAD in COPD patients.

METHODS

The study included 73 stable COPD patients admitted between June 2023 and June 2024 and 35 healthy volunteers matched by age and gender. COPD patients were categorized into two groups: those without CAD (Group 1) and those with CAD (Group 2). Serum levels of apelin 12, 13, 17, and 36 were measured using ELISA.

RESULTS

Serum apelin levels were significantly lower in COPD patients than in controls (p < 0.001). Among COPD patients, those with CAD showed lower serum apelin levels compared to those without CAD (p = 0.005 for apelin 12, p < 0.001 for apelin 13, 17, and 36). ROC analysis indicated high sensitivity and specificity for apelin 13 and 36 in predicting CAD in COPD patients. Apelin 13 and 36 were positively correlated with ejection fraction (EF) (R = 0.43, p = 0.01; R = 0.4, p = 0.01), and apelin 12 was positively correlated with FEV1 and FVC (R = 0.24, p = 0.04; R = 0.27, p = 0.02).

CONCLUSION

While CAD worsens the prognosis in COPD patients, it remains underdiagnosed. Serum apelin, especially apelin 13 and 36, may assist in the early diagnosis and management of CAD in COPD patients.

The Effects of Circadian Rhythms and Exercise Preconditioning on Cardiac Troponin T Levels Following Graded Exercise

This study explored the impact of circadian rhythms on the circulating cardiac troponin T (cTnT) response to a graded exercise test (GXT) and examined whether an initial GXT influenced the cTnT response to a subsequent GXT performed 7-9 days later. Twenty-one healthy young males (age: 20.6 ± 2.2 years, body mass index: 22.2 ± 2.6 kg/m2, V̇O2max: 31.8 ± 8.7 mL.kg-1.min-1) participated in three trials: an initial GXT (GXT1), a resting control trial (CON) and a second GXT (GXT2), separated by at least 72 h. The serum cTnT levels were measured pre-exercise, 4 h post-exercise or during the control. In GXT1, the cTnT levels did not show significant changes (median [range], pre: 3.80 [3.00-10.59] ng.L-1, post: 4.22 [3.00-9.08] ng.L-1, p > 0.05). During CON, the cTnT levels decreased significantly from morning to early afternoon (3.52 [3.00-10.84] vs. 3.00 [3.00-7.57] ng.L-1, p < 0.05), reflecting a circadian rhythm. Interestingly, GXT1 appeared to prevent this circadian decline. Furthermore, in GXT2, the cTnT levels significantly decreased post-exercise (4.13 [3.00-15.48] vs. 3.24 [3.00-12.96] ng.L-1, p < 0.05), suggesting a possible "late exercise preconditioning" effect from GXT1. These findings suggest that GXT can interact with circadian rhythms, altering cTnT dynamics, and that prior exercise may induce prolonged cardioprotective effects. This study highlights the importance of accounting for circadian variability and late preconditioning effects in future research on exercise-induced cTnT release.

Management of Refractory Thrombus in the Right Coronary Artery: Innovative Techniques in a Single Case

Managing a significant thrombus burden during acute myocardial infarction (AMI) presents a considerable challenge in percutaneous coronary intervention (PCI). Traditional thrombus aspiration catheters can sometimes prove insufficient, necessitating novel strategies. We present a case in which an innovative approach using a guide extension catheter for direct thrombus aspiration successfully restored flow in a refractory and massive thrombotic occlusion of the right coronary artery (RCA). This case also underscores the remarkable potential of innovative interventional techniques, particularly the use of a kinked wire in conjunction with a thrombus aspiration catheter, to effectively ensnare and extract thrombus, even in the most challenging cases of coronary thrombectomy.

Urinary metabolomics reveals myo-inositol and (E)-Monocrotophos associate with prognosis in ACS comorbid with T2DM and preserved renal function

Type 2 diabetes mellitus (T2DM) is closely associated with an increased risk and adverse event of acute coronary syndrome (ACS). The present study aims to investigate the association between differential urinary metabolites and major adverse cardiovascular events (MACEs) in patients with ACS co-morbid T2DM with preserved renal function, and to explore the potential value of the metabolites as prognostic biomarkers in this population. Ultra-high performance liquid chromatography-mass spectrometry (UHPLC/MS) was used to analyze urine samples from ACS co-morbid T2DM. Spearman's correlation was used to examine the association between differential metabolites and serum fasting blood glucose (FBG), glycated hemoglobin (HbA1c), Syntax score I, and MACE. The Cox proportional hazards models and Kaplan-Meier survival curves were used to identify MACE risk factors. A total of 101 differential urinary metabolites were identified, of which seven showed a correlation with FBG, HbA1c, Syntax score I and MACE. In particular, myo-inositol and (E)-Monocrotophos emerged as significant indicators of poor prognosis in ACS co-morbid with T2DM. Urinary metabolomic alteration is closely associated with clinical manifestation of ACS co-morbid T2DM. Urinary myo-inositol and (E)-Monocrotophos may be considered as prognostic biomarkers of ACS co-morbid T2DM.

Effectiveness and Safety of Ticagrelor Monotherapy After Short-Duration Dual Antiplatelet Therapy in PCI Patients: A Systematic Review and Meta-Analysis

Dual antiplatelet therapy (DAPT), consisting of aspirin and a P2Y12 inhibitor, is the standard treatment for patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES). However, the optimal duration of DAPT remains debated due to the need to balance ischemic event reduction with bleeding risks. This study evaluates the efficacy and safety of ticagrelor monotherapy after short-duration DAPT (1 to 3 months) compared to extended DAPT, focusing on major bleeding and cardiovascular outcomes. A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. Randomized controlled trials (RCTs) comparing ticagrelor monotherapy after short-duration DAPT to extended DAPT were identified from PubMed, Embase, and the Cochrane Library. Data on major bleeding, major adverse cardiovascular and cerebrovascular events (MACCE), myocardial infarction, stroke, stent thrombosis, and mortality were analyzed, and risk ratios (RR) with 95% confidence intervals (CI) were calculated using a random-effects model. Five RCTs involving 32,393 patients were included. Ticagrelor monotherapy significantly reduced MACCE (RR: 0.88; 95% CI: 0.77 to 0.99; p = 0.04) and major bleeding (RR: 0.53; 95% CI: 0.37 to 0.77; p = 0.0008) compared to extended DAPT. It also significantly reduced all-cause mortality (RR: 0.82; 95% CI: 0.67 to 0.99; p = 0.04) and cardiovascular death (RR: 0.68; 95% CI: 0.49 to 0.94; p = 0.02). The incidence of myocardial infarction, stent thrombosis, and stroke were similar between the groups. Net adverse clinical events (NACE) were 27% lower with ticagrelor monotherapy (RR: 0.73; 95% CI: 0.63 to 0.85; p <0.0001). In conclusion, ticagrelor monotherapy after short-duration DAPT reduces major bleeding complications without compromising cardiovascular protection. This approach offers a promising strategy to optimize outcomes for PCI patients, particularly those at high bleeding risk. Further studies are needed to refine the optimal DAPT duration in various patient populations, especially those with higher ischemic risk.

Long-term Antithrombotic Therapy in Patients With Chronic Coronary Syndrome: An Updated Review of Current Evidence

PURPOSE

Despite improvements in the secondary prevention of atherothrombosis in patients with coronary artery disease during the past decade, it is estimated that approximately 19 million people annually die from cardiovascular diseases worldwide. Atherothrombosis remains the core pathobiology of acute complications including myocardial infarction (MI), and therefore, antithrombotic therapy plays a pivotal role in the strategies for major adverse cardiovascular event (MACE) prevention. Unlike early antithrombotic management after acute coronary syndrome, less evidence is available on long-term antithrombotic therapy in patients with chronic coronary syndrome (CCS). In addition, greater recognition of the impact of bleeding complications of such therapies has led to a more complex and personalized approach to their application. The purpose of this article is to review the available evidence on long-term antithrombotic therapy in patients with CCS including those with high-risk characteristics such as prior MI or polyvascular disease.

METHODS

A comprehensive literature review was performed in major databases including PubMed, Embase, and the Cochrane Library. The main focus of this narrative review was on available data from guidelines, meta-analysis, randomized controlled trials, and observational studies that assessed the efficacy and safety profile of long-term antithrombotic therapy in patients with CCS.

FINDINGS

Several studies suggest that long-term antithrombotic therapy is effective in reducing the risk of recurrent MACEs in patients with CCS. Current clinical guidelines recommend single antiplatelet therapy with aspirin as a first-line long-term strategy for patients without indication for oral anticoagulation. However, novel approaches focused on P2Y12 inhibitor monotherapy are emerging. More intensive antithrombotic strategies including long-term dual antiplatelet therapy and dual pathway inhibition further reduce ischemic risk but at the cost of increased bleeding.

IMPLICATIONS

This review highlights the importance of close monitoring and regular reassessment of the risk-benefit balance of antithrombotic therapy in patients with CCS. Overall, long-term antithrombotic therapy with either single antiplatelet therapy or dual antiplatelet therapy/dual pathway inhibition is effective in reducing the risk of MACEs in patients with CCS. The choice of antithrombotic therapy should be individualized based on the patient's clinical profile, particularly for thrombohemorrhagic risk. Future research should focus on identifying the optimal antithrombotic regimen for specific subgroups of patients with prior MI particularly for those with high bleeding risk.

Urinary metabolomics analysis based on LC-MS for the diagnosis and monitoring of acute coronary syndrome

Background

Acute coronary syndrome (ACS) is a cardiovascular disease caused by acute myocardial ischemia. The aim of this study was to use urine metabolomics to explore potential biomarkers for the diagnosis of ACS and the changes in metabolites during the development of this disease.

Methods

Urine samples were collected from 81 healthy controls and 130 ACS patients (103 UA and 27 AMI). Metabolomics based on liquid chromatography-mass spectrometry (LC-MS) was used to analyze urine samples. Statistical analysis and functional annotation were applied to identify potential metabolite panels and altered metabolic pathways between ACS patients and healthy controls, unstable angina (UA), and acute myocardial infarction (AMI) patients.

Results

There were significant differences in metabolic profiles among the UA, AMI and control groups. A total of 512 differential metabolites were identified in this study. Functional annotation revealed that changes in arginine biosynthesis, cysteine and methionine metabolism, galactose metabolism, sulfur metabolism and steroid hormone biosynthesis pathways occur in ACS. In addition, a panel composed of guanidineacetic acid, S-adenosylmethionine, oxindole was able to distinguish ACS patients from healthy controls. The AUC values were 0.8339 (UA VS HCs) and 0.8617 (AMI VS HCs). Moreover, DL-homocystine has the ability to distinguish between UA and AMI, and the area under the ROC curve is 0.8789. The metabolites whose levels increased with disease severity the disease were involved mainly in cysteine and methionine metabolism and the galactose metabolism pathway. Metabolites that decrease with disease severity are related mainly to tryptophan metabolism.

Conclusion

The results of this study suggest that urinary metabolomics studies can reveal differences between ACS patients and healthy controls, which may help in understanding its mechanisms and the discovery of related biomarkers.

Kinetic changes in high-sensitivity cardiac troponin for risk stratification of emergency department chest pain patients

OBJECTIVE

Kinetic patterns of high-sensitivity cardiac troponin I (hs-cTnI) levels may provide prognostic value in chest pain patients. This study aimed to evaluate the association between these patterns and 30-day major adverse cardiac events (MACE).

METHODS

A retrospective observational study was conducted, involving Emergency Department (ED) chest pain patients with at least two serial hs-cTnI measurements during their ED stay. Patients were categorized into three groups based on their hs-cTnI kinetic patterns: no change (delta hs-cTnI ≤15 ng/L), rising pattern (RP, delta hs-cTnI>15 ng/L), and falling pattern (FP, delta hs-cTnI>15 ng/L). Thirty-day MACE outcomes were compared across these groups. A stepwise multivariable logistic regression was utilized to evaluate the association of hs-cTnI patterns with 30-day MACE.

RESULTS

This study included 4243 patients. No changes in hs-cTnI were observed in 3777 patients, with 136 (3.6 %) experiencing 30-day MACE. RP was identified in 294 patients, of whom 101 (34.4 %) experienced 30-day MACE, while FP was observed in 172 patients, with 25 (14.5 %) experiencing 30-day MACE. After adjusting for potential confounders, the adjusted odds ratio (AOR) for RP associated with 30-day MACE was 7.68 (95 % CI 5.34-11.05, p < 0.001) and the AOR for FP associated with 30-day MACE was 1.99 (95 % CI 1.14-3.48, p = 0.016).

CONCLUSIONS

Serial hs-cTnI measurements are valuable for identifying patients at risk for 30-day MACE, as both a RP and a FP in hs-cTnI levels are associated with a significantly increased risk of 30-day MACE.

Obesity is associated with impaired long-term prognosis in patients undergoing coronary angiography: Results from a large-scaled single centre registry

BACKGROUND

The study investigates the prognostic value of body mass index (BMI) in a large cohort of unselected patients undergoing invasive coronary angiography (CA). More than one third of the world population is overweight or obese with increasing prevalence. Obesity is an established risk factor for the development of coronary artery disease (CAD), but its impact on outcomes in patients undergoing CA remains controversial.

METHODS

Consecutive patients undergoing invasive CA were included at one institution from 2016 to 2022. Patients were stratified by BMI on admission according to the current WHO definition into the following subgroups: BMI 18.5- < 25 kg/m2, 25- < 30 kg/m2, 30- < 35 kg/m2 and ≥ 35 kg/m2. The prognostic value of BMI was investigated with regard to the primary endpoint rehospitalization for heart failure (HF) at 36 months and the secondary endpoints acute myocardial infarction (AMI) and coronary revascularization at 36 months.

RESULTS

From 2016 to 2022, 6583 patients undergoing CA were included with a median BMI of 27.5 kg/m2 (mean: 28.3 kg/m2). Patients with a BMI of 25- < 30 kg/m2 had the highest prevalence of CAD (71.1 %) and 3-vessel CAD (30.5 %), whereas patients with a BMI ≥ 35 kg/m2 had the lowest prevalence (61.4 % and 20.1 %, respectively). After multivariable adjustment, patients with a BMI ≥ 35 kg/m2 had the highest risk of HF-related rehospitalization at 36 months compared to those with a BMI in the normal range (adjusted HR = 1.210; 95 % CI: 1.011-1.448; p = 0.038).

CONCLUSION

In patients undergoing CA, a BMI ≥35 kg/m2 was associated with the highest risk of HF-related rehospitalization at 36 months.

Impact of the Killip class of heart failure on treatment times and intrahospital mortality among STEMI patients

AIMS

While timely reperfusion is known to reduce mortality, the extent to which the severity of heart failure, as classified by the Killip system, influences treatment delays remains unclear. Our study aims to address the existing gap in evidence regarding the relationship between Killip classification at presentation and treatment times in ST-elevation myocardial infarction (STEMI) patients.

METHODS

We conducted a correlative analysis using data from patients treated in our hospital and enrolled in the FITT-STEMI Register from 2009 to 2022. We focused on the relation of treatment times allocating patients into the four Killip classes and used an ANOVA test (significance level: P < 0.05). Killip class and intrahospital mortality were studied via binary logistic regression.

RESULTS

In total, 1264 patients were identified. Door-to-balloon time among Killip I patients was 54 (±35) min (mean ± SD) and 53 (±26) min among Killip II and prolonged up to 77.5 (±46) min for class III and 79.7 (±45) min for class IV (overall P-value < 0.001). This remained statistically significant even after the exclusion of patients with out-of-hospital cardiac arrest (OHCA) (overall P-value: <0.001).Post hoc analysis showed a significant difference between Killip II and III classes for both all-comers (P = 0.014) as well as after the exclusion of OHCA patients (P = 0.012).Intrahospital mortality increased from <5% for classes I and II up to 10.3% for class III and 35.4% for class IV.

CONCLUSION

The severity of heart failure among STEMI patients significantly affects the duration of treatment times. Patients presenting with Killip class III and IV demonstrate high intrahospital mortality rates.

DNA origami signal amplification in lateral flow immunoassays

Lateral flow immunoassays (LFIAs) enable a rapid detection of analytes in a simple, paper-based test format. Despite their multiple advantages, such as low cost and ease of use, their low sensitivity compared to laboratory-based testing limits their use in e.g. many critical point-of-care applications. Here, we present a DNA origami-based signal amplification technology for LFIAs. DNA origami is used as a molecularly precise adapter to connect detection antibodies to tailored numbers of signal-generating labels. As a proof of concept, we apply the DNA origami signal amplification in a sandwich-based LFIA for the detection of cardiac troponin I (cTnI) in human serum. We show a 55-fold improvement of the assay sensitivity with 40-nm gold nanoparticle labels and an adjustable signal amplification of up to 125-fold with fluorescent dyes. The technology is compatible with a wide range of existing analytes, labels, and sample matrices, and presents a modular approach for improving the sensitivity and reliability of lateral flow testing.

Proteomics of urinary exosomes for discovering novel non-invasive biomarkers of acute myocardial infarction patients

BACKGROUND

Patients with acute myocardial infarction (AMI) can be identified by myocardial enzymes in peripheral blood, but no protein markers have been found in urinary exosomes derived from AMI patients.

METHODS

In the present study, a comprehensive proteomics analysis of urinary exosomes derived from patients with AMI was performed. Firstly, we employed the outstanding separation method known as EXODUS to isolate urinary exosomes from AMI patients and healthy controls. Then, we characterized urinary exosomes by nanoparticle tracking analysis (NTA), western blotting and transmission electron microscopy (TEM). After that, we identified the protein components of exosomes through label-free proteomics and conducted bioinformatics analysis.

RESULT

High-quality exosomes were obtained through separation using EXODUS, which could be demonstrated by NTA, Western blotting and TEM. NTA analysis showed that partilce amount in AMI patients was significantly higher than healthy controls. The equal-volume Western blotting experiment indicated that the expression level of classic exosomal markers Alix, heat shock protein90 (HSP90), CD63 and TSG101 (Tumor susceptibility gene101) in AMI patents was obviously stronger than healthy subjects. We first described the protein profiles of urinary exosomes in AMI patients through proteomics. In this study, We have identified 3194 proteins, among which a total of 30 differential proteins were detected between the urinary exosomes of AMI patients and healthy controls. We investigated F2 and OLR1 among identified exosomal proteins significantly elevated in AMI group, whereas F3 and APCS dysregulated in AMI development.

CONCLUSIONS

F2, F3, OLR1 and APCS are able to distinguish individuals between the AMI group and the healthy controls, and the protein panel represent a novel prospective non-invasive biomarkers for the diagnostic process of acute myocardial infarction.

The Role of IVUS in Coronary Complications

Intravascular ultrasound (IVUS) is an essential tool in the diagnostic and therapeutic management of coronary artery disease. In daily practice, IVUS is particularly useful for plaque characterization, optimizing stent implantation, and identifying the cause of in-stent restenosis. In acute coronary syndromes, it helps to detect culprit lesions that are not clearly visible on angiography and plays a key role in the diagnostic algorithm for myocardial infarction with non-obstructive coronary arteries (MINOCA). Additionally, IVUS is frequently used in complex and calcified lesions to guide optimal plaque modification strategies and improve procedural and long term outcomes. Beyond these common applications, IVUS is crucial in managing coronary complications, such as coronary dissection, perforation, intramural hematoma, and side-branch occlusion. In these challenging cases, IVUS allows us to overcome some of the limitations of angiography. This review explores the role of IVUS in bail out situations, offering practical tips and techniques for navigating coronary complications and improving procedural success in a safer and more refined manner.

Deep learning for electrocardiogram interpretation: Bench to bedside

BACKGROUND

Recent advancements in deep learning (DL), a subset of artificial intelligence, have shown the potential to automate and improve disease recognition, phenotyping and prediction of disease onset and outcomes by analysing various sources of medical data. The electrocardiogram (ECG) is a valuable tool for diagnosing and monitoring cardiovascular conditions.

METHODS

The implementation of DL in ECG analysis has been used to detect and predict rhythm abnormalities and conduction abnormalities, ischemic and structural heart diseases, with performance comparable to physicians. However, despite promising development of DL algorithms for automatic ECG analysis, the integration of DL-based ECG analysis and deployment of medical devices incorporating these algorithms into routine clinical practice remains limited.

RESULTS

This narrative review highlights the applications of DL in 12-lead ECG analysis. Furthermore, we review randomized controlled trials that assess the clinical effectiveness of these DL tools. Finally, it addresses different key barriers to widespread implementation in clinical practice, including regulatory hurdles, algorithm transparency and data privacy concerns.

CONCLUSIONS

By outlining both the progress and the obstacles in this field, this review aims to provide insights into how DL could shape the future of ECG analysis and enhance cardiovascular care in daily clinical practice.

Safety and efficacy of post-procedure anticoagulation in ST-elevation myocardial infarction complicated by cardiogenic shock undergoing primary percutaneous coronary intervention

INTRODUCTION

Cardiogenic shock (CS) is a lethal complication of ST-elevation myocardial infarction (STEMI). The impact of post-procedure anticoagulants (PPAC) in STEMI-CS patients undergoing primary percutaneous coronary intervention (PPCI) remains unknown.

METHOD

In the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome registry (2014-2019), STEMI patients with CS on admission undergoing PPCI were stratified into two groups based on the use of PPAC or not. The primary outcome was all-cause mortality during hospitalization. Other outcomes including major bleeding were also investigated.

RESULTS

Of 36,873 patients with STEMI, 855 eligible patients with CS undergoing PPCI were included in our study, among which 614 patients were treated by PPAC and 241 were not. Adjusted by multi-variable Cox regression, PPAC was associated with a lower risk of in-hospital all-cause mortality (14.9% vs. 30.3%; adjusted HR: 0.60; 95% CI: 0.37 to 0.97; p = 0.037), while a non-significant difference in major bleeding (4.6% vs. 7.0%; adjusted HR: 1.05; 95% CI: 0.36 to 3.05; p = 0.925) was observed between PPAC and non-PPAC. Consistent results were observed in the sensitivity analyses adjusted by propensity score matching and inverse probability of treatment weighting.

CONCLUSION

Our study suggested the use of PPAC in STEMI-CS patients undergoing PPCI was associated with a lower risk of in-hospital all-cause mortality without increasing the risk of major bleeding.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02306616. Registered 29 November 2014.

Applicable Strategies Against Acute Decompensated Heart Failure Patients According to Time of Hospitalization

BACKGROUND

Heart failure (HF) is growing global issue, especially among older adults, and patients can be hospitalized at any time of day. We compared patients' characteristics, including precipitating factors leading to HF hospitalization, between daytime and nighttime admissions.

METHODS AND RESULTS

A total of 1,124 patients, who were primarily admitted with a diagnosis of acute decompensated HF were enrolled. Patients were divided according to time of hospitalization into daytime (n=770; 8 am-6 pm) and nighttime (n=354; 6 pm-8 am) groups. The prevalence of hypertension, new-onset HF, and clinical scenario 1 [systolic blood pressure (BP) at admission ≥140 mmHg], frequency of New York Heart Association class IV symptoms, systolic and diastolic BP, heart rate, estimated glomerular filtration rate (eGFR), serum concentrations of albumin and hemoglobin, and treatment with vasodilators and noninvasive ventilation were greater, while the prevalence of atrial fibrillation, duration of persistent HF symptoms ≥24 h, serum concentration of total bilirubin, loop diuretic use and mineralocorticoid antagonist use before admission were lower in the nighttime group. Among the HF-precipitating factors, nonadherence was the most prevalent in both the daytime (32.2%) and nighttime (29.9%) groups. Poorly controlled hypertension was common in nighttime patients (10.5% vs. 5.1% P<0.001).

CONCLUSIONS

Prehospital BP control may contribute to preventing nighttime hospitalizations. Additionally, the most essential step in preventing hospitalizations due to HF, day or night, is patient education and disease management.

Cardio-cerebral infarction: a narrative review of pathophysiology, treatment challenges, and prognostic implications

Cardio-cerebral infarction (CCI) is a rare clinical syndrome characterized by the simultaneous or sequential occurrence of acute myocardial infarction (AMI) and acute ischemic stroke (AIS). Despite its complex pathogenesis and more severe prognosis compared to isolated AMI or AIS, no consensus has been established regarding its definition, classification, epidemiology, treatment protocols, or prognostic management. Current research is largely confined to case reports or small case series, and there are no unified diagnostic or treatment guidelines, nor any expert consensus. Consequently, clinicians often rely on single-disease guidelines for AMI or AIS, or personal experience, when managing CCI cases. This approach complicates treatment decisions and may result in missed opportunities for optimal interventions, thereby adversely affecting long-term patient outcomes. This narrative review aimed to systematically summarize the definition, classification, epidemiological features, pathogenesis and therapeutic strategies, and prognostic aspects of CCI while thoroughly examining the progress and limitations of existing studies to guide future research and clinical practice. By offering a detailed analysis of reperfusion strategies, antiplatelet therapy, and anticoagulation in CCI patients, this review highlights the safety and efficacy differences among current treatments and explores methods for optimizing individualized management to improve clinical outcomes. Furthermore, this article aimed to enhance clinicians' understanding of CCI, provide evidence-based recommendations for patient care, and outline directions for future research. Ultimately, by refining diagnostic and therapeutic strategies, we aimed to reduce CCI-related mortality and improve long-term prognoses for affected patients.

European Society of Cardiology quality indicators for the management of acute coronary syndromes: developed in collaboration with the Association for Acute CardioVascular Care and the European Association of Percutaneous Cardiovascular Interventions of the ESC

AIMS

Closing the evidence-practice gap for the treatment of acute coronary syndrome (ACS) is central to improving quality of care. Under the European Society of Cardiology (ESC) framework, we aimed to develop updated quality indicators (QIs) for the evaluation of quality of care and outcomes for patients with ACS.

METHODS AND RESULTS

A Working Group of experts including members of the ESC Clinical Practice Guidelines Task Force for ACS, Association for Acute Cardiovascular Care, and European Association of Percutaneous Cardiovascular Interventions followed the ESC methodology for QI development. This methodology involved (i) the identification of the domains of ACS care for the diagnosis and management of ACS; (ii) the construction of candidate QIs through a systematic review of the literature; and (iii) the selection of the final set of QIs (using a modified Delphi method). Five domains of care for the diagnosis and management of ACS were identified: (i) structural framework and logistics, (ii) in-hospital non-invasive care, (iii) invasive strategy and periprocedural management, (iv) secondary prevention interventions, and (v) outcomes. In total, 21 main QIs were selected, covering all five domains of care for the diagnosis and management of ACS.

CONCLUSION

This document defines the five domains of ACS care and provides 21 QIs for the diagnosis and management of ACS. The updated ESC QIs for ACS may be used for quality improvement initiatives.

Complete Revascularisation Following Acute MI: A Contemporary Review

Acute MI (AMI) is a leading cause of mortality globally. Swift diagnosis is imperative, with timely reperfusion crucial to minimise adverse outcomes. Revascularisation strategies include culprit-vessel-only therapy, staged complete revascularisation or immediate complete revascularisation. Evidence from randomised trials strongly favours complete revascularisation in ST-elevation MI (STEMI). Data regarding immediate complete revascularisation compared to a staged approach are limited, with uncertainties regarding the advantages of physiology-guided treatment compared to angiographic assessment alone. Non-STEMI (NSTEMI) patients with multivessel disease are often complex and current guidelines offer limited recommendations for this patient group, emphasising the need for individualised treatment. Observational studies have sought to find the optimal approach, yet conflicting data prevails. Dedicated trials for this issue in NSTEMI patients are currently unavailable. To enhance the decision-making processes for patients with AMI, future trials should consider the inclusion of functional health status and health-related quality of life outcomes. The existing gaps in knowledge underscore the intricacies of managing AMI and the ongoing necessity for comprehensive research to refine treatment strategies.

Effect of Global Longitudinal Strain at Discharge Period on Predicting Cardiac Defibrillator Implantation in STEMİ Patients with Impaired Left Ventricle Systolic Functions

Background and Objectives: Contemporary studies have shown that low ejection fraction (EF) is a significant predictor of sudden cardiac death in ischemic heart failure. However, relying solely on EF and waiting 90 days for ICD implantation is inadequate for preventing sudden death in STEMI patients. Materials and Methods: This study aims to explore if left ventricular global longitudinal strain (GLS) measured at discharge can predict EF < 35% at the third-month follow-up in STEMI patients with impaired systolic function (EF < 35%). The study involved 69 patients diagnosed with STEMI. The results from 29 patients with EF ≤ 35% and 40 patients with EF between 36 and 49% were compared. Echocardiographic images were recorded, and the LV GLS value was measured. Results: In both univariate and multivariate regression analyses, LV GLS at discharge was the only independent predictor of EF ≤ 35% after three months. An LV GLS value below 9.55% at discharge predicted an EF below 35% at 90 days, with 75% sensitivity and 76.5% specificity (AUC = 0.814, p = 0.005). Conclusions: Current guidelines recommend waiting three months before ICD implantation in STEMI patients with EF ≤ 35%, but this study suggests that low GLS can help identify high-risk patients earlier, potentially reducing the waiting period for ICD implantation.

Sex-specific outcomes in myocardial infarction: a dual-cohort analysis using clinical and real-world data

BACKGROUND

Sex-related differences in symptoms, treatment, and outcomes in patients presenting with myocardial infarction have been reported but vary largely between studies. We sought to characterize sex differences in presentation and outcomes of patients with acute ST segment elevation myocardial infarction (STEMI) undergoing primary percutaneous intervention (PPCI).

METHODS AND RESULTS

We included 1206 STEMI patients from a clinical cohort and 35,123 STEMI patients obtained from the German health insurance claims. Women, despite being older and thus having a worse cardiovascular risk profile, had greater myocardial salvage and smaller infarct size than men in all patients (median with [interquartile ranges (25th-75th percentiles), IQR]; salvage index: 0.58 [IQR: 0.32-0.91] in females vs. 0.47 [IQR: 0.23-0.77] in males, p < 0.0001; infarct size: 7.0% [IQR: 1.0-22.0%] in females vs. 11.0% [IQR: 3.0-23.0%] of the left ventricle in males, p = 0.002). Same results were shown for propensity score matched pairs (n = 242) (salvage index: 0.60 [IQR: 0.33-0.91] in females vs. 0.44 [IQR: 0.23-0.70] in males, p = 0.0002; infarct size: 7.0% [IQR: 1.0-23.0%] vs. 10% [IQR: 3.0-23.0%] of the left ventricle in males, p = 0.042). Furthermore, women showed a lower risk of 5-year mortality, assessed after propensity score matching, in the health insurance cohort (n = 19,404) (HR = 0.92 [95% CI 0.87-0.97], p = 0.002).

CONCLUSIONS

In patients with STEMI, women appear to have better myocardial salvage and smaller infarct size after PPCI and a lower 5-year mortality compared with men, suggesting better ischemic tolerance in female patients.

Sodium-Glucose Cotransporter-2 Inhibitors After Acute Myocardial Infarction

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are a specific class of drugs originally developed for treating type 2 diabetes mellitus. Subsequently, studies demonstrated that their action was not limited to glycemic control but could also have positive effects on other specific outcomes, particularly at the cardiovascular level. Indeed, due to their diuretic effect, SGLT2i improve the clinical control of chronic heart failure and reduce the risk of rehospitalization. In addition, other studies reported a protective effect on major cardiovascular events and mortality. More recently, it has been suggested that the prescription of SGLT2i after an acute myocardial infarction may have positive effects due to their possible effect on inflammation, arrhythmias, and ventricular remodeling. Here, we reviewed studies focused on SGLT2i after an acute myocardial infarction in patients treated with percutaneous coronary intervention.

Inflammatory and Bleeding Risks on Clinical Outcomes in Acute Coronary Syndrome Patients Undergoing Percutaneous Coronary Intervention

This study aimed to evaluate the impact of systemic inflammation burden using high-sensitivity C-reactive protein (hsCRP) and long-term prognosis in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) stratified by bleeding risk status.Consecutive patients admitted for ACS and who received PCI between March 2016 and March 2022 were enrolled in the analysis. Elevated systemic inflammation was defined as hsCRP >2 mg/L, and high bleeding risk (HBR) was defined the Academic Research Consortium (ARC)-HBR criteria. The primary outcome was ischemic events at 12 months, composed of cardiac death, myocardial infarction, and/or stroke. The main secondary outcomes included all-cause death, and Bleeding Academic Research Consortium (BARC) types 2, 3, and 5 bleeding and types 3 and 5 bleeding.Of 15,013 patients, 4,606 (30.7%) were qualified as HBR and 8,395 (55.9%) had hsCRP >2 mg/L. Elevated hsCRP was consistently associated with higher risk of ischemic events in both HBR (adjusted hazard ratio [aHR]: 1.20; 95% confidence interval [CI]: 0.91-1.58) and non-HBR (aHR: 1.34; 95% CI: 1.01-1.78) subgroups (P interaction = 0.755). Although the incidence of bleeding events was higher in HBR patients, an elevated hsCRP level was not associated with bleeding events regardless of HBR status. Restricted cubic spline regression represented an inverse J-shaped relation between hsCRP and non-HBR for ischemic events (P nonlinearity <0.001) and all-cause death (P nonlinearity = 0.003).Regardless of HBR status, high levels of hsCRP were associated with an increased risk of ischemic events and all-cause death in ACS patients following PCI, but not for bleeding.

The Development of a Nomogram Predictive Model for Intracardiac Thrombosis Risk: A Study Based on Risk Factors in Patients with Acute Myocardial Infarction

Background/Objectives: Intracardiac thrombosis (ICT) is a serious complication in acute myocardial infarction (AMI) patients. This study aimed to identify potential risk factors of ICT in AMI patients, providing valuable insights for clinical management. Methods: A case-control study was conducted involving consecutive AMI patients admitted to the First Affiliated Hospital of Xi'an Jiaotong University between January 2019 and December 2022. Binary logistic regression identified independent risk factors of ICT and a nomogram prediction model was constructed and validated for accuracy. Conclusions: A total of 7341 patients with ICT and 74 without ICT were included. Multivariate logistic regression identified male gender, acute anterior wall myocardial infarction (AWMI), ventricular aneurysm, and lower prothrombin activity as independent risk factors of ICT in AMI patients. A nomogram based on these factors demonstrated excellent performance (AUC: 0.910, 95% CI: 0.877-0.943, p < 0.001), with calibration and sensitivity analyses confirming its robustness. This nomogram provides an accurate tool for predicting ICT risk, facilitating personalized management and early intervention in AMI patients.

Nomogram Predicting In-Hospital Mortality in Patients with Myocardial Infarction Treated with Primary Coronary Interventions Based on Logistic and Angiographic Predictors

Background: Systems developed in recent years to assess the risk of in-hospital death in patients with myocardial infarction (MI) are mainly based on angiographic, electrocardiographic, and laboratory variables. Risk systems based on contemporary angiographic data and logistic variables have not been reported. The aim of this study was to develop and validate a system to assess the risk of in-hospital death in patients across the entire clinical spectrum of MI treated with primary coronary intervention (PCI) based on modern angiographic and logistic predictors. Methods: A subgroup of patients from the observational single-centre registry of MI treated with PCIs (from 1 February 2019 until 31 January 2020) was used to develop a multivariate logistic regression model predicting in-hospital mortality. The population (603 patients) was divided, with 60% of the sample used for model derivation and the remaining 40% used for internal model validation. Results: The main findings were as follows: (1) coronary angiography results and suboptimal flow after PCI were important predictors of in-hospital mortality; (2) the time of PCI as well as the mode of presentation of patients with MI contributed to in-hospital mortality; and (3) the discrimination (C statistic = 0.848, 95% CI: [0.765, 0.857]) and calibration (χ2 = 2.78, pHL = 0.94) were good in the derivation set, while the discrimination (C statistic = 0.6438, 95% CI: [0.580, 0.703]) in the validation set was satisfactory. Conclusions: A novel clinical nomogram based on four available logistic and angiographic variables was developed and validated for in-hospital mortality after PCIs in a wide range of MIs.

Artificial Intelligence-Powered Electrocardiogram Detecting Culprit Vessel Blood Flow Abnormality: AI-ECG TIMI Study Design and Rationale

Background

The 12-lead electrocardiogram (ECG) is the gold standard for detecting patients who will benefit from emergent revascularization due to occlusive myocardial infarction (OMI). However, the pathophysiology of acute coronary syndromes (ACS) is dynamic, and nearly half of patients with OMI do not present with typical ST elevation or have dynamic ECG changes due to spontaneous recanalization before invasive coronary angiography (ICA). Recently, an ECG-based artificial intelligence (AI) model was developed using expert interpretation of OMI. However, its performance is limited to retrospective evaluation of ECGs recorded minutes to hours before ICA.

Methods

The AI-ECG thrombolysis in myocardial infarction (TIMI) study is an investigator-initiated prospective multicenter registry planning to enroll over 700 consecutive patients with ACS undergoing ICA in 9 centers across Europe. For all participants, a standard 10-second 12-lead ECG will be recorded at the time of coronary angiography. The primary end point is the AI model's ability to identify patients with an actively occluded (TIMI 0-1) culprit coronary artery at the time of invasive coronary angiography using only single-standard 12-lead ECGs. Standardized angiograms will be used as a reference standard.

Conclusions

AI-ECG TIMI is the first prospective registry of consecutive patients with ACS with standard 12-lead ECGs recorded at the very moment of ICA. This study will help characterize ECG findings of abnormal myocardial perfusion due to acute active ischemia and prospectively validate an AI model's ability to detect them.

The Dual Role of Oxidative Stress in Atherosclerosis and Coronary Artery Disease: Pathological Mechanisms and Diagnostic Potential

Oxidative stress plays a pivotal role in the pathogenesis of atherosclerosis and coronary artery disease (CAD), with both beneficial and detrimental effects on cardiovascular health. On one hand, the excessive production of reactive oxygen species (ROS) contributes to endothelial dysfunction, inflammation, and vascular remodeling, which are central to the development and progression of CAD. These pathological effects drive key processes such as atherosclerosis, plaque formation, and thrombosis. On the other hand, moderate levels of oxidative stress can have beneficial effects on cardiovascular health. These include regulating vascular tone by promoting blood vessel dilation, supporting endothelial function through nitric oxide production, and enhancing the immune response to prevent infections. Additionally, oxidative stress can stimulate cellular adaptation to stress, promote cell survival, and encourage angiogenesis, which helps form new blood vessels to improve blood flow. Oxidative stress also holds promise as a source of biomarkers that could aid in the diagnosis, prognosis, and monitoring of CAD. Specific oxidative markers, such as malondialdehyde (MDA), isoprostanes (isoP), ischemia-modified albumin, and antioxidant enzyme activity, have been identified as potential indicators of disease severity and therapeutic response. This review explores the dual nature of oxidative stress in atherosclerosis and CAD, examining its mechanisms in disease pathogenesis as well as its emerging role in clinical diagnostics and targeted therapies. The future directions for research aimed at harnessing the diagnostic and therapeutic potential of oxidative stress biomarkers are also discussed. Understanding the balance between the detrimental and beneficial effects of oxidative stress could lead to innovative approaches in the prevention and management of CAD.

Circulating Microvesicles Enriched in miR-126-5p and miR-223-3p: Potential Biomarkers in Acute Coronary Syndrome

Background. The molecular mechanisms underlying acute coronary syndrome (ACS) have been extensively investigated, with a particular focus on the role of circulating microvesicles (MVs) as carriers of regulatory elements that influence hemodynamic changes and coronary flow. Endothelial and platelet dysfunction during ACS alters MV composition, impacting clinical outcomes. This study explores the levels of miR-126-5p and miR-223-3p in circulating MVs and their association with the Thrombolysis in Myocardial Infarction (TIMI) coronary flow classification scale, proposing their potential as biomarkers. Methods. Bioinformatic tools identified miRNAs linked to ACS. Plasma MVs were isolated from ACS patients and healthy controls through high-speed centrifugation. miRNA levels were quantified using quantitative reverse transcription polymerase chain reaction (qRT-PCR) and compared across TIMI 0 and TIMI 3 groups. Diagnostic efficacy was assessed via receiver operating characteristic (ROC) curve analysis. Results. The bioinformatic analysis identified miR-126 and miR-223 present in ACS. miR-126-5p and miR-223-3p were significantly reduced in MVs from TIMI 0 patients compared to TIMI 3. ROC analysis showed high diagnostic accuracy for miR-126-5p (AUC = 0.918; 95% CI: 0.818-1.00; p = 0.001) and miR-223-3p (AUC = 1.00; 95% CI: 1.00-1.00; p < 0.001). Conclusions. Reduced levels of miR-126-5p and miR-223-3p in circulating MVs are strongly associated with impaired coronary flow, positioning these miRNAs as potential biomarkers for ACS risk stratification and therapeutic targeting.

Clinical characteristics and outcomes of patients undergoing percutaneous coronary intervention at Gesund Cardiac and Medical Center, Addis Ababa, Ethiopia, 2024

INTRODUCTION

Percutaneous coronary intervention (PCI) is a critical procedure for improving blood flow by alleviating arterial blockage. However, its availability in Ethiopia is limited because of insufficient resources, staff, and infrastructure.

OBJECTIVE

To evaluate the clinical characteristics and outcomes of patients who underwent percutaneous coronary intervention at Gesund Cardiac and Medical Center in Addis Ababa, Ethiopia, in 2024.

METHODS

This retrospective observational chart review included 224 patients who underwent percutaneous coronary intervention. Data were collected using a standardized checklist, imported into EPI information v7, and analyzed using SPSS v26. A binary logistic regression model was used to identify factors associated with percutaneous coronary intervention.

RESULTS

The study found that most participants (n = 186, 83%) were male, with a mean age of 57.82 ± 11.5 years. Diabetes mellitus was prevalent among participants (n = 135, 60.3%), followed by hypertension (n = 127, 56.7%). A notable portion (n = 31, 13.8%) had previously undergone percutaneous coronary intervention. Most patients presented with typical chest pain, with ST-Elevation Myocardial Infarction (STEMI) being the primary indication for percutaneous coronary intervention. Post-procedure complications includes significant bleeding (n = 6, 2.6%), myocardial infarction (n = 20, 8.9%), death (n = 2, 0.9%), transfer to another hospital (n = 12, 5.4%), and acute kidney injury (n = 16, 7.14%). The use of bare metal stents was significantly associated with transfer to other hospitals (AOR = 5; 95% CI = 1.69-10.29). Male gender (AOR = 0.09; 95% CI = 0.03-0.34) and a history of myocardial infarction (AOR = 10; 95% CI = 2.31-13.31) were linked to an increased risk of post-percutaneous coronary intervention death.

CONCLUSION AND RECOMMENDATIONS

Our findings suggest that coronary artery stenosis (CAS) is more prevalent in older individuals and men. Chronic illnesses often coexist with coronary artery stenosis, thereby complicating the prognosis. Interestingly, men exhibited a lower risk of unfavorable outcomes compared to women. Adherence to procedural guidelines and effective management techniques are essential for improving patient outcomes following percutaneous coronary intervention.

A Mathematical Exploration of the Effects of Ischemia-Reperfusion Injury After a Myocardial Infarction

INTRODUCTION

After myocardial infarction (MI), the heart undergoes necrosis, inflammation, scar formation, and remodeling. While restoring blood flow is crucial, it can cause ischemia-reperfusion (IR) injury, driven by reactive oxygen species (ROSs), which exacerbate cell death and tissue damage. This study introduces a mathematical model capturing key post-MI dynamics, including inflammatory responses, IR injury, cardiac remodeling, and stem cell therapy. The model uses nonlinear ordinary differential equations to simulate these processes under varying conditions, offering a predictive tool to understand MI pathophysiology better and optimize treatments.

METHODS

After myocardial infarction (MI), left ventricular remodeling progresses through three distinct yet interconnected phases. The first phase captures the immediate dynamics following MI, prior to any medical intervention. This stage is mathematically modeled using the system of ordinary differential equations: The second and third stages of the remodeling process account for the system dynamics of medical treatments, including oxygen restoration and subsequent stem cell injection at the injury site.

RESULTS

We simulate heart tissue and immune cell dynamics over 30 days for mild and severe MI using the novel mathematical model under medical treatment. The treatment involves no intervention until 2 h post-MI, followed by oxygen restoration and stem cell injection at day 7, which is shown experimentallyand numerically to be optimal. The simulation incorporates a baseline ROS threshold (Rc) where subcritical ROS levels do not cause cell damage.

CONCLUSION

This study presents a novel mathematical model that extends a previously published framework by incorporating three clinically relevant parameters: oxygen restoration rate (ω), patient risk factors (γ), and neutrophil recruitment profile (δ). The model accounts for post-MI inflammatory dynamics, ROS-mediated ischemia-reperfusion (IR) injury, cardiac remodeling, and stem cell therapy. The model's sensitivity highlights critical clinical insights: while oxygen restoration is vital, excessive rates may exacerbate ROS-driven IR injury. Additionally, heightened patient risk factors (e.g., smoking, obesity) and immunodeficiency significantly impact tissue damage and recovery. This predictive tool offers valuable insights into MI pathology and aids in optimizing treatment strategies to mitigate IR injury and improve post-MI outcomes.

Part 2-Cardiac Rehabilitation After an Acute Myocardial Infarction: Timing and Gender Differences in Adherence; Where Do We Stand?

Cardiac rehabilitation is a beneficial multidisciplinary interventional protocol that improves cardiovascular health and reduces mortality and morbidity rates in patients with cardiovascular diseases. Multiple studies have demonstrated that the implementation of such protocols in patients with acute myocardial infarction (MI) dramatically improved patients' outcome. It is unfortunate that in practice, in spite of the advantages of cardiac rehabilitation, this approach is seldom employed. Indeed, only some guidance, such as American College of Cardiology and European Society of Cardiology guidelines, recommends cardiac rehabilitation in their protocols. In particular, the European guideline recommends its early implementation while the patient is still in hospital, whereas the American guideline suggests that it should be approximately three weeks after discharge. In Part 1 of this two-part comprehensive review, we provided a historical overview of cardiac rehabilitation, a detailed examination of each component of the cardiac rehabilitation programme, and its impact on cardiovascular health. In Part 2, the objective was to provide a comprehensive explanation of the optimal timing for the commencement of the cardiac rehabilitation programme, and to elucidate the factors that influence low engagement in such programmes, as well as the gender-based differences in adherence.

Part 1-Cardiac Rehabilitation After an Acute Myocardial Infarction: Four Phases of the Programme-Where Do We Stand?

Cardiac rehabilitation is a well-established multidisciplinary interventional protocol that plays a pivotal role in the management and prevention of future cardiovascular events in patients with cardiovascular diseases. This patient-tailored approach includes educating patients about their cardiovascular condition and how to control the associated risk factors, an expert-designed lifestyle modification plan that may include exercise, proper nutrition, pharmacological treatment, and psychological support at each step. Exercise training represents a fundamental component of cardiac rehabilitation. It facilitates an enhancement of cardiovascular fitness, a reduction in heart rate, blood pressure and cardiac remodeling, an increase in the left ventricular ejection fraction, the optimization of endothelial function, and a reduction in inflammation and oxidative stress. Moreover, the beneficial physiological changes resulting from cardiac rehabilitation contribute to a reduction in morbidity and mortality in survivors of myocardial infarction (MI). Furthermore, the European Society of Cardiology Guidelines advocate for the initiation of cardiac rehabilitation as early as possible, while the patient who survived MI is still in hospital. This two-part comprehensive review commences with a historical overview of cardiac rehabilitation, followed by a detailed exploration of the four phases of the cardiac rehabilitation programme and its impact on cardiovascular health. In Part 2, the study aims to provide a detailed account of the optimal timing for starting cardiac rehabilitation programs and to examine the factors affecting low engagement in such programs, as well as gender-based differences in adherence.

Age-Related Outcomes in Patients Undergoing Coronary Angiography: In Which Subgroups Does Age Matter? Results from a Large-Scale Retrospective Registry

Background: The study investigates age-related differences in the prevalence and extent of coronary artery disease (CAD), as well as long-term outcomes in a large cohort of unselected patients undergoing invasive coronary angiography (CA). The aging population, along with an increasing number of older and multi-morbid patients undergoing CA, poses challenges for healthcare systems. Despite this, studies investigating age-related differences in the long-term outcomes of unselected patients undergoing CA are limited. Methods: Consecutive patients undergoing invasive CA from 2016 to 2022 were included from one institution. The prognosis of patients undergoing CA stratified by pre-specified age groups (i.e., 40-<60, 60-<80 and ≥80 years) was investigated with regard to the primary endpoint of rehospitalization for heart failure (HF), as well as the risks of acute myocardial infarction (AMI) and coronary revascularization at 36 months. Results: From 2016 to 2022, 7520 patients undergoing CA were included with a median age of 70 years (mean: 69 years). The prevalence of CAD (61.9% vs. 71.8% vs. 77.3%; p = 0.001), as well as the prevalence of three-vessel CAD (21.0% vs. 31.5% vs. 36.1%) increased with age. At 36 months, patients ≥ 80 years of age had the highest rates of rehospitalization for HF, followed by patients 60-<80 years and patients 40-<60 years (28.4% vs. 23.2% vs. 14.0%; p = 0.001). Consequently, compared to younger patients (i.e., 40-<60 years of age), those ≥80 years of age exhibited the highest risk of HF-related rehospitalization (≥ 80 years: HR = 2.205; 95% CI 1.884-2.579; p = 0.001), followed by those 60-< 80 years (HR = 1.765; 95% CI 1.536-2.029; p = 0.001). The increased risk of rehospitalization for HF at 36 months was still observed after multivariable adjustment (i.e., ≥80 years: HR = 1.265; 95% CI 1.049-1.524; p = 0.014; 60-<80 years: HR = 1.339; 95% CI 1.145-1.565; p = 0.001) and was specifically evident in patients with left ventricular ejection fraction ≥ 35% and in patients without evidence of CAD/single-vessel CAD. In contrast, the rates of AMI and coronary revascularization at 36 months did not differ significantly among different age groups. Conclusions: Advanced age is an independent predictor of rehospitalization for HF in patients undergoing CA, but not AMI and revascularization during long-term follow-up. This highlights the importance of optimizing diagnostic and therapeutic strategies for HF, particularly in older patients undergoing CA.

Sex-Based Differences and Outcomes in Unselected Patients Undergoing Coronary Angiography

Background: The study investigates sex-related differences and outcomes in unselected patients undergoing invasive coronary angiography (CA). Sex-based differences with regard to baseline characteristics and management of patients with cardiovascular disease have yet been demonstrated. However, their impact on long-term outcomes in unselected patients undergoing CA remains unknown. Methods: Consecutive patients undergoing invasive CA from 2016 to 2022 were included at one institution. Prognosis of male and female patients undergoing CA was investigated with regard to the primary endpoint of rehospitalization for heart failure (HF) at 36 months. Secondary endpoints comprised the risk of acute myocardial infarction (AMI) and coronary revascularization at 36 months, as well as in-hospital all-cause mortality. Statistical analyses included Kaplan-Meier analyses, as well as uni- and multivariable Cox proportional regression analyses. Results: From 2016 to 2022, 7691 patients undergoing CA were included (males: 65.1%; females: 34.9%). Males had a higher prevalence of coronary artery disease (CAD) (76.2% vs. 57.4%; p = 0.001), alongside a higher prevalence of 3-vessel CAD compared to females (33.9% vs. 20.3%; p = 0.001). The risk of rehospitalization for HF at 36 months was higher in males compared to females (22.4% vs. 20.3%; p = 0.036; HR = 1.127; 95% CI: 1.014-1.254; p = 0.027), which was no longer observed after multivariable adjustment. Male sex was associated with a higher risk of coronary revascularization (9.6% vs. 5.9%; p = 0.001; HR = 1.659; 95% CI: 1.379-1.997; p = 0.001), which was still evident after multivariable adjustment (HR = 1.650; 95% CI 1.341-2.029; p = 0.001). However, neither the risk of AMI at 36 months (8.1% vs. 6.9%; p = 0.077), nor the risk of in-hospital all-cause mortality (6.9% vs. 6.5%; p = 0.689) differed significantly between the two sexes. Conclusions: In consecutive patients undergoing coronary angiography, male sex was independently associated with an increased risk of coronary revascularization, but not HF-related rehospitalization.

Predictive value of the Naples prognostic score for no-reflow phenomenon after saphenous vein graft stenting

BACKGROUND

No-reflow is a critical adverse event associated with percutaneous coronary intervention (PCI), particularly during saphenous vein graft (SVG) procedures. The Naples Prognostic Score (NPS) reflects inflammatory status, but its relationship with no-reflow remains unclear. Therefore, we aimed to evaluate the relationship between NPS and no-reflow occurrence following SVG PCI.

METHODS

We retrospectively analyzed 286 patients who underwent SVG PCI from January 2020 to January 2024, with a median age of 65 years and 85.7% male. Participants were categorized into low NPS (0-2, 48.6%) and high NPS (3-4, 51.4%) groups. Two nested models were developed by adding NPS (continuous and categorical, respectively) to the base model.

RESULTS

Higher no-reflow rates were noted in the high-NPS group (48.5% vs. 9.5%, p < 0.05). Multivariable regression revealed that a higher NPS significantly increased no-reflow risk, with odds ratios of 5.966 (95% CI: 3.066-11.611) for continuous NPS and 10.110 (95% CI: 3.194-32.002) for categorical NPS. Adding NPS to the base model significantly improved predictive performance (likelihood-ratio test p < 0.001). Model 1 demonstrated the best performance (X2 : 84.857, R2 : 0.468) and discriminative ability (AUC: 0.888).

CONCLUSION

Our findings suggest that NPS is a strong predictor of no-reflow following SVG PCI.

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

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

Hypercholesterolemia and inflammation-Cooperative cardiovascular risk factors

BACKGROUND

Maintaining low concentrations of plasma low-density lipoprotein cholesterol (LDLc) over time decreases the number of LDL particles trapped within the artery wall, slows the progression of atherosclerosis and delays the age at which mature atherosclerotic plaques develop. This substantially reduces the lifetime risk of atherosclerotic cardiovascular disease (ASCVD) events. In this context, plaque development and vulnerability result not only from lipid accumulation but also from inflammation.

RESULTS

Changes in the composition of immune cells, including macrophages, dendritic cells, T cells, B cells, mast cells and neutrophils, along with altered cytokine and chemokine release, disrupt the equilibrium between inflammation and anti-inflammatory mechanisms at plaque sites. Considering that it is not a competition between LDLc and inflammation, but instead that they are partners in crime, the present narrative review aims to give an overview of the main inflammatory molecular pathways linked to raised LDLc concentrations and to describe the impact of lipid-lowering approaches on the inflammatory and lipid burden. Although remarkable changes in LDLc are driven by the most recent lipid lowering combinations, the relative reduction in plasma C-reactive protein appears to be independent of the magnitude of LDLc lowering.

CONCLUSION

Identifying clinical biomarkers of inflammation (e.g. interleukin-6) and possible targets for therapy holds promise for monitoring and reducing the ASCVD burden in suitable patients.

Scp776, A Novel IGF-1 Fusion Protein for Acute Therapy to Promote Escape From Apoptosis in Tissues Affected by Ischemic Injury: 2 Randomized Placebo-Controlled Phase 1 Studies in Healthy Adults

Apoptosis is a major driver of cell loss and infarct expansion in ischemic injuries such as acute ischemic stroke (AIS) and acute myocardial infarction (AMI). Insulin-like growth factor-1 (IGF-1) can mitigate cell death and potentiate recovery following acute ischemic injury, but short half-life and nonspecificity limit its therapeutic potential. Scp776 is an IGF-1 fusion protein designed to target damaged tissue and promote apoptosis escape and is in clinical development as an acute therapy for AIS and AMI. Two phase 1 placebo-controlled studies in healthy volunteers evaluated safety, tolerability, pharmacokinetic profile, and pharmacodynamics under single (1, 2, or 4 mg/kg) or multiple (6, 6.2, or 7.25 mg/kg total doses) dosing regimens. In addition, a blood glucose management plan was developed and implemented to mitigate hypoglycemia that may develop following scp776 injection. Scp776 was well tolerated in healthy volunteers (n = 51) without serious adverse events. Exposure increased in a near dose-proportional manner with a mean half-life across all doses of 8 hours. Adaptive dextrose infusions maintained normal blood glucose levels with occasional mild hypoglycemic events. These results informed scp776 dose selection and the design of blood glucose monitoring protocols for phase 2 studies.

Effects of stress hyperglycemia ratio upon long-lasting prognosis in coronary artery disease patients with or lacking chronic renal impairment: findings from a Chinese multi-center observational study

BACKGROUND

Lately, numerous researches have portrayed stress hyperglycemia ratio (SHR) is predominantly connected with short-term adverse prognosis among individuals who have acute coronary syndrome. Nevertheless, the relation of SHR with prolonged effects and the value of SHR in predicting in coronary artery disease (CAD) patients with or lacking chronic kidney disease (CKD) remain unclear. The present study was designed to elucidate the relation of SHR with prolonged prognosis and the value of SHR in predicting the long-term all-cause and cardiovascular death of CAD patients with CKD or non-CKD.

METHODS

We assessed 45,780 adults with CAD from a Chinese multi-center registry. SHR was computed via a formula [SHR = (admission glucose) (mmol/L) / (1.59 * HbA1c [%] - 2.59)]. Based on the presence or absence of CKD and SHR levels, patients were categorized into four groups. Long-term all-cause and cardiovascular mortality were the primary endpoints. The Kaplan-Meier method, restricted cubic spline (RCS), cox regression analysis, subgroups analysis, and sensitivity analysis were employed to estimate the connection between SHR and all-cause as well as cardiovascular mortality.

RESULTS

During a median follow-up of 5.2 years ( IQR 3.0-8.0), among 45,780 CAD patients (mean age [SD]: 62.8 ± 10.6 years; 23.9% female), the number of all-cause deaths was 7144(15.6%), and cardiovascular-related deaths was 3255 (7.1%). In cohorts with CKD, patients with high SHR had higher all-cause mortality (30.2% vs. 27.6%; adjusted hazard ratio HR 1.13, 95% CI 1.04-1.22; P = 0.003) and cardiovascular mortality (18.2% vs. 15.6%; HR adjusted 1.17, 95% CI 1.06-1.30; P = 0.002) compared to the individuals in low SHR. However, this was not the case in CAD cohorts without CKD [all-cause mortality (12.9% vs. 11.9%; HR adjusted 1.04, 95%CI 0.98-1.10, P = 0.206); cardiovascular mortality (5.1% vs. 4.4%; HR adjusted 1.09, 95%CI 0.99-1.20, P = 0.084)]. KM analysis revealed that high SHR is linked with all-cause mortality [CKD (log-rank P < 0.001); no-CKD (log-rank P = 0.024)] and cardiovascular mortality [CKD (log-rank P < 0.001); no-CKD (log-rank P = 0.01)] in CAD patients with or without CKD. RCS demonstrated that the relation between SHR and all-cause mortality was U-shaped after full modification, which was shown for CKD patients (P for non-linearity = 0.003) and also for patients without CKD (P for non-linearity = 0.001). Analogous effects were discovered for cardiovascular mortality, which was the case for CKD patients (P for non-linearity < 0.001) and also for patients without CKD (P for non-linearity = 0.001).

CONCLUSIONS

Among patients with CAD, an elevated stress hyperglycemia ratio (SHR) is implicated in a heightened risk of long-term outcomes, particularly in those with CKD. This signifies that SHR might have a latent function in the cardiovascular risk categorization of the CAD population.

Reversible right bundle branch block caused by spasm of the anterior septal branch: case report

BACKGROUND

Coronary Artery Spasm (CAS) often presents in the epicardial coronary arteries. The anterior septal branch is distributed within the myocardium, and occurrences of spasms are rare. Currently, there is no available literature on this topic, and the onset of symptoms remains elusive, potentially leading to misdiagnosis.

CASE PRESENTATION

We present a case of acute myocardial infarction (AMI) caused by spasm in the anterior septal branch, accompanied by transient right bundle branch block (RBBB). The administration of nitroglycerin via intracoronary injection resulted in the alleviation of spasm in the anterior septal branch and the disappearance of RBBB. After the administration of anti-coronary spasm medications, the patient exhibited favorable recovery outcomes. No episodes of myocardial ischemia were observed during the six-month follow-up.

CONCLUSIONS

The presence of new RBBB in patients may warrant consideration of anterior septal coronary artery spasm, which necessitates urgent coronary angiography to clarify the underlying cause and facilitate the prompt initiation of anti-spasm treatment.

Advances in Atrial Fibrillation Management: A Guide for General Internists

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, impacting approximately 6.1 million adults in the United States, with projections to increase two-fold by 2030. AF significantly increases the risk of stroke and other adverse cardiovascular events, leading to increased morbidity and mortality. The 2023 ACC/AHA/ACCP/HRS guidelines present a paradigm shift in AF management, moving from a duration-based classification to a more comprehensive, patient-centered approach. This includes a novel AF classification system that emphasizes early detection and intervention, including risk factors and lifestyle modification tailored to each patient's risk profile. Moreover, the recommendations advocate for a multidisciplinary care model, ensuring coordinated management involving primary care providers and specialists. Primary care providers play a crucial role in initiating risk factor management and lifestyle interventions, even before the development of AF. This review aims to thoroughly examine the guidelines for the diagnosis and management of AF and equip general internists with the necessary insights to navigate the evolving landscape of AF care effectively.

An Atypical Presentation of Acute Cholecystitis with Left Sided Chest Pain and ST Elevation - A Case Report

Background

ST elevation combined with typical chest pain is an indication for acute coronary vascularization and is usually associated with acute myocardial infarction. Herein, we present an unusual case of ST elevation.

Case Presentation

A 57-year-old male patient presented to the emergency department with chest pain radiating to both arms and the back. Typical clinical presentation and inferolateral ST elevations were suggestive of ST elevation myocardial infarction. Interestingly, coronary occlusion was excluded by coronary angiography. Despite extensive diagnostic workup, no underlying diagnosis was made. Four days later, the patient returned and reported pain in the right upper abdomen. Clinical presentation, laboratory analysis, and imaging features led to a diagnosis of calculous acute cholecystitis. Laparoscopic cholecystectomy was performed, and the diagnosis was confirmed. Electrocardiographic changes and pain resolved completely.

Conclusion

Acute calculous cholecystitis is initiated by gallbladder distension due to biliary duct occlusion caused by gallstones. ST elevations in response to gallbladder distension have been demonstrated in animal models. We hypothesize that the ST elevations observed in this patient with chest pain were linked to stone-mediated distension of the gallbladder, leading to reflex coronary vasoconstriction.

ST-Segment Elevation: Hypocalcemia or Takotsubo Syndrome? A Diagnostic Dilemma

A wide range of etiologies, both ischemic and nonischemic, can produce an electrocardiographic pattern of ST-segment elevation (STE), including Takotsubo syndrome (TTS) and electrolyte imbalances. Instances of hypocalcemia-induced TTS and STE are exceedingly rare in medical literature. This paper presents the case of a 75-year-old woman with advanced ovarian cancer and no prior heart issues, who exhibited diffuse STE on electrocardiogram, resembling acute coronary syndrome. Additionally, echocardiography suggested left ventricle apical ballooning, as per TTS, in the context of severe hypocalcemia and elevated troponin I level. After confirming no coronary artery disease via angiography, we administered calcium supplementation. Subsequently, the electrocardiogram displayed widespread giant T-wave inversions, and the patient's cardiac function fully recovered on normalization of calcium levels within few days. This case serves to highlight the importance of recognizing rare causes of STE (eg, hypocalcemia-induced cardiomyopathy), particularly in patients with neoplastic condition. However, the precise mechanism underlying a potential hypocalcemia-induced TTS remains to be elucidated, and there are only a limited number of case reports in the literature. In light of the aforementioned considerations, we propose a comprehensive examination of cases associated with hypocalcemia and STE and left ventricular systolic impairment.

Does Chronic Kidney Disease Influence Revascularization Strategy After Acute Coronary Syndrome? A Systematic Review and Meta-Analysis

Background

Coronary artery bypass grafting (CABG) provides superior long-term outcomes to percutaneous coronary intervention (PCI) for complex multivessel coronary artery disease (CAD). People with chronic kidney disease (CKD) have increased prevalence of multivessel CAD, but also increased surgical risk. We investigated whether CKD predicted real-world use of CABG, versus PCI, in patients revascularized for acute coronary syndrome (ACS).

Methods

Embase, MEDLINE, Scopus and CENTRAL were searched to identify articles referring to ACS and invasive coronary intervention in high-income countries (2012 - 2023). Articles were included if CABG rates were reported in ACS patients with and without CKD receiving revascularization. CKD was defined as an estimated glomerular filtration rate < 60 mL/min/1.73 m2; proxy definitions were accepted. Random effect meta-analyses were used to determine the average effect of CKD on odds of CABG, stratified by ACS type and dialysis use.

Results

Searches generated 15,138 articles, of which 13 observational studies were included (n = 1,682,207). Amongst revascularized ACS patients, those with CKD were more likely to receive CABG than those without (pooled odds ratio (OR) = 1.50 (95% confidence interval (CI) = 1.30 - 1.72). This association was stronger following ST-elevation myocardial infarction (STEMI) than non-ST-elevation ACS (NSTE-ACS) (OR: 1.54 (95% CI: 1.23 - 1.93)) versus 1.16 (1.10 - 1.23), respectively).

Conclusions

In high-income countries, revascularized ACS patients with CKD receive CABG (versus PCI) more frequently than those without kidney disease. However, accounting for lower use of coronary angiography in the CKD population removed this association following NSTE-ACS. Greater use of invasive angiography in those with NSTE-ACS and CKD might therefore increase access to revascularization, and thereby improve outcomes.

Hepatic Tissue Alterations in ST-Elevation Myocardial Infarction: Determinants and Prognostic Implications

BACKGROUND

The presence and clinical significance of hepatic tissue alterations as assessed by cardiac magnetic resonance imaging in patients with ST-segment-elevation myocardial infarction (STEMI), are unclear. This study aimed to investigate associations of hepatic T1 patterns with myocardial tissue damage and clinical outcomes in patients suffering from STEMI.

METHODS

We analyzed 485 patients with STEMI treated with percutaneous coronary intervention who were enrolled in the prospective MARINA STEMI study (Magnetic Resonance Imaging In Acute ST-Elevation Myocardial Infarction). Myocardial function and left and right ventricular (RV) infarct characteristics were assessed by cardiac magnetic resonance within the first week after STEMI. Native hepatic T1 times and extracellular volume were evaluated from standard cardiac T1 maps at baseline and 4 months thereafter.

RESULTS

Median hepatic T1 times were 559 ms (interquartile range, 514-605) at baseline and decreased to 542 ms (interquartile range, 507-577) at 4 months (P<0.001). Hepatic T1 times at baseline were independently associated with female sex (β 0.116; P=0.008), hyperlipidemia (β -0.116; P=0.008), and myocardial tissue damage (infarct size: β 0.178; P<0.001; microvascular obstruction: β 0.193; P<0.001; RV infarction: β 0.161; P<0.001). Determinants of hepatic T1 times at 4 months were female sex (β 0.123; P=0.002), multivessel disease (β 0.121; P=0.002), N-terminal pro-B-type natriuretic peptide (β 0.101; P=0.010), RV infarction (β 0.501; P<0.001), and RV end-systolic volume index (β 0.087; P=0.031). Patients without a decrease exhibited a higher frequency of major adverse cardiovascular events (13% versus 5%; P=0.003). Hepatic T1 times at baseline (hazard ratio, 1.87 [95% CI, 1.40-2.50]; P<0.001), 4 months (hazard ratio, 2.69 [95% CI, 2.15-3.36]; P<0.001), and hepatic extracellular volume at 4 months (hazard ratio, 1.59 [95% CI, 1.33-1.90]; P<0.001) were associated with major adverse cardiovascular events. After adjustment for univariable associates, only hepatic T1 times at 4 months were independently associated with adverse outcomes (hazard ratio, 2.86 [95% CI, 1.99-4.12]; P<0.001).

CONCLUSIONS

Hepatic tissue alterations determined by T1 mapping were associated with female sex, hyperlipidemia, multivessel disease, N-terminal pro-B-type natriuretic peptide, and left and RV myocardial tissue damage. These alterations can persist into the chronic phase after STEMI and indicate a worse clinical outcome.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT04113356.

Comparison of the effects of contrast medium and low-molecular-weight dextran on coronary optical coherence tomographic imaging in relatively complex coronary lesions

Background

Optical coherence tomography (OCT) has gained increasing popularity in coronary artery intervention due to its high resolution and excellent tissue correlation as a novel intravascular imaging modality. However, the current use of OCT requires contrast agent injection for imaging, and excessive use of contrast agents may adversely affect renal function, exacerbate cardiac burden, and even lead to contrast agent-induced nephropathy and heart failure. In recent years, several researchers have proposed the use of low molecular weight dextran (LMWD) as a substitute for contrast agents in OCT imaging because of its low toxicity, low cost, and wide availability. However, the inclusion of lesions in these studies is relatively simple, and the image quality criteria remain to be optimized.

Methods

This study included 26 patients with coronary artery disease who were scheduled for OCT imaging in a real-world clinical practice involving various complex lesions. All patients underwent two OCT examinations at the same vascular site, one each using contrast agent and LMWD. Both contrast media and LMWDs were infused by an autoinjector. The primary endpoint of the study was the average image quality score. Secondary endpoints included clear image length, clear image segments, minimum lumen area, average lumen area, and contrast-induced nephropathy, among others.

Results

In terms of image clarity, the average image quality score was similar when comparing contrast media with LMWD (3.912 ± 0.175 vs. 3.769 ± 0.392, P = 0.071). The lengths of the clear images and the segments of the clear images were also similar between the two groups (50.97 ± 16.25 mm vs. 49.12 ± 18.15 mm, P = 0.110; 255.5 ± 81.29 vs. 250.5 ± 89.83, P = 0.095). Additionally, strong correlations were noted between the two flushing solutions regarding the minimum lumen area and mean lumen area. During their hospital stay, none of the patient exhibited deterioration in renal function, and no patient experienced any major adverse cardiovascular events.

Conclusions

The quality of coronary artery OCT imaging using LMWD may be comparable to that achieved with traditional contrast agents, even in real-world clinical practice involving various complex lesions. For high-risk patients, LMWD may serve as an excellent substitute for contrast agents in OCT examinations.

Elevated cardiac troponin secondary to heterophile antibodies: a case series highlighting an underrecognized differential

Background

Heterophile antibody presence confounds troponin assay results, causing falsely elevated troponin levels. This rare phenomenon is an important differential to consider when evaluating patients with suspected acute coronary syndrome. We present a case series of three patients with similar clinical presentations where the presence of heterophile antibodies was confirmed.

Case summary

We reviewed three patients from our hospital who presented with chest pain in a 12-month period. All patients were males aged 50-70. All patients had elevated troponin, and there was clinical concern for acute coronary syndrome in two patients. Two patients underwent coronary angiography during admission, and the third had a recent angiogram within the last 6 months. No obstructive lesions were found, and no alternative diagnoses were identified. Ultimately, the presence of heterophile antibodies was confirmed in all three patients.

Discussion

Heterophile antibody presence is an important differential to consider in patients with unexplained troponin elevation. Once the presence of heterophile antibodies is confirmed, this aids in clinician decision-making and helps to guide investigations and treatment in future.

Association between stress hyperglycemia ratio and mortality in acute myocardial infarction patients with and without atrial fibrillation: a retrospective cohort study from the MIMIC-IV database

BACKGROUND

The stress hyperglycemia ratio (SHR) potently predicts adverse outcomes in patients with acute myocardial infarction (AMI), and previous studies reported U-shaped relationships between SHR and adverse prognosis. However, the relationship between SHR and mortality risk in AMI patients with or without atrial fibrillation (AF) remained unknown, and which factors affect the mortality in lower SHR patients were unclear. This study aims to research the relationship between SHR and mortality risk in AMI patients with or without AF, and whether AF affects the mortality in lower SHR patients.

METHODS

We conducted a cohort study using data from 3233 patients with a first diagnosis of AMI from the MIMIC-IV (version 2.2) database. Patients were divided into two groups based on AF. The study outcome was 1-year all-cause mortality. SHR was defined as the index calculated by the formula: SHR = (admission glucose) (mmol/L) / (1.59 * HbA1c [%] - 2.59).

RESULTS

U-shaped association between SHR and all-cause mortality was found only in AMI patients with AF, not in AMI patients without AF. For AMI patients with AF, the inflection point for the curve was found to be a SHR of 1.09, either lower (OR, 0.30; 95%CI, 0.10, 0.94) or higher (OR, 3.28; 95%CI, 2.01, 5.34) SHR is associated with increased mortality. However, a linear relationship was found in patients without AF, higher (OR, 1.95; 95%CI, 1.52, 2.51) SHR is associated with increased mortality. For patients with SHR ≤ 1.09, AF increased the risk of all-cause mortality(OR, 1.50; 95%CI, 1.10, 2.05), while this effect was not found in patients with SHR > 1.09.

CONCLUSION

The association between SHR and mortality in AMI patients with or without AF is different: U-shaped association between SHR and all-cause mortality only in AMI patients with AF, not in AMI patients without AF. AF is a factor that make the difference by increasing the risk of mortality in AMI patients with low SHR. Lower SHR may increase mortality through the onset of AF. This study emphasizes avoiding "relative hypoglycemia", SHR = 1.09 is the moderately tight glycemic control, which means glucose level is about (1.59 * HbA1c [%] - 2.59) * 1.09 mmol/L.

TRIAL REGISTRATION

Clinical trial number: not applicable.