2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation

Re-engineering the clinical approach to suspected cardiac chest pain assessment in the emergency department by expediting research evidence to practice using artificial intelligence. (RAPIDx AI)-a cluster randomized study design

BACKGROUND

Clinical work-up for suspected cardiac chest pain is resource intensive. Despite expectations, high-sensitivity cardiac troponin assays have not made decision making easier. The impact of recently validated rapid triage protocols including the 0-hour/1-hour hs-cTn protocols on care and outcomes may be limited by the heterogeneity in interpretation of troponin profiles by clinicians. We have developed machine learning (ML) models which digitally phenotype myocardial injury and infarction with a high predictive performance and provide accurate risk assessment among patients presenting to EDs with suspected cardiac symptoms. The use of these models may support clinical decision-making and allow the synthesis of an evidence base particularly in non-T1MI patients however prospective validation is required.

OBJECTIVE

We propose that integrating validated real-time artificial intelligence (AI) methods into clinical care may better support clinical decision-making and establish the foundation for a self-learning health system.

DESIGN

This prospective, multicenter, open-label, cluster-randomized clinical trial within blinded endpoint adjudication across 12 hospitals (n = 20,000) will randomize sites to the clinical decision-support tool or continue current standard of care. The clinical decision support tool will utilize ML models to provide objective patient-specific diagnostic probabilities (ie, likelihood for Type 1 myocardial infarction [MI] versus Type 2 MI/Acute Myocardial Injury versus Chronic Myocardial Injury etc.) and prognostic assessments. The primary outcome is the composite of cardiovascular mortality, new or recurrent MI and unplanned hospital re-admission at 12 months post index presentation.

SUMMARY

Supporting clinicians with a decision support tool that utilizes AI has the potential to provide better diagnostic and prognostic assessment thereby improving clinical efficiency and establish a self-learning health system continually improving risk assessment, quality and safety.

TRIAL REGISTRATION

ANZCTR, Registration Number: ACTRN12620001319965, https://www.anzctr.org.au/.

Association of fasting blood glucose with in-hospital mortality in acute coronary syndrome patients with different glycemic statuses: Findings from the CCC-ACS project

BACKGROUND

Fasting blood glucose (FBG) is a significant risk factor for in-hospital mortality in acute coronary syndrome (ACS). This study examines the relationship between FBG levels and outcomes in ACS patients with different glycemic statuses.

METHODS AND RESULTS

Data from 50,365 ACS patients in the CCC-ACS Project (2014-2019) were analyzed in a prospective cohort study. Patients were categorized into three groups based on diabetes history and HbA1c levels: Group A (good), Group B (intermediate), and Group C (poor) glycemic status. A non-linear relationship between FBG and mortality was found. The lowest mortality risks were associated with FBG levels of 4.96 mmol/L (Group A), 5.71 mmol/L (Group B), and 7.44 mmol/L (Group C). Elevated FBG levels were linked to increased mortality risk in all groups: Group A (OR: 1.17), Group B (OR: 1.14), and Group C (OR: 1.10), all p < 0.001. The model showed moderate accuracy (AUC: 0.78 for Groups A/B, 0.80 for Group C)·In Group A, each unit increase in FBG raised the mortality risk by 1.08 times compared to Group B (OR: 1.08, 95 % CI: 1.03-1.14, p = 0.002) and by 1.07 times compared to Group C (OR: 1.07, 95 % CI: 1.03-1.12, p = 0.002).

CONCLUSIONS

In ACS patients, elevated FBG is an independent risk factor for in-hospital mortality, regardless of glycemic status. Different glycemic statuses have varied optimal glycemic targets. The effect of FBG on mortality differs across glycemic groups, with patients in good glycemic status facing the highest mortality risk as FBG increases.

Geriatric-Specific Considerations in the Care of Older Adults with Pulmonary/Respiratory Diseases

Older adult patients (age ≥ 65 years) frequently present to the emergency department with dyspnea, and the most common cause is pulmonary disease. Clinical presentation, examination findings, and existing diagnostic tests can be affected by the pathophysiological changes associated with aging and other comorbidities. As a result, to provide the highest quality care to older adult patients with pulmonary disease, physicians should understand these changes and their implications.

Prognostic Value of Strain by Tissue Tracking Cardiac Magnetic Resonance in Myocardial Infarction With Nonobstructive Coronary Arteries

BACKGROUND

Strain assessed by cardiac magnetic resonance (CMR) is a key prognostic indicator in myocardial infarction. However, the strain characteristics and prognostic value in myocardial infarction with nonobstructive coronary arteries (MINOCA) with different causes are unclear. This study aims to describe left atrial (LA) and left ventricular strain in patients with MINOCA and evaluate their predictive value for major adverse cardiovascular events (MACEs) in "true MINOCA" cases.

METHODS AND RESULTS

This single-center retrospective study included patients suspected of myocardial infarction who completed CMR during hospitalization. CMR images were used to obtain LA and left ventricular strain via CMR feature tracking. True MINOCA was defined by evidence of ischemia or infarction on CMR. MACEs included all-cause death, recurrent myocardial infarction, stroke, heart failure, atrial fibrillation, and angina pectoris. This study included 386 patients, with a median time from admission to CMR of 4 days. LA and left ventricular strains varied by pathogenesis, with the lowest strain in patients with cardiomyopathy. For patients with true MINOCA, Cox regression showed that global longitudinal strain (hazard ratio [HR], 0.90 [95% CI, 0.82-0.99]; P=0.022) and LA reservoir strain (HR, 0.95 [95% CI, 0.91-0.99]; P=0.014) were independently associated with MACEs. Kaplan-Meier analysis indicated that patients with LA reservoir strain ≤21.25% or global longitudinal strain ≤16.4% had a significantly higher MACE risk (P<0.001). Integrating global longitudinal strain and LA reservoir strain improved MACE prediction.

CONCLUSIONS

LA and left ventricular strains vary among MINOCA pathogeneses. In true MINOCA patients, global longitudinal strain and LA reservoir strains independently predict MACE risk. Integrating these strains enhances MACE prediction.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique Identifier: NCT06502899.

Association between in-hospital hemoglobin drop without overt bleeding and 1-year outcome of percutaneous coronary intervention in acute myocardial infarction patients

Whether an in-hospital hemoglobin drop adversely affects the prognosis of patients with acute myocardial infarction (AMI) remains controversial. The present study aimed to investigate the impacts of in-hospital hemoglobin drop without overt bleeding on 1-year clinical outcomes of AMI patients after percutaneous coronary intervention (PCI). A total of 5,036 AMI patients who underwent PCI and presented with an in-hospital hemoglobin decline without overt bleeding were recruited in this study. Subsequently, these patients were stratified into three cohorts based on tertiles of hemoglobin drop values: < 0.8 g/dL (n = 1652), 0.8-1.49 g/dL (n = 1651) and ≥ 1.5 g/dL (n = 1733). The primary endpoint was defined as ischemic events at 1 year, composed of cardiac death, myocardial infarction (MI), and stroke. Secondary endpoints were defined as 1-year all-cause death, Bleeding Academic Research Consortium (BARC) types 2, 3, or 5, and 3 or 5 bleeding. There were significant differences in 1-year incidence of ischemic events (1.88% vs. 3.27% vs. 3.46%; P = 0.0114), all-cause death (1.45% vs. 2.18% vs. 2.94%; P = 0.0128), as well as cardiac death (1.15% vs. 1.82% vs. 2.37%; P = 0.0282) and MI (0.30% vs. 1.15% vs. 0.92%; P = 0.0175) across tertiles of hemoglobin drop values. For each 1 g/dL drop in hemoglobin values, the adjusted risk for ischemic events and all-cause death increased by 2% and 3%, respectively. Among AMI patients undergoing PCI, an in-hospital decline in hemoglobin levels was associated with an increased risk of 1-year ischemic events and all-cause death, even in the absence of overt bleeding.

Identification of patients with suspected NSTE-ACS in the observe zone: evaluating GRACE 1.0 score and a biomarker panel for risk stratification and management optimization

BACKGROUND

Current guidelines recommend additional diagnostic work-up for patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) triaged in the observe zone using accelerated diagnostic protocols. This study assessed the effectiveness of combining the Global Registry of Acute Coronary Events (GRACE) 1.0 score with additional non-cardio-specific biomarkers for risk stratification in the observe zone.

METHODS

A total of 6789 patients with suspected NSTE-ACS were enrolled over 24 months, with 961 (21.8%) assigned to the observe zone. A classification and regression tree (CART) analysis dichotomized risk using the GRACE-score and additional biomarkers beyond high-sensitivity cardiac troponin including C-reactive protein < 10 mg/dL, N-terminal pro-B-type natriuretic peptide < 300 ng/L, D-dimers < 5 mg/L, estimated glomerular filtration rate > 30 mL/min/1.73m2, Copeptin < 10 pmol/L, and hemoglobin > 10 g/dL. The primary endpoint was 1-year all-cause mortality, validated using the Biomarkers in Acute Cardiac Care (BACC) cohort.

RESULTS

A low GRACE 1.0 score < 109 points was found in 37.6% of observe zone patients, showing a negative predictive value of 98.6% and sensitivity of 89.8% for death. Adding biomarker information reduced predicted 1-year-mortality from 1.38% with the GRACE-score alone to 0.46% when none of the biomarkers were above cutoff (prevalent in 22.7%). The proportion of protocol-eligible patients increased from 22.7 to 37.6%, with no events within 30 days. Findings were confirmed in the BACC cohort.

CONCLUSION

A low GRACE 1.0 score combined with ≤ 1 elevated biomarker significantly improves mortality prediction in the observe zone, helping identify low-risk patients for further out-of-hospital diagnostic work-up, potentially decongesting crowded emergency departments. Registration URL: https://www.

CLINICALTRIALS

gov ; Unique identifier: NCT05774431.

Predictive Value of the Systemic Immune-Inflammation Index and CRUSADE Score for Bleeding and Mortality in Older Patients With Acute Coronary Syndrome

BACKGROUND

There are currently no adequate studies evaluating the relationship between the systemic immune-inflammation index (SII) and bleeding in older patients presenting with acute coronary syndrome (ACS). This study investigated the predictive value of SII for in-hospital bleeding and the CRUSADE Bleeding Score (CBS) for long-term mortality in older patients with ACS.

METHODS

The study included 367 older patients, aged 75 years and above, admitted with ACS between April 2015 and January 2023. Predictors of in-hospital bleeding were determined using multivariate logistic regression analysis. Survival curves were generated using the Kaplan-Meier method.

RESULTS

The patients' median age was 81 (77-85), and 179 (48.8%) were male. The median follow-up was 24 months (Q1-Q3: 5-47, maximum: 96). In-hospital bleeding was significantly elevated in patients in the high SII group (p = 0.005); all long-term mortality was significantly increased in those with a high CBS (p = 0.001). Multivariate logistic regression analysis revealed that the estimated glomerular filtration rate (eGFR) (odds ratio [OR]: 0.980, 95% confidence interval [CI]: 0.964-0.995, p = 0.009) and SII (OR: 1.001, 95% CI: 1.001-1.003, p = 0.001) were independent predictors of in-hospital bleeding. Kaplan-Meier analysis confirmed that the all-cause mortality rate in patients with high CBS (≥ 46) was significantly higher than that of patients with low CBS (Long Rank: 37.12, p = 0.001).

CONCLUSION

A high SII was an independent predictor of in-hospital bleeding, and a high CBS at admission was associated with increased long-term mortality in older patients with ACS.

Copeptin in Acute Myocardial Infarction: Is There a Role in the Era of High-Sensitivity Troponins?

The quest for prompt and effective diagnosis of acute myocardial infarction (AMI) has been in the spotlight for decades. Ongoing research focuses on refined biomarker strategies for the early identification and disposition of patients with symptoms suggestive of AMI. Copeptin, a surrogate of the hormone arginine vasopressin, has emerged as a novel biomarker that could potentially aid in the diagnostic approach of patients with chest pain presenting to the emergency department. Observational studies have demonstrated that copeptin is upregulated in patients with AMI, although the exact pathophysiological mechanisms implicated in its release during myocardial ischemia remain unclear. Following these observations, copeptin was proposed as an adjunct to troponin in an effort to augment the diagnostic accuracy of conventional troponin assays. However, after the introduction of high-sensitivity troponin assays, the diagnostic utility of copeptin has been debated. This narrative review aims to elucidate plausible pathophysiological mechanisms involved in copeptin release during myocardial ischemia and to summarize the most recent evidence regarding its diagnostic potential in combination with high-sensitivity troponin assays.

Mesoporous Silica Nanotraps for Mitigating Bleeding Risk From 'Irreversible' Antiplatelet Drugs

The severe bleeding complications of long-term antiplatelet therapy limit its broader application in the treatment or prevention of thrombosis-associated diseases. This risk is particularly serious when facing emergency surgeries where rapid restoration of normal platelet function is required. Timely reversal of the effects of antiplatelet agents becomes crucial in such scenarios. Despite the widespread use of clopidogrel and prasugrel for their potent antiplatelet activity, the absence of specific and effective reversal agents remains a notable challenge. The pharmacological activity of clopidogrel and prasugrel is mediated by sulfhydryl-containing active metabolites, which form disulfide bonds with P2Y12 receptors on the surface of platelets to inhibit their aggregation. Taking advantage of this action mechanism of these "irreversible" antiplatelet drugs, click chemistry-functionalized mesoporous silica (SiO2-Mal) nanotraps are fabricated to capture the antiplatelet drugs' active metabolites and restore hemostasis. Subsequently, a comprehensive assessment of the effectiveness and safety of the SiO2-Mal nanotraps is conducted using mouse, rabbit, and pig animal models, highlighting their potential application as a functional reversal agent for clinically relevant thienopyridine antiplatelet drugs, believed until now to be irreversible in their inhibition of platelet activity.

Role of the endothelial cell glycocalyx in sepsis-induced acute kidney injury

Sepsis-induced acute kidney injury (S-AKI) is a common complication of sepsis. It occurs at high incidence and is associated with a high level of mortality in the intensive care unit (ICU). The pathophysiologic mechanisms underlying S-AKI are complex, and include renal vascular endothelial cell dysfunction. The endothelial glycocalyx (EG) is a polysaccharide/protein complex located on the cell membrane at the luminal surface of vascular endothelial cells that has anti-inflammatory, anti-thrombotic, and endothelial protective effects. Recent studies have shown that glycocalyx damage plays a causal role in S-AKI progression. In this review, we first describe the structure, location, and basic function of the EG. Second, we analyze the underlying mechanisms of EG degradation in sepsis and S-AKI. Finally, we provide a summary of the potential therapeutic strategies that target the EG.

Determinants and Prognostic Value of Early Gadolinium Enhancement-Derived Myocardial Salvage Index in STEMI

BACKGROUND

T2-weighted imaging is commonly used to measure myocardial salvage in reperfused myocardial infarction but is hindered by poor reproducibility and indistinct boundaries. Early gadolinium enhancement (EGE) emerges as an alternative for measuring the area at risk. This study aims to evaluate the determinants of the myocardial salvage index (MSI) derived from EGE and its prognostic implications.

METHODS

We analyzed acute cardiac magnetic resonance scans of 453 reperfused patients with ST-segment-elevation myocardial infarction (mean age, 60±12 years; 389 men) from April 2017 to July 2023 at a single center retrospectively. EGE was collected at 3 minutes after contrast agent injection, where hyperintense areas (signal intensities > mean+2SD of remote myocardium) were considered as the area at risk, plus the hypointense core within. MSI was calculated as the ratio of salvageable myocardium to the area at risk. Major adverse cardiovascular events included cardiovascular death, hospitalization for heart failure, reinfarction, and unplanned revascularization for the target vessel.

RESULTS

During a median follow-up of 3.2 years (interquartile range, 1.6-4.7 years), at least one major adverse cardiac event occurred in 91 participants (20.1%). The median MSI was 35.0% (interquartile range, 22.9-59.5%), with smaller MSI observed in patients with larger infarcts (P<0.001). Linear regression identified prepercutaneous coronary intervention Thrombolysis in Myocardial Infarction flow (β=3.35, P<0.001) and microvascular obstruction (β=-11.92, P<0.001) as independent determinants of MSI. Multivariable Cox regression showed that every 10% increase in MSI was associated with a 32% reduction in major adverse cardiac event risk (hazard ratio, 0.68 [95% CI, 0.53-0.86]; P=0.001). A graded response was observed between MSI and cardiovascular death and reinfarction. MSI greater than the median was associated with nontarget vessel-related reinfarctions but not target vessel-related ones (nontarget, P=0.027; target vessel, P=0.36). Good reproducibility was reported with EGE-measured area at risk (intraobserver, intraclass correlation coefficient [ICC]=0.95; interobserver, ICC=0.89).

CONCLUSIONS

EGE-derived MSI was associated with prepercutaneous coronary intervention Thrombolysis in Myocardial Infarction flow and microvascular injuries. It was an independent predictor of major adverse cardiac events. Our results highlight the prognostic potential of EGE imaging in acute myocardial infarction.

Value of upfront coronary computed tomography angiography in patients with non-ST-segment elevation acute coronary syndrome

This study aimed to evaluate the diagnostic performance of coronary computed tomography angiography (CCTA) in ruling out coronary artery stenosis ≥ 70% across all segments and its role in providing preprocedural guidance for chronic total occlusion (CTO) management in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS). This study was a post hoc analysis of a prospective, multicenter cohort comprising 347 patients with NSTE-ACS. All patients underwent CCTA immediately after being diagnosed with NSTE-ACS, followed by invasive coronary angiography (ICA) within 1 day. The diagnostic performance of CCTA in ruling out obstructive coronary stenosis was assessed using negative predictive value (NPV). Additionally, segments distal to CTO were analyzed to compare the detection capabilities of CCTA and ICA. The NPV of CCTA for ruling out coronary stenosis ≥ 70% was robust, ranging from 94.7 to 100.0% across the 18-segment model at the segment level, and 25.9% of patients had no significant stenosis and could have avoided unnecessary ICA based on CCTA findings. CCTA identified 71.0% of segments distal to CTO, significantly higher than ICA (48.8%, P < 0.001). 25.1% of patients had CTO, where CCTA provided valuable preprocedural guidance for revascularization. CCTA demonstrated high diagnostic accuracy in ruling out significant stenosis and provided critical information for CTO revascularization, highlighting its potential as a triaging and planning tool in NSTE-ACS.

Decreased plasma lipoxin A4, resolvin D1, protectin D1 are correlated with the complexity and prognosis of coronary heart disease: A retrospective cohort study

This study aimed to assess the predictive capacity of specialized pro-resolving mediators (SPMs) regarding the complexity and prognosis of coronary heart disease (CHD). Total of 602 CHD patients were included in this study and categorized into low-risk, medium-risk, and high-risk groups based on the Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) score. Follow-up was conducted for two years, during which patients were dichotomized into poor and good prognosis groups. Additionally, twenty healthy controls were incorporated. Plasma concentrations of lipoxin A4 (LXA4), resolvin D1 (RvD1), protectin D1 (PD1), C-reactive protein (CRP), interleukin-6 (IL-6), and IL-10 were quantified. Plasma LXA4, RvD1, PD1, and the ratios LXA4/IL-6, RvD1/IL-6, PD1/IL-6 exhibited a gradual decrease across control, low-risk, medium-risk, and high-risk groups and exhibited a negative correlation with the SYNTAX score. Spearman's correlation analysis revealed negative correlations between plasma LXA4, RvD1, PD1, and both CRP and IL-6, and positive correlations with IL-10. Multiple linear regression models demonstrated negative associations between plasma LXA4, RvD1, PD1, and SYNTAX score. Moreover, both univariate and multivariate binary logistic regression analyses identified plasma LXA4, RvD1, and PD1 as protective factors against medium/high-risk SYNTAX score categorization. In the poor prognosis group, plasma PD1 was reduced at short-term follow-up, and the ratios LXA4/IL-6, RvD1/IL-6, PD1/IL-6 were reduced at long-term follow-up. Plasma LXA4, RvD1, and PD1 demonstrated negative correlations with CHD complexity and potentially served as protective factors against CHD. Plasma PD1 provided predictive value for short-term prognosis, while the ratios LXA4/IL-6, RvD1/IL-6, PD1/IL-6 were indicative for long-term prognosis.

Resolving the observe zone: validation of the ESC 0/3-hour and the APACE criteria for NSTEMI triage

BACKGROUND

High-sensitivity cardiac troponin tests have enhanced early myocardial infarction diagnosis, yet many patients still land in the observe zone (OZ). Guidelines suggest a 3-hour troponin measurement for those in the European Society of Cardiology (ESC) 0/1 hour-algorithm's OZ, but evidence on extended troponin testing times and their impact on diagnostic accuracy and outcomes remains sparse.

METHODS

Patients with suspected acute coronary syndrome were consecutively enrolled in a single-centre observational study. The triage protocol allowed an optional third troponin measurement at 3 hours or later to evaluate the performance and safety of two validated triage algorithms used to resolve the OZ.

RESULTS

Of the 4605 patients, 948 were triaged to the OZ (20.6%). The prevalence of non-ST-segment elevation myocardial infarction (NSTEMI) within the OZ was 7.2%. 212 patients (22.3% of OZ patients) had a third troponin measurement and were included in the comparative analysis. For diagnosing NSTEMI, the ESC 0/3-hour criteria showed lower sensitivity (69.4%) than the criteria defined in the Advantageous Predictors of Acute Coronary Syndromes Evaluation (APACE) study (86.1%, p=0.053), with both having high negative predictive value (93.5% vs 87.5%, p=0.339). By definition, the ESC 0/3-hour algorithm categorises all patients into rule-in or rule-out, eliminating the need for an OZ, whereas 55.6% of patients remained in the OZ with the APACE criteria. Mortality rates in the OZ were similar across different timing protocols, with 30-day rates of 0.78% for third blood draws within 210 min (n=128) and 1.19% for those over 210 min (n=84); 3-year rates were 5.51% and 4.82%, confirming the safety of extended sampling.

CONCLUSIONS

Although the ESC 0/3-hour criteria have a lower sensitivity than the APACE criteria, it is by definition more effective because it does not leave patients in the OZ. Extending the timing for the third troponin measurement beyond 3 hours proves to be effective and safe, supporting its implementation in clinical practice.

TRIAL REGISTRATION NUMBER

NCT03111862.

Types and hospital manifestation of the "risk-treatment" paradox in non-ST-elevation acute coronary syndrome: the regional vascular centre experience

BACKGROUND

There is reason to believe that unfavorable outcomes of non-ST-elevation acute coronary syndrome (NSTE-ACS) is due to the "risk-treatment" paradox (RTP). However, the true prevalence, types and causes of RTP have not been studied, and data from previous studies have shown an equivocal effect of RTP on outcomes of NSTE-ACS.

METHODS

The retrospective analysis included 600 patients initially diagnosed with NSTE-ACS. Upon admission, all patients were re-stratified into four groups according to their risk of adverse ischemic events. RTP was defined as a mismatch between a patient's risk profile and the recommended invasive strategy.

RESULTS

RTP was present in 53.5% of the study population (321/600), with the highest frequency observed in the intermediate-risk group (74%) and the lowest in the high-risk group (28.5%). In the overall cohort, the presence of RTP (n = 321) was not associated with a significant difference in in-hospital adverse cardiovascular events or length of stay compared to patients without RTP (n = 279). After adjustment for RTP in each risk group, only the high-risk group showed an increase in adverse outcomes in the presence of RTP (5.4% mortality vs. 2.9% (OR 1.9 (95% CI 0.5-8.9), p = 0.037) and a negative effect of RTP on the risk of recurrent myocardial ischemia (RMI) after 24 h (7.1% vs. 0.7%, OR 10.7 (95% CI 1.2-97.9), p = 0.01).

CONCLUSIONS

RTP in relation to the type of invasive strategy is common in patients with NSTE-ACS (53.5%). For high-risk patients, RTP worsened in-hospital outcome and influenced the risk of RMI after 24 h.

CLINICAL TRIAL NUMBER

This research is a retrospective observational study, which does not require mandatory registration as defined by the ICMJE.

Propensity score analysis of very long-term outcome after coronary thrombus aspiration in acute myocardial infarction

BACKGROUND

The long-term prognostic impact of thrombus aspiration (TA) in acute myocardial infarction (AMI) is unclear.

AIM

To assess the long-term prognostic impact of TA in AMI.

METHODS

Data were obtained from three nationwide French surveys (FAST-MI 2005, 2010 and 2015) including consecutive patients with AMI. Long-term death rate (up to 10 years) was assessed according to use of TA in patients with AMI treated with percutaneous coronary intervention (PCI).

RESULTS

TA was used in 1781/9654 patients (18%; 2005, 7%; 2010, 27%; 2015, 18%), including 1546 (86.8%) with ST-segment elevation myocardial infarction. Patients who had TA were younger (61 vs. 65 years; P<0.001), mostly men (81 vs. 74%; P<0.001) and their culprit lesion was more often on the right coronary artery (40 vs. 31%; P<0.001). Crude very long-term mortality was lower with TA (25.0 vs. 32.5%; crude hazard ratio [HR] 0.74, 95% confidence interval [CI] 0.68-0.82; P<0.001). Adjusting on a propensity score (PS) for getting TA, very long-term mortality did not differ (HR 1.03, 95% CI 0.89-1.20; P=0.67). In-hospital stroke was more frequent with TA (0.7 vs. 0.4%; P=0.04). After PS matching (two cohorts, 1430 patients in each), very long-term mortality was similar in the two PS-matched cohorts (HR 1.02, 95% CI 0.87-1.19; P=0.84). In patients with a high thrombus burden, the adjusted HR for very long-term mortality was 0.76 (95% CI 0.59-0.98; P=0.03) in favour of TA.

CONCLUSIONS

These routine-practice data show that TA use increased until 2010 and declined thereafter, in keeping with international guidelines. In the overall population of patients with AMI who underwent PCI, TA had no effect on long-term survival. In those with a high thrombus burden, TA was associated with improved long-term survival.

Prognostic Relevance of Type 4a Myocardial Infarction and Periprocedural Myocardial Injury in Patients With Non-ST-Segment-Elevation Myocardial Infarction

BACKGROUND

Periprocedural myocardial injury (PMI) with or without type 4a myocardial infarction (MI) might occur in patients with non-ST-segment-elevation MI (NSTEMI) after percutaneous coronary intervention (PCI). This study investigated the incidence and prognostic relevance of these events, according to current definitions, in patients with NSTEMI undergoing PCI. The best cardiac troponin I (cTnI) threshold of PMI for prognostic stratification is also suggested.

METHODS

Consecutive patients with NSTEMI from January 2017 to April 2022 undergoing PCI with stable or falling pre-PCI cTnI levels were enrolled. According to the Fourth Universal Definition of Myocardial Infarction, the study population was stratified into those experiencing (1) PMI with type 4a MI, (2) PMI without type 4a MI, or (3) no PMI. Post-PCI cTnI increase >20% with an absolute postprocedural value of ≥5 times the 99th percentile upper reference limit within 48 hours after PCI was used to define PMI. The primary end point was 1-year all-cause mortality, and the secondary end point consisted of major adverse cardiovascular events at 1 year, including all-cause mortality, nonfatal reinfarction, urgent revascularization, nonfatal ischemic stroke, and hospitalization for heart failure. Internal validation was performed in patients enrolled between May 2022 and April 2023.

RESULTS

Among 1412 patients with NSTEMI undergoing PCI with stable or falling cTnI levels at baseline, 240 (17%) experienced PMI with type 4a MI, 288 (20.4%) experienced PMI without type 4a MI, and 884 (62.6%) experienced no PMI. PMI was associated with an increased risk of adverse clinical outcomes, with patients with type 4a MI demonstrating the highest rates of 1-year all-cause mortality and major adverse cardiovascular events. A post-PCI ΔcTnI >20% but ≤40% showed similar outcomes to patients without PMI, whereas >40% was identified as the optimal threshold for prognostically relevant PMI, confirmed in an internal validation cohort of 305 patients.

CONCLUSIONS

Periprocedural ischemic events were frequent in patients with NSTEMI undergoing PCI with prognostic implications. A post-PCI ΔcTnI >40%, combined with an absolute postprocedural value of ≥5 times the 99th percentile upper reference limit, was identified as the optimal threshold for diagnosing prognostically relevant PMI. Recognizing these events may improve risk stratification and management of patients with NSTEMI.

Mediastinal hematoma following transradial percutaneous coronary intervention: case report and literature review

Mediastinal hematoma due to transradial PCI is rare. We reported a case of chest tightness, dyspnea, progressive neck swelling after transradial PCI. Clinical examinations such as chest computer tomography were completed and identified as mediastinal hematoma caused by a rupture of the subclavian artery branch and occlude the artery under digital subtraction angiography guidance, the artery was considered to be a collateral vessel of non-bronchial arterial circulation. This case highlights the necessity of exercising extreme caution when utilizing hydrophilic-coated curved-tip guidewires during the advancement process in peripheral vascular procedures. Mediastinal hematoma is a life-threatening complication and progresses rapidly, we need timely identification and diagnosis based on symptoms and appropriate clinical examination, interventional embolization therapy is critical for patients with poor response of conservative treatment.

Machine-learning models to predict serious adverse hospitalization events after ACS

OBJECTIVE

We developed a risk stratification model to predict serious adverse hospitalization events (mortality, cardiac shock, cardiac arrest) (SAHE) after acute coronary syndrome (ACS) based on machine-learning models and logistic regression model.

METHODS

This cohort study is based on the CCC-ACS project. The primary efficacy outcomes were SAHE. Clinical prediction models were established based on five machine-learning (XGBoost, RF, MLP, KNN, and stacking model) and logistic regression models.

RESULTS

Among the 112 363 patients in the study, age (55-65 years: OR: 1.392; 95%CI: 1.212-1.600; 65-75 years: OR: 1.878; 95%CI: 1.647-2.144; ≥75 year: OR: 2.976; 95%CI: 2.615-3.393), history of diabetes mellitus (OR: 1.188; 95%CI: 1.083-1.302), history of renal failure (OR: 1.645; 95%CI: 1.311-2.044), heart rate (60-100 beats/min: OR: 0.468; 95%CI: 0.409-0.536; ≥100 beats/min: OR: 0.540; 95%CI: 0.454-0.643), shock index (0.4-0.8: OR: 1.796; 95%CI: 1.440-2.264; ≥0.8: OR: 5.883; 95%CI: 4.619-7.561), KILLIP (II: OR: 1.171; 95%CI: 1.048-1.306; III: OR: 1.696; 95%CI: 1.469-1.952; IV: OR: 7.811; 95%CI: 7.023-8.684), and cardiac arrest at admission (OR: 12.507; 95%CI: 10.757-14.530) were independent predictors of severe adverse hospitalization events for ACS patients. In several machine-learning models, RF (AUC: 0.817; 95%CI: 0.808-0.826) and XGBoost (AUC: 0.816; 95%CI: 0.807-0.825) also showed good discrimination in the training set, which ranked the first two positions. They also presented good accuracy and the best clinical benefits in the decision curve analysis. In addition, logistic regression was able to discriminate the SAHE (AUC: 0.816; 95%CI: 0.807-0.825) and performed the best prediction accuracy (0.822; 95%CI: 0.822-0.822) compared to several machine-learning models. Model calibration and decision curve analysis showed these prediction models have similar predictive performance. Based on these findings, we developed two CCC-ACS In-hospital Major Adverse Events Risk Scores and its online calculator. One is based on machine-learning model (https://ccc-acs-sae-3-xcnjsvoccusjwkfhfthh44.streamlit.app/), and another is based on logistic regression model (https://ccc-acs-sae-logistic-9te57ylnq3kazkeuyc7dub.streamlit.app/), offering a validated tool to predict survival for patients with ACS during hospitalization.

CONCLUSIONS

Machine-learning-based approaches for identifying predictors of SAHE after an ACS were feasible and practical. Based on this, we developed two online risk prediction websites for clinicians' decision-making. The CCC-ACS-MSAE score showed accurate discriminative capabilities for predicting severe adverse hospitalization events and might help guide clinical decision-making. Key messages: Three research questions and three bullet points What is already known on this topic? Observational studies have identified risk factors for in-hospital death in patients with acute coronary syndromes (ACS). However, the real-world results of a large sample in China still need to be further explored. What does this study add? Machine-learning-based approaches for identifying predictors of SAHE after an ACS were feasible and practical. Based on these findings, we developed two CCC-ACS In-hospital Major Adverse Events Risk Scores and its online calculator. One is based on machine-learning model (https://ccc-acs-sae-3-xcnjsvoccusjwkfhfthh44.streamlit.app/), and another is based on logistic regression model (https://ccc-acs-sae-logistic-9te57ylnq3kazkeuyc7dub.streamlit.app/), offering a validated tool to predict survival for patients with ACS during hospitalization. How this study might affect research, practice, or policy? Early identification of high-risk ACS patients will help reduce in-hospital deaths and improve the prognosis of ACS patients.

Swift and Safe high-sensitive troPonin Evaluation in the Emergency Department with a 30-min protocol: The SPEED-30 cohort study

STUDY OBJECTIVE

This study aimed to determine whether myocardial infarction (MI) could be safely diagnosed or excluded within 30 min instead of 1 h.

METHODS

This single-center, prospective, observational study included patients presenting with non-traumatic chest pain. Patients underwent a thorough evaluation, including medical history, physical exams, ECG, and serial hs-cTn T measurements at 0, 30, and 60 min. Patients were classified into STEMI or further evaluated for NSTEMI-ACS based on ECG results. The hs-cTn T tests placed patients into rule-in, observation, or rule-out groups. Diagnostic performance was assessed using sensitivity and negative predictive value (NPV) to rule out MI (primary endpoints) and specificity and positive predictive value (PPV) to rule in MI (secondary endpoints).

RESULTS

809 patients were analyzed, with a median age of 53 ± 15.9 years, 36.1 % of whom were women. MI was confirmed in 15.6 % of patients. The 0-h/30-min algorithm placed 457 patients in the rule-out group, 222 in observation, and 188 in the rule-in, while the 0-h/1-h algorithm placed 507, 141, and 161 patients, respectively. The 0-h/30-min and 0-h/1-h algorithms showed identical sensitivity [100 % (96.11 %-100 %) and 100 % (99.61 %-100.00 %), respectively] and NPV [100 %] for excluding MI. Both had high specificity in the rule-in group [94.83 % (92.95 %-96.34 %) and 92.31 % (90.08 %-94.17 %)]. The 0-h/30-min algorithm had a superior PPV [71.54 % (64.75 %-77.48 %)] compared to the 0-h/1-h algorithm [66.46 % (60.53 %-71.91 %)].

CONCLUSION

The 0-h/30-min algorithm is as effective as the 0-h/1-h algorithm in safely ruling out MI and may offer improved diagnostic efficiency in ruling in MI.

The Complex Inflammatory and Nutritional Indices to Predict Prognostic Risk for Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

PURPOSE

To investigate the role of the systemic inflammatory response index (SIRI) and high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) levels in predicting the risk of major adverse cardiovascular events (MACEs) in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI).

PATIENTS AND METHODS

Overall, 1377 patients with ACS who underwent PCI between January 2016 and December 2018 were consecutively enrolled. The patients were divided into MACEs (n = 60) and non-MACEs (n = 1317) groups. The study endpoints were MACEs, including cardiac-related mortality and rehospitalization for severe heart failure (HF), myocardial infarction (MI), and in-stent restenosis.

RESULTS

Both groups showed significant differences in the patients with age > 65 years, history of HF, acute MI, cardiogenic shock, left ventricular ejection fraction < 40%, SIRI ≥ 2.848, SIRI/HDL-C ≥ 1.977, and SIRI × LDL-C ≥ 4.609. The Kaplan-Meier curve showed that the low SIRI group had higher cumulative survival than the high SIRI group. Additionally, the univariate and multivariate Cox proportional hazards model demonstrated that SIRI ≥ 2.848, SIRI/HDL-C ≥ 1.977, and SIRI × LDL-C ≥ 4.609 were independent risk factors for patients with ACS undergoing PCI. Restricted cubic spline models were generated to visualize the relationship between SIRI, SIRI/HDL-C, and SIRI × LDL-C and the prognostic risk.

CONCLUSION

SIRI ≥ 2.848, SIRI/HDL-C ≥ 1.977, and SIRI × LDL-C ≥ 4.609 were all independent prognostic risk factors in patients with ACS undergoing PCI, which may be useful markers for assessment for long prognosis.

Accuracy of the 0/1-Hour Algorithm for Diagnosing Myocardial Infarction in Patients With Atrial Fibrillation

BACKGROUND

Patients with atrial fibrillation (AF) often present with symptoms similar to acute coronary syndrome (ACS), including chest pain and elevated levels of high-sensitivity cardiac troponin (hs-cTn). The 0/1-hour algorithm using hs-cTn is a rapid diagnostic tool endorsed by the European Society of Cardiology to rule out myocardial infarction (MI). However, because its effectiveness in patients with AF remains unclear, in this study we assessed the diagnostic accuracy of the 0/1-hour algorithm in patients with and without AF presenting with chest pain in the emergency department.

METHODS AND RESULTS

We conducted a secondary analysis of the DROP-ACS cohort, including 1,333 patients from Japan and Taiwan, with AF in 10.3% of cases. We examined the algorithm's negative predictive value (NPV), sensitivity, positive predictive value (PPV), and specificity for ruling MI in or out. Patients with AF were more frequently placed in the observe group (54% vs. 34.9%, P<0.05) and less often in the rule-out group (24.1% vs. 44.6%, P<0.05). The NPV and sensitivity for ruling out MI were 100%, while the PPV and specificity were lower in patients with AF (60% and 89.7%, respectively).

CONCLUSIONS

The 0/1-hour algorithm effectively ruled out MI in patients with AF, with high safety and accuracy. However, patients with AF are more likely to be stratified into the observe group, requiring further examination for final diagnosis.

Mortality after high-risk myocardial infarction over the last 20 years: Insights from the VALIANT and PARADISE-MI trials

AIMS

The temporal changes in clinical profiles and outcomes of high-risk myocardial infarction survivors enrolled in clinical trials are poorly described. This study compares mortality rates, baseline characteristics, and the prognostic impact of therapies among participants of the VALIANT and PARADISE-MI trials.

METHODS AND RESULTS

Exclusively VALIANT participants who matched the inclusion criteria of the PARADISE-MI trial were included in the analysis. Risk of death was compared between trials using Cox regression models. The impact of baseline characteristics and therapies on mortality was estimated by the magnitude reduction of β coefficients using Cox proportional hazards regression models. A total of 9617 VALIANT participants matched the inclusion criteria of the PARADISE-MI trial (n = 5661). All-cause mortality in PARADISE-MI was less than half that in VALIANT (4.2 vs 9.9 per 100 patient-years; hazard ratio [HR] 0.41, 95% confidence interval [CI] 0.37-0.46). This difference was reduced after adjustment for clinical variables but remained substantial (adjusted HR 0.68, 95% CI 0.58-0.80). The most important mediator of this reduction related to covariate adjustment was the use of percutaneous coronary intervention (PCI), accounting for almost half of the attenuation observed. Similar results were found for cardiovascular (CV) death, while no between-trial significant differences were found in the non-CV mortality risk.

CONCLUSIONS

Cardiovascular mortality following high-risk myocardial infarction has significantly declined over time, while the risk for non-CV death has remained unchanged. This improvement is partially attributable to advancements in CV care, particularly the use of PCI. Continued efforts to implement guidelines and standardize the quality of care are needed to sustain this positive trend.

Trends in dual antiplatelet therapy regimens and clinical outcomes among patients with acute coronary syndrome undergoing percutaneous coronary intervention with drug-eluting stents: A multicenter real-world study

Background

The patterns of dual antiplatelet therapy (DAPT) use and the associated clinical outcomes in current practice remain limited. This study evaluates DAPT regimen patterns and clinical outcomes among acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI).

Methods

This multicenter retrospective cohort study included ACS patients treated with PCI from January 2017 to February 2022 at five tertiary hospitals in Thailand. DAPT was categorized as nonpotent (NP-DAPT) or potent (P-DAPT). We described DAPT trends, with major adverse cardiovascular events (MACEs) and major bleeding, as primary efficacy and safety outcomes. Outcomes were assessed using inverse probability treatment weighting (IPTW) with Cox's proportional hazards model.

Results

The study included 1877 patients with ACS undergoing PCI. The mean age was 64.51 years (standard deviation 11.34), with 639 (34.04%) female patients and 1159 (61.75%) presenting ST-elevation myocardial infarction (STEMI). Of these, 924 (49.23%) received NP-DAPT, and 953 (50.77%) were prescribed P-DAPT. Crude MACE incidence was lower in the P-DAPT compared to the NP-DAPT group (6.82% vs. 10.28%). After applying IPTW and conducting Cox's proportional hazard analysis, no significant differences in MACE were observed between groups (hazard ratio [HR]: 0.85, 95% confidence interval [CI]: 0.58-1.25, p = 0.408), nor in major bleeding (HR: 0.80, 95% CI: 0.37-1.70, p = 0.555). P-DAPT was associated with any higher bleeding risk (HR: 1.52, 95% CI: 1.13-2.03, p = 0.005).

Conclusion

Standard DAPT remains predominant among Thai ACS patients, with NP-DAPT prescriptions approaching those of P-DAPT. Despite similar rates of MACE and major bleeding between the groups, P-DAPT was associated with a higher risk of any bleeding.

Understanding Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA): a comprehensive meta-analysis of clinical characteristics, management, and prognosis compared to MI with the Obstructive Coronary Artery (MIOCA)

BACKGROUND

MINOCA (Myocardial Infarction with Non-Obstructive Coronary Arteries) represents a unique subset of acute coronary syndrome, distinct from MIOCA (Myocardial Infarction with Obstructive Coronary Arteries) and a control group. This study systematically compares their prevalence, clinical characteristics, management strategies, and outcomes to improve understanding and treatment approaches.

METHODS

This systematic review and meta-analysis followed PRISMA guidelines across multiple databases up to 2024. STATA 17 was used for statistical analyses, and the Newcastle-Ottawa Scale was employed to assess study quality.

RESULTS

One-hundred and twelve studies, including 5,908,768 patients, were analyzed. The pooled prevalence of MINOCA among patients undergoing coronary angiography was 8.92% (95% CI: 8.90-8.94). MINOCA patients were generally younger, predominantly female, and more likely to present with atypical chest pain and dyspnea compared to MIOCA patients. Laboratory findings showed higher levels of CRP, BNP, and fibrinogen in MINOCA patients, suggesting inflammation and microvascular dysfunction as key mechanisms. In contrast, MIOCA patients had higher rates of diabetes and dyslipidemia, highlighting differences in pathophysiological processes. Medication use differed between the groups, with MINOCA patients more likely to be prescribed anticoagulants and β-blockers. Prognostically, MINOCA patients experienced significantly lower rates of adverse short- and long-term outcomes, including major adverse cardiac events (MACE) and cardiovascular death, compared to MIOCA patients.

CONCLUSIONS

This study demonstrated that patients with MINOCA have a better prognosis compared to those with MIOCA and are at a lower risk of serious cardiac events. Based on the findings of this study, we emphasize that microcirculation and vascular spasm are the main mechanisms involved in MINOCA. Considering these findings, it is suggested that a better management strategy for MINOCA patients can be established by precisely defining diagnostic criteria and focusing on anti-inflammatory treatments and risk factor control.

Left Ventricular Thrombosis in Ischemic and Non-Ischemic Cardiomyopathies: Focus on Evidence-Based Treatment

Left ventricular thrombosis (LVT) is one of the most feared complications of both ischemic and non-ischemic cardiopathy, and despite its incidence having decreased over the years (mostly due to novel reperfusion therapies in acute coronary syndromes), it is still not negligible. If transthoracic echocardiography, possibly with the adjunction of echo contrast, represents the cornerstone in LVT diagnosis, sometimes it is found to be nonconclusive and advanced cardiovascular imaging, namely cardiac magnetic resonance, needs to be performed to fully exclude intraventricular masses or to better characterize them. Vitamin K antagonists always represented the anticoagulant of choice for the treatment of LVT; however, the recent spread of direct oral anticoagulants (DOACs) pushed clinicians to adopt them also in this setting despite the absence of robust evidence in their favor. If the optimal duration of anticoagulation for the treatment of LVT in non-ischemic cardiopathy is still a matter of debate, an initial treatment of 3-6 months seems to be reasonable in the setting of ischemic cardiopathy, with possible extension according to the follow-up findings. High-quality randomized studies are strongly needed to evaluate the potential role of prophylactic anticoagulation in high-risk patients and provide conclusive evidence for the use of DOACs in LVT treatment.

Hs-CRP/ALB Levels Are Associated With Poor Long-term Prognosis in Patients With STEMI Undergoing Percutaneous Coronary Intervention

Research has explored the relationship between inflammatory biomarkers and cardiovascular diseases, highlighting the potential prognostic significance of the high-sensitivity C-reactive protein (hs-CRP)/albumin (ALB) ratio. However, it remains unclear whether this ratio is associated with adverse prognosis in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). This retrospective cohort study included 752 STEMI patients undergoing PCI at Tianjin Chest Hospital between January 2017 and December 2018. During a median follow-up of 52 months, 183 cases (24.0%) experienced major adverse cardiovascular events (MACE) events and 75 cases (10.0%) died. Cox regression analysis demonstrated that hs-CRP/ALB was independently associated with MACE as both a continuous (hazard ratio [HR] 1.152, 95% CI 1.097-1.210, P < .001) and categorical variable (HR 1.257, 95% CI 1.084-1.458, P = .027). Similar findings were observed for all-cause mortality (HR 1.119, 95% CI 1.058-1.183, P < .001; HR 2.228, 95% CI 1.009-4.920, P = .032). The receiver operating characteristic (ROC) curve indicated that hs-CRP/ALB levels have predictive capability for overall mortality in patients (the area under the curve [AUC] = 0.68). hs-CRP/ALB levels independently correlate with poor long-term prognosis in STEMI patients with prior PCI.

Evidence for stability of cardiac troponin T concentrations measured with a high sensitivity TnT test in serum and lithium heparin plasma after six-year storage at -80 °C and multiple freeze-thaw cycles

OBJECTIVES

As high-sensitivity cardiac troponin T (hs-cTnT) is making the transition from diagnostic to prognostic use, a long-term stability study of 5th generation hs-cTnT according to EFLM CRESS recommendations was set up for investigation of frozen clinical specimens (two matrices).

METHODS

Study samples collected in serum tubes and lithium heparin tubes with gel from patients admitted for suspected minor myocardial damage were measured directly after completion of the study (0 years), and after 3-year and 6-year storage at -80 °C, and recovery of hs-cTnT concentrations after long-term storage (%hs-cTnT concentration compared to 0-year) was calculated. Hs-cTnT changes were also compared to decisive delta changes, such as the ones proposed in the ESC NSTEMI 0 h/1 h algorithm (<3 or >5 ng/L for ruling out and ruling in suspected NSTEMI patients).

RESULTS

Eighty-six patients were included in the study, whereof 28 both lithium heparin plasma and serum samples were collected simultaneously, in others only serum (n=30) or plasma (n=28). Multiple aliquots per patient were made, so that 479 serum and 473 plasma samples were available for analysis. Across the overall hs-cTnT measuring range, median recovery after 6 years was 105.4 % and 106.2 % for serum and plasma, respectively. Based on these decisive delta changes, serum showed consistent results upon long term storage (max 0.8 % of samples above delta threshold of >5 ng/L) as compared to heparin plasma (up to 19.2 % of samples above threshold).

CONCLUSIONS

Over 6 years of storage at -80 °C, recovery of hs-cTnT in serum and heparin plasma was similar and within common lot-to-lot variation. Yet, when evaluating absolute delta increments around hs-cTnT clinical decision points, long-term stored sera displayed better clinical performance compared to heparin plasma samples.

Effect of 24-hour heart rate fluctuations on mortality in patients with acute myocardial infarction: based on the MIMIC III database

BACKGROUND

Heart rate (HR) was one of the risk factors for cardiovascular disease, but there was insufficient evidence to demonstrate a relationship between heart rate fluctuations and the prognosis of patients with acute myocardial infarction (AMI). The objective of this study is to investigate the relationship between 24-h heart rate fluctuations after admission to the Intensive Care Unit (ICU) and 30-day, 1-year, and 3-year mortality rates in patients with AMI in order to examine its implications for prognosis in AMI patients.

METHODS

All data were obtained from the Medical Information Mart for Intensive Care III Database (MIMIC III). We calculated heart rate fluctuations using the maximum and minimum values of the patient's heart rate during the first 24 h after ICU admission and divided them into three groups (< 23beats/min, 23-33beats/min, > 33beats/min) according to tertiles. The COX risk regression model was applied to the analysis, and subgroup analyses were performed for use in testing the robustness of the results. Curve fitting was performed to explore whether there was a nonlinear relationship between heart rate fluctuations and mortality. Outcome measures were 30-day, 1-year, and 3-year mortality in patients with AMI.

RESULTS

After strict confounding adjustment, COX multifactorial analysis showed that patients' heart rate fluctuations were positively associated with 30-day, 1-year, and 3-year mortality rates (HR = 1.17, 95%CI: 1.11 ~ 1.23; HR = 1.17, 95%CI: 1.12 ~ 1.22; HR = 1.17, 95%CI: 1.12 ~ 1.21). In addition, the high heart rate fluctuation group (> 33 beats/min) had a significantly increased risk of death (HR = 1.76, 95%CI: 1.28 ~ 2.42; HR = 1.59, 95%CI: 1.25 ~ 2.03; HR = 1.43, 95%CI: 1.15 ~ 1.77). In the curve-fitting analysis, a J-shaped curve relationship among heart rate fluctuations and 1- and 3-year mortality was found (p for non-linearity = 0.049; p for non-linearity = 0.004), with an inflection point of 28 beats/min. In subgroup analyses, there was an interaction between heart rate fluctuations and age (P for interaction = 0.041).

CONCLUSIONS

Heart rate fluctuations within 24 h after ICU admission of AMI patients were associated with 30-day, 1-year, and 3-year mortality, which is a simple and stable predictor of patients' short- and long-term prognosis. Furthermore, 24-h heart rate fluctuations showed a "J" curve relationship with 1- and 3-year mortality, with fluctuations of 28 beats/min predicting the best prognosis.

What does real-world data reveal about cangrelor's safety? An analysis of FDA adverse event reporting system (FAERS) database

BACKGROUND

Cangrelor is used to reduce thrombotic events in adults undergoing percutaneous coronary intervention, but real-world safety data is limited. This study analyzes adverse events (AEs) related to cangrelor using the FDA adverse event reporting system (FAERS) database.

METHODS

We employed statistical techniques such as the reporting odds ratio, proportional reporting ratio, bayesian confidence propagation neural network, and multi-item gamma poisson shrinker to analyze the data from the FAERS database.

RESULTS

Out of a total of 15,011,506 case reports, 209 events were related to cangrelor. Thirty-one preferred term (PT) describing AEs were identified, affecting eight organ systems. The most reported PT was off-label use (n = 163). Several unexpected AEs not listed in the drug labeling emerged, including cardiac arrest, and cardiac failure. Although percutaneous coronary intervention was the most common indication (35.4%), numerous events were associated with off-label use, particularly for conditions such as acute myocardial infarction, antiplatelet therapy, and anticoagulant therapy.

CONCLUSION

Our research reveals both anticipated and unexpected AEs, providing important new information on the safety profile of cangrelor. Furthermore, we have discovered certain problems pertaining to product applications. It is recommended that manufacturers clearly highlight indications and usage instructions, and medical personnel closely follow drug administration protocols.

Dyspnea Management in Patients Presenting to the Emergency Department at Cantonal Hospital Baselland-A Retrospective Observational Study and Medical Audit

Background/Objectives: Dyspnea, the subjective experience of breathing discomfort, accounts for approximately 5% of emergency department (ED) presentations, 10% of general ward admissions, and 20% of intensive care unit (ICU) admissions. Despite its prevalence, dyspnea remains a challenging clinical manifestation for physicians. To the best of our knowledge, there are no international guidelines for the assessment and management of patients with dyspnea coming to the ED. In this study, we aim to evaluate how dyspnea cases are assessed and managed at Cantonal Hospital Baselland in Liestal (KSBL) and to audit these practices. Methods: We conducted a retrospective, observational study of hospital records from KSBL, including all patients presenting to the ED with dyspnea as their primary symptom who were subsequently admitted to the internal medicine ward for at least one night between January and December 2022. Data on assessment and management practices were compared using the medStandards algorithm. Results: A total of 823 cases were included. The median age at admission was 76 years (with a range of 15-99), and 57% of the patients were male. Blood pressure and heart rate were documented in 93.8% of the cases, respiratory rate in 61.4%, oxygen saturation in 96.1%, and body temperature in 86.3%. The patient's subjective dyspnea description was recorded in 14.8% of the cases, while the temporal onset (timing of symptoms) was documented in 98.8%, and the intensity of effort triggering dyspnea was noted in 36.2% of cases. A dyspnea index scale was used in 7.8% and smoking status was documented in 41.1% of the cases. Lung percussion was performed in 2.6% of the cases, while a lung auscultation was performed in 94.4% and a heart auscultation was performed in 85.3% of cases. A complete blood count with a basic metabolic panel and TSH test was collected in 86.9% of the cases, while a blood gas analysis was collected in 34.0% of the cases. An ECG was reported in 87.5% of the cases. From the 337 patients who should have received an emergency ultrasound, 10.1% received one. The three most frequent final diagnoses were decompensated heart failure (28.4%), pneumonia (26.4%), and COVID-19 (17.0%). None of the three patients with a known neuromuscular disease were admitted to the shock room. Conclusions: Our findings reveal that the medStandards algorithm was only partially followed at the ED in KSBL Liestal, highlighting gaps in detailed history taking, respiratory rate measurement, lung percussion, and emergency ultrasound use. Given the frequency of dyspnea-related presentations, systematic improvements in the adherence to assessment protocols are urgently needed to enhance patient outcomes.

Impact of CT-angiography derived plaque characteristics on cardiac events in patients with a negative invasive fractional flow reserve

BACKGROUND

Fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) for chronic coronary syndromes (CCS) improves outcomes compared with angiography-guided PCI, however cardiac events still occur during long-term follow-up of FFR-negative patients. In the PREVENT study preventive PCI reduced cardiac-events in lesions which were FFR-negative (FFR > 0.80) and had intracoronary imaging defined vulnerable plaque. Coronary computed tomography angiography (CTA)-defined high risk plaque (HRP) is known to predict future cardiac events. We hypothesized that CTA defined HRP would identify which FFR-negative patients were at greatest risk of future cardiac events.

METHODS AND RESULTS

We examined 373 consecutive CCS patients undergoing CTA followed not more than 90 days later by invasive FFR. Cardiac events were defined as cardiac death, non-fatal acute coronary syndromes, and ischemia-driven revascularization. Clinical follow-up was performed in all patients at a median of 32 months. Revascularization was performed in 131 of the 373 patients due to an FFR ≤ 0.80 (Treat group), with the remaining 242 having revascularization deferred (Defer group) due to an FFR > 0.80. In the Treat group the cardiac event rates between patients with and without HRP on CTA were similar (9.4 % versus 10.1 %, p = 0.90), whilst in the Defer group they were higher in patients with HRP (21.1 % versus 4.7 %, Log-rank-p < 0.0001). In multivariate Cox hazard analysis the presence of HRP (Hazard-ratio 12.79, 95 %confidence-intervals: 3.57-45.83, p < 0.0001) was an independent predictor for cardiac events in the Defer group.

CONCLUSIONS

HRP on CTA was associated with future cardiac events in patients in whom revascularization was deferred due to a negative invasive-FFR (UMIN000054067; CAPTURE).

Percutaneous coronary intervention in patients with acute coronary syndromes and increased platelet count

BACKGROUND

In patients with acute coronary syndromes (ACS) requiring percutaneous coronary intervention (PCI), abnormally elevated platelet counts are often associated with an increased risk of stent thrombosis and bleeding.

AIMS

To explore the associations between clinical benefits and PCI in patients with ACS and elevated platelet counts.

METHODS

Between July 2017 and December 2019, 50,009 patients with ACS were enrolled in the Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome Project. This study included patients with platelet count≥300×109/L. The primary outcome was net adverse clinical events (NACE), including major adverse cardiovascular or cerebrovascular events (MACCE; all-cause death, myocardial infarction, ischaemic stroke and stent thrombosis) and major bleeding during the index hospitalization. The difference in the risk of NACE between PCI and non-PCI groups was analysed using multivariable analysis and inverse probability of treatment weighting.

RESULTS

Among 4501 patients, PCI rates decreased as platelet count increased, with 3029 patients ultimately undergoing PCI. These patients exhibited a lower rate of NACE (adjusted odds ratio [OR]: 0.53, 95% confidence interval [95% CI]: 0.37-0.77; P=0.001) and a reduced risk of MACCE (OR: 0.44, 95% CI: 0.29-0.67; P<0.001). No significant differences in major bleeding were observed (adjusted OR: 1.40, 95% CI: 0.62-3.16; P=0.417). Inverse probability of treatment weighting confirmed these findings.

CONCLUSION

In patients with ACS and increased platelet counts who have more complex thrombohaemorrhagic profiles, PCI can effectively reduce the risk of ischaemic events without increasing the risk of bleeding.

CLINICAL TRIAL REGISTRATION

https://clinicaltrials.gov/study/NCT02306616.

Rapid rule-out of acute myocardial infarction using the 0/1-hour algorithm for cardiac troponins in emergency primary care: the OUT-ACS implementation study

BACKGROUND

Acute chest pain has a high hospital referral rate due to the limited ability to exclude acute myocardial infarction (MI) in primary care. We aimed to evaluate the effectiveness of implementing the European Society of Cardiology (ESC) 0/1-hour algorithm for high-sensitivity cardiac troponin T (hs-cTnT) testing in emergency primary care.

METHODS

In a prospective study (April-October 2023), the ESC 0/1-hour algorithm for hs-cTnT was implemented at the main emergency primary care clinic in Oslo, Norway. All consecutive patients ≥ 18 years with acute non-traumatic chest pain having hs-cTnT measurements done were registered. The patients were assigned to MI rule-out, rule-in, or further observation using the algorithm. Patients in the observation group had a 4-hour hs-cTnT measurement done. The outcome measures were the proportion of patients conclusively assessed by the protocol, personnel adherence, reduction in length of stay (LOS) compared to the previous 0/4-hour protocol (historical cohort), and disposition.

RESULTS

During six months, hs-cTnT measurements were conducted in 32.6% (995/3053) of chest pain patients (median age 58 years (IQR 45-68); 50.6% female). A single hs-cTnT measurement assigned 24.1% (n = 240/995) towards MI rule-out, suitable for early discharge, increasing to 63.8% after adding a 1-hour measurement. The observation group (319/995, 32.1%) was reduced to 23.0% (229/995) after a 4-hour measurement. A total of 77.0% of the patients were conclusively assigned to either rule-out or rule-in group. The personnel adhered well to the new protocol, with a median 1-hour sampling interval of 63 min (IQR 60-66) and 4.6 h (IQR 4.1-5.5) for the 4-hour sample. The protocol was misinterpreted or overruled in 8.6% of the cases. Compared to the previous 0/4-hour protocol, LOS was reduced by -2.2 h (95% confidence intervals - 2.6 to -1.7). After completed assessment at the clinic, 14.8% were transferred to hospital, where 20 patients were diagnosed with an MI. The remaining patients were sent home or managed in the outpatient setting; any occurrence of MIs in this group is unknown.

CONCLUSIONS

The ESC 0/1-hour algorithm effectively assesses low-risk acute chest pain in emergency primary care, reinforcing its gatekeeper role by managing these patients at a lower level of care.

P2Y12 Inhibitor Pretreatment in Non-ST-Segment Elevation Acute Coronary Syndrome: The NCDR Chest Pain-MI Registry

BACKGROUND

Although high rates of P2Y12 inhibitor pretreatment (defined as the administration before coronary angiography) for non-ST-segment elevation acute coronary syndrome (NSTE-ACS) have been reported, contemporary U.S. practice patterns are not well studied.

OBJECTIVES

The goal of this study was to investigate the temporal U.S. trends, variability, and clinical outcomes of P2Y12 inhibitor pretreatment in NSTE-ACS.

METHODS

Consecutive patients who underwent early invasive strategy for NSTE-ACS (coronary angiography ≤24 hours of arrival) in the National Cardiovascular Data Registry Chest Pain-Myocardial Infarction (MI) Registry were analyzed. A time-trend analysis was conducted on a complete cohort between January 1, 2013, and March 31, 2023. Subsequently, a more recent cohort (January 1, 2019, to March 31, 2023) with a complete set of variables was used to construct hierarchical regression models to quantify the variability in the use of pretreatment among operators and institutions. For this contemporary cohort, instrumental variable analysis, with operator preference as the instrument, was performed to compare the in-hospital outcomes between patients who received pretreatment and those who did not.

RESULTS

Use of P2Y12 inhibitor pretreatment decreased from 24.8% in 2013Q1 to 12.4% in 2023Q1. Among the contemporary cohort of 110,148 patients (2019-2023; mean age 63.9 ± 12.5 years; 33.0% female), 17,509 (15.9%) received pretreatment. Significant variability in P2Y12 inhibitor pretreatment was observed (range: 0%-100%): hierarchical regression model demonstrated that 2 similar patients would have a >3-fold difference in the odds of pretreatment from 1 random operator or institution as compared with another (median OR: 3.74 [95% CI: 3.57-3.91] and 3.63 [95% CI: 3.51-3.74], respectively). Instrumental variable analysis demonstrated no significant differences in in-hospital all-cause death (1.5% vs 1.7%; P = 0.07), recurrent MI (0.6% vs 0.6%; P = 0.98), or major bleeding (2.7% vs 2.8%; P = 0.98) with pretreatment. However, in patients who underwent coronary artery bypass surgery, pretreatment was associated with a longer length of stay (11.2 ± 5.1 days vs 9.8 ± 5.0 days; P < 0.01).

CONCLUSIONS

In a national U.S. registry, we observed significant variability in the use of P2Y12 inhibitor pretreatment among NSTE-ACS patients. Given the lack of clear advantages and the potential for prolonged hospital stays, our findings highlight the importance of efforts to improve standardization.

30-day unplanned readmission rates and causes in patients hospitalised for acute coronary syndrome based on DANish CoMorbidity index for Acute Myocardial Infarction score

OBJECTIVE

This study aimed to investigate the association of the DANish CoMorbidity Index for Acute Myocardial Infarction (DANCAMI) score with 30-day unplanned readmission rates and causes in patients with acute coronary syndrome (ACS).

METHODS

Using the US National Readmission Database, all index hospitalisations with a principal diagnosis of ACS between October 2015 and December 2019 were stratified by their DANCAMI score using International Classification of Diseases-10th edition codes. Thirty-day unplanned readmission rates and causes were analysed, including the assessment of factors associated with readmission. Multivariable regression analyses were reported as adjusted odds ratios (aOR) with 95% confidence intervals (95% CI).

RESULTS

Of 2,066,328 ACS admissions, 173,304 (8.4%) had a DANCAMI score of 0, 602,640 (29.2%) had a DANCAMI score of 1-3, 327,046 (15.8%) had a DANCAMI score of 4-5, and 963,338 (46.6%) had a DANCAMI score ≥6. 189,240 (9.2%) had an unplanned readmission within 30 days. Patients with a higher DANCAMI score were more likely to be older and have an index presentation of non-ST-elevation ACS. A DANCAMI score ≥6 (aOR 1.30 95% CI 1.27-1.34), age (aOR 1.01 95% CI 1.01-1.01), female sex (aOR 1.09 95% CI 1.08-1.10), index ST-elevation ACS (aOR 1.03 95% CI 1.01-1.04), and atrial fibrillation (aOR 1.35 95% CI 1.33-1.37) were independently associated with readmission (all p < 0.001). Higher scores were associated with an increasing likelihood of readmission for non-cardiovascular causes.

CONCLUSION

Increased DANCAMI score was associated with higher readmissions in patients with ACS. The DANCAMI score could be a valuable tool to assess risk.

Effect of apixaban versus vitamin K antagonist and aspirin versus placebo on days alive and out of hospital: An analysis from AUGUSTUS

BACKGROUND

Clinical trials of antithrombotic agents typically use separate time-to-event analyses for bleeding and ischemic events, but this framework has limitations. Days alive and out of hospital (DAOH) is an alternative that may provide additional insight. We assessed the utility of DAOH as a clinical trial endpoint among patients with atrial fibrillation and acute coronary syndrome or percutaneous coronary intervention METHODS: AUGUSTUS, a randomized clinical trial, compared apixaban with warfarin and aspirin with placebo in 4614 patients with atrial fibrillation and acute coronary syndrome or percutaneous coronary intervention. We used Poisson regression with a robust variance estimate to compare DAOH by treatment group.

RESULTS

Mean (SD) DAOH was 168 (31); median (IQR) was 177 (169-180); 75% of patients neither died nor were hospitalized. Mean (SD) DAOH was 169 (28) with apixaban + placebo, 168 (29) with apixaban + aspirin, 168 (33) with warfarin + placebo, and 167 (33) with warfarin + aspirin. There were no significant differences in the rate ratio for DAOH for apixaban vs. warfarin (RR 1.00, 95% CI 0.99-1.01) or aspirin vs. placebo (RR 1.00, 95% CI 1.00-1.01). Compared with warfarin, apixaban increased the proportion of patients who neither died nor were hospitalized during follow-up (76.8 vs. 73.3%; OR 0.83, 95% CI 0.73-0.95).

CONCLUSION

In this analysis of AUGUSTUS, there was no difference in DAOH by treatment arm. These findings contrast with time-to-event analyses, which showed lower rates of major bleeding and hospitalization with apixaban and placebo. DAOH may not be very a useful measure of effects of antithrombotic therapies in this population.

TRIAL REGISTRATION

clinicaltrials.gov; NCT02415400; https://clinicaltrials.gov/study/NCT02415400.

Gender-Related Outcomes in Saphenous Vein Graft Interventions

BACKGROUND

Saphenous vein graft percutaneous coronary intervention (SVG-PCI) is a relatively common procedure in patients after coronary artery bypass grafting (CABG). Although internal mammary artery is considered optimal, SVG is still used in the majority of patients.

AIMS

Investigating the potential role of gender differences in the incidence and outcomes of SVG-PCI.

METHODS

The study was based on a prospectively collected registry of 1199 consecutive patients (169 female) who underwent SVG-PCI in a tertiary medical center between 2004 and 2023. Primary outcomes included MACE (death, myocardial infarction [MI], target vessel revascularization [TVR], stroke) and mortality, at 1 and 3 years.

RESULTS

Female patients were older (73.6 ± 9.1 years vs. 70.6 ± 9.7 years, p < 0.001), suffered from higher rates of diabetes mellitus, peripheral vascular disease, and congestive heart failure (78.1% vs. 61.3% p < 0.001, 13.6% vs. 7% p < 0.003, 66.3% vs. 51.8% p < 0.001 respectively). Additionally, female patients had lower trans-radial access use (11.9% vs. 19.3%, p < 0.025), and underwent SVG-PCI earlier following their CABG procedure (11.3 ± 6.2 years vs 12.9 ± 6.1 years, p < 0.003), as compared to male patients. There were no differences in MACE rates between the groups. Mortality was higher in the female group at 1 year (13.6% vs. 6.9%, p = 0.003), but no significant differences were observed at 3 years (24.3% vs. 20.9%, p = 0.320). Cox regression analysis identified age, renal function, ejection fraction, MI and trans-femoral as independent risk factors for mortality.

CONCLUSION

Gender-specific monitoring and early intervention, especially for women, are required for better management of graft patency, potentially improving long-term outcomes.

Concomitant use of clopidogrel and proton pump inhibitors: A retrospective analysis of prescription behaviour

AIMS

Since omeprazole and esomeprazole reduce the effect of clopidogrel on the inhibition of platelet aggregation, concomitant use of these drugs has been discouraged by the Food and Drug Administration (FDA) and European Medicines Agency (EMA) since 2010. Currently, it is unknown how often this undesired drug-drug combination is prescribed. The aim of this article is to determine the proportion of patients using omeprazole or esomeprazole among patients using clopidogrel with gastroprotective drugs and to identify differences between these two groups with regard to patient characteristics and prescriber characteristics.

METHODS

This was a retrospective analysis of Dutch outpatient medication prescription records between 2015 and 2022. The database had a coverage of approximately 62% of all outpatient prescriptions dispensed in The Netherlands.

RESULTS

The proportion of patients using omeprazole or esomeprazole as gastroprotective drug in combination with clopidogrel declined from 19.7% to 8.7% between 2015 and 2022. The undesired drug-drug combination was more often prescribed by internists, to women and to patients with polypharmacy (using >10 drugs).

CONCLUSIONS

Although the proportion of patients using clopidogrel together with omeprazole or esomeprazole declined between 2015 and 2022, the undesired combination is still frequently prescribed in The Netherlands. Education about this drug-drug interaction for pharmacists and prescribers is needed since pharmacotherapeutic alternatives are available.

Influence of Worsening Renal Function and Baseline Chronic Kidney Disease on Clinical Outcomes in Patients With Chronic Coronary Syndromes: Insights From the REAL-CAD Study

BACKGROUND

The effect of worsening renal function and baseline chronic kidney disease (CKD) on outcomes in patients with chronic coronary syndrome in the setting of optimal medical therapy remains unknown.

METHODS AND RESULTS

The REAL-CAD (Randomized Evaluation of Aggressive or Moderate Lipid Lowering Therapy With Pitavastatin in Coronary Artery Disease) study is a prospective, multicenter, randomized trial of high-dose (pitavastatin 4 mg/day) or low-dose (pitavastatin 1 mg/day) statin therapy in 12 118 patients with chronic coronary syndrome. The primary end point was a composite of cardiovascular death, nonfatal myocardial infarction, stroke, or unstable angina requiring hospitalization (major adverse cardiac and cerebral events [MACCE]). CKD was defined as an estimated glomerular filtration rate [eGFR] <60 mL/min per 1.73 m2. WRF was defined as a decrease in eGFR ≥20% in the initial year; borderline renal function was an annual decrease of 0%

CONCLUSIONS

Baseline CKD was an independent predictor for MACCE in patients with CCS. WRF was a significant predictor for MACCE in patients with CKD. Because borderline renal function was an independent predictor for MACCE even in patients without CKD, mild-to-moderate annual declines of eGFR should be carefully monitored (NCT01042730).

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique Identifier: NCT01042730.

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Key Words

• CCS
• CKD
• MACCE
• PCI
• deterioration

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MESH Headings

• Humans
• Male
• Female
• Renal Insufficiency, Chronic/physiopathology
• Renal Insufficiency, Chronic/complications
• Renal Insufficiency, Chronic/diagnosis
• Aged
• Glomerular Filtration Rate
• Middle Aged
• Prospective Studies
• Hydroxymethylglutaryl-CoA Reductase Inhibitors/therapeutic use
• Kidney/physiopathology
• Treatment Outcome
• Quinolines/therapeutic use
• Risk Factors
• Coronary Artery Disease/physiopathology
• Coronary Artery Disease/complications
• Coronary Artery Disease/diagnosis
• Coronary Artery Disease/mortality
• Disease Progression
• Time Factors

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Grants Collapse

Affiliation(s)

Yu Yoshiki Department of Cardiology Fujita Health University School of Medicine Toyoake Aichi Japan
Yukio Ozaki Department of Cardiology Fujita Health University School of Medicine Toyoake Aichi Japan
Mitsuru Abe Department of Cardiology National Hospital Organization Kyoto Medical Center Kyoto Japan
Tevfik F Ismail King's College London, London UK & Guy's and St Thomas' Hospital NHS Foundation Trust London United Kingdom
Hiroshi Takahashi Division of Medical Statistics Fujita Health University Hospital Toyoake Aichi Japan
Masaharu Akao Department of Cardiology National Hospital Organization Kyoto Medical Center Kyoto Japan
Hideki Kawai Department of Cardiology Fujita Health University School of Medicine Toyoake Aichi Japan
Takashi Muramatsu Department of Cardiology Fujita Health University School of Medicine Toyoake Aichi Japan
Masahide Harada Department of Cardiology Fujita Health University School of Medicine Toyoake Aichi Japan
Masaya Ohta Department of Cardiology Fujita Health University School of Medicine Toyoake Aichi Japan
Yosuke Hashimoto Department of Cardiology Fujita Health University School of Medicine Toyoake Aichi Japan
Yuichiro Shiki Department of Cardiology Fujita Health University School of Medicine Toyoake Aichi Japan
Masayuki Koshikawa Department of Cardiology Fujita Health University School of Medicine Toyoake Aichi Japan
Keiichi Miyajima Department of Cardiology Fujita Health University School of Medicine Toyoake Aichi Japan
Hidemaro Takatsu Department of Cardiology Fujita Health University School of Medicine Toyoake Aichi Japan
Yudai Niwa Department of Cardiology Fujita Health University School of Medicine Toyoake Aichi Japan
Naoyuki Kawashima Department of Cardiology Fujita Health University School of Medicine Toyoake Aichi Japan
Reina Ozaki Department of Cardiology Fujita Health University School of Medicine Toyoake Aichi Japan Nagoya University Graduate School of Medicine Nagoya Japan
Naotake Tsuboi Department of Nephrology Fujita Health University School of Medicine Toyoake Aichi Japan
Satoshi Iimuro Teikyo Academic Research Center Teikyo University Tokyo Japan
Hiroshi Iwata Department of Cardiovascular Medicine Juntendo University Graduate School of Medicine Tokyo Japan
Ichiro Sakuma Caress Sapporo Hokko Memorial Clinic Sapporo Japan
Yoshihisa Nakagawa Department of Cardiovascular Medicine Shiga University of Medical Science Hospital Otsu Japan
Kiyoshi Hibi Division of Cardiology Yokohama City University Medical Center Yokohama Japan
Takafumi Hiro Division of Cardiology, Department of Medicine Nihon University School of Medicine Tokyo Japan
Yoshihiro Fukumoto Division of Cardiovascular Medicine, Department of Internal Medicine Kurume University School of Medicine Kurume Japan
Seiji Hokimoto Department of Cardiovascular Medicine Kumamoto University Hospital Kumamoto Japan
Katsumi Miyauchi Department of Cardiovascular Medicine Juntendo University Graduate School of Medicine Tokyo Japan
Hisao Ogawa Department of Cardiovascular Medicine Kumamoto University Hospital Kumamoto Japan
Hiroyuki Daida Department of Cardiovascular Medicine Juntendo University Graduate School of Medicine Tokyo Japan
Hiroaki Shimokawa Department of Cardiovascular Medicine Tohoku University Graduate School of Medicine Sendai Japan
Hideo Izawa Department of Cardiology Fujita Health University School of Medicine Toyoake Aichi Japan
Takeshi Kimura Department of Cardiovascular Medicine Kyoto University Graduate School of Medicine Kyoto Japan
Ryozo Nagai Jichi Medical University Shimotsuke Japan

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Pre-Hospital Point-of-Care Troponin: Is It Possible to Anticipate the Diagnosis? A Preliminary Report

Background: Thanks to the evolution of laboratory medicine, point-of-care testing (POCT) for troponin levels in the blood (hs-cTn) has been greatly improved in order to quickly diagnose acute myocardial infarction (AMI) with an accuracy similar to standard laboratory tests. The rationale of the HEART POCT study is to propose the application of the 0/1 h European Society of Cardiology (ESC) algorithm in the pre-hospital setting using a POCT device (Atellica VTLi). Methods: This is a prospective study comparing patients who underwent pre-hospital point-of-care troponin testing (Atellica VTLi) with a control group that underwent standard hospital-based troponin testing (Elecsys). The primary objectives were to determine if the 0/1 h algorithm of the Atellica VTLi is non-inferior to the standard laboratory method for diagnosing AMI and to analyze rule-out/rule-in times and emergency department (ED) stay times. The secondary objective was to evaluate the feasibility of pre-hospital troponin testing. Results: The Atellica VTLi demonstrated reasonable sensitivity for detecting AMI, with sensitivity increasing from 60% at the first measurement (time 0) to 80% at the second measurement (time 1 h). Both the Atellica VTLi and the Elecsys method showed high negative predictive value (NPV), indicating that a negative troponin result effectively ruled out AMI in most cases. Patients in the Atellica VTLi group experienced significantly shorter times to diagnosis and discharge from the emergency department compared to the control group (Elecsys). This highlights a potential benefit of point-of-care testing: streamlining the diagnostic and treatment processes. Conclusions: POCT allows for rapid troponin measurement, leading to a faster diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI). This enables earlier initiation of appropriate treatment, potentially improving patient outcomes and the efficiency of emergency department operations. POCT could be particularly beneficial in pre-hospital settings, enabling faster triage and transportation of patients to appropriate care centers.

Diabetes and cardiovascular disease in older adults

An aging population combined with a rapidly increasing prevalence of diabetes foreshadows a global epidemic of cardiovascular and kidney disease that threatens to halt improvements in life and health-span and will have particularly severe consequences in older adults. The management of diabetes has been transformed with the recent development of newer anti-hyperglycemic agents that have demonstrated superior efficacy. However, the utility of these drugs extends beyond glycemic control to benefits for managing obesity, cardiovascular disease (CVD), chronic kidney disease, and heart failure. Numerous cardiovascular and kidney outcomes trials of these drugs have played an instrumental role in shaping current guidelines for the management of diabetes and CVD. Older adults with diabetes are diverse in terms of their comorbidities, diabetic complications, and cognitive and functional status. Therefore, there is an unmet need for personalized management of diabetes and CVD in this population. In this review, we provide an overview of the epidemiological burden and management of diabetes and CVD in older adults. We then focus on randomized cardiovascular and kidney outcome trials with anti-hyperglycemic agents to propose an evidence-based approach to the management of diabetes in older adults with high risk of cardiovascular and kidney disease.

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

Background

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

Methods

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

Results

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

Conclusions

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

Evaluating high-sensitivity cardiac troponin I for early detection of treatment-related cardiotoxicity in HER2-positive breast cancer patients

Background

Trastuzumab-related cardiotoxicity is a common adverse effect of HER2-positive breast cancer treatment, especially when combined with anthracyclines. However, to date, no definitive prognostic markers have been found to predict trastuzumab-related cardiotoxicity.

Methods

Patients diagnosed with HER2-positive breast cancer, scheduled to receive anthracyclines followed by 12 months of trastuzumab or with pertuzumab, were prospectively followed up for 27 months. Measurements of left ventricular ejection fraction LVEF, high-sesitivity troponin I hs-Tn I, and a full cardiac examination were performed at baseline, after anthracycline treatment, and after four cycles of anti-HER2 agents. Subsequently, LVEF measurement and full cardiac examination were conducted every 3 months until the end of the follow-up. Cardiotoxicity was defined as an absolute decrease in LVEF of ≥15%, or a drop in LVEF of ≥10% from the baseline to <50%.

Results

Among 78 patients, cardiotoxicity occurred in 13 (16.7%). A higher risk of cardiotoxicity was linked to hs-Tn I measured after four cycles of anti-HER2 agents (P < 0.001), with a significant cutoff of >84 ng/L. No short-term effects of the anthracycline agents (doxorubicin or epirubicin), were found. However, there was a slightly higher tendency to develop cardiotoxicity (P = 0.046) in patients treated with trastuzumab plus pertuzumab.

Conclusion

Hs-Tn I measured after four cycles of trastuzumab in HER2-positive breast cancer patients could be an important predictor of cardiotoxicity induced by chemotherapy followed by anti-HER2 agents, particularly in the first year post-treatment, with a different cutoff value than that used in other cardiac conditions.

Bioinformatics-based Analysis and Verification of Chromatin Regulators and the Mechanism of Immune Infiltration Associated with Myocardial Infarction

BACKGROUND

Recent studies have shown that dysfunction in chromatin regulators (CRs) may be an important mechanism of myocardial infarction (MI). They are thus expected to become a new target in the diagnosis and treatment of MI. However, the diagnostic value of CRs in MI and the mechanisms are not clear.

METHODS

CRs-related differentially expressed genes (DEGs) were screened between healthy controls and patients with MI via GSE48060, GSE60993, and GSE66360 datasets. DEGs were further analyzed for enrichment analysis. Hub genes were screened by least absolute shrinkage and selection operator (LASSO) regression and weighted gene co-expression network analysis (WGCNA). GSE61144 datasets were further used to validate hub genes. RT-qPCR examined peripheral blood mononuclear cells (PBMCs) to verify expressions of hub genes. In addition, a correlation between hub genes and immune cell infiltration was identified by CIBERSORT and single-sample gene set enrichment analysis (ssGSEA). Finally, we constructed a diagnostic nomogram and ceRNA network and found possible therapeutic medicines which were based on hub genes.

RESULTS

Firstly, 16 CR-related DEGs were identified. Next, Dual-specificity phosphatase 1 (DUSP1), growth arrest and DNA damage-inducible 45 (GADD45A), and transcriptional regulator Jun dimerization protein 2 (JDP2) were selected as hub genes by LASSO and WGCNA. Receiver operating characteristic curves in the training and test data sets verified the reliability of hub genes. Results of RT-qPCR confirmed the upregulation of hub genes in MI. Subsequently, the immune infiltration analysis indicated that DUSP1, GADD45A, and JDP2 were correlated with plasmacytoid dendritic cells, natural killer cells, eosinophils, effector memory CD4 T cells, central memory CD4 T cells, activated dendritic cells, and activated CD8 T cells. Furthermore, a nomogram that included DUSP1, GADD45A, and JDP2 was created. The calibration curve, decision curve analysis, and the clinical impact curve indicated that the nomogram could predict the occurrence of MI with high efficacy. The results of the ceRNA network suggest that hub genes may be cross-regulated by various lncRNAs and miRNAs. In addition, 10 drugs, including 2H-1-benzopyran, Nifuroxazide, and Bepridil, were predicted to be potential therapeutic agents for MI.

CONCLUSION

Our study identifies three promising genes associated with the progression of chromatin regulators (CRs)-related myocardial infarction (MI) and immune cell infiltration, including Dual-specificity phosphatase 1 (DUSP1), growth arrest and DNA damage-inducible 45 (GADD45A), and Jun dimerization protein 2 (JDP2), which might be worthy of further study.

The effectiveness of HALP score in predicting mortality in non-ST-elevation myocardial infarction patients

BACKGROUND

The HALP score, measured based on hemoglobin, albumin, lymphocyte, and platelet levels, is regarded as a novel scoring system that indicates the status of systemic inflammation and nutritional health. Our study aimed to evaluate the relationship between HALP score and prognosis in non-ST-elevation myocardial infarction (NSTEMI) patients.

METHODS

Between 1 January 2020 and 1 January 2022, 568 consecutive patients diagnosed with NSTEMI from a single center were included in the study retrospectively. The patients were divided into two equal groups according to the median HALP cutoff value of 44.05. Patients were followed for at least 1 year from the date of admission.

RESULTS

The average age of the patients was 62.3 ± 10.6 years and 43.7% were female. In-hospital and 1-year mortality were found to be significantly higher in the group with low HALP scores (6.0 vs. 2.1%, P  = 0.019 and 22.5 vs. 9.9%, P  < 0.001, respectively). In receiver operating characteristic curve analysis, a cutoff level of 34.6 of the HALP score predicted 1-year mortality with 71% sensitivity and 65% specificity (area under the curve: 0.707, 95% confidence interval: 0.651-0.762, P  < 0.001). In Kaplan-Meier analysis, higher mortality rates were observed over time in the group with lower HALP scores (log-rank test=16.767, P  < 0.001). In Cox regression analysis, the HALP score was found to be an independent predictor of 1-year mortality (odds ratio: 0.969, 95% confidence interval: 0.958-0.981, P  < 0.001).

CONCLUSION

We found that a low HALP score could predict in-hospital and 1-year mortality in patients admitted to the hospital with a diagnosis of NSTEMI.

Frequency of periprocedural myocardial injury and infarction stratified by cardiac troponin I and cardiac troponin T

BACKGROUND

There are different definitions of periprocedural myocardial infarction (PPMI) both in terms of thresholds for cardiac biomarkers and the ancillary criteria for myocardial ischemia. Cardiac Troponin I (cTnI) and cardiac Troponin T (cTnT) are used interchangeably to diagnose PPMI.

OBJECTIVES

This study evaluated the frequency of periprocedural myocardial injury and infarction as defined by the Society of Cardiovascular Angiography & Interventions (SCAI), the Academic Research Consortium-2 (ARC-2), and the 4th Universal definition of MI (4UDMI) stratified using cTnT versus cTnI, among patients with chronic coronary syndrome (CCS) and unstable angina.

RESULTS

Among 830 patients, PPMI rates according to the SCAI, ARC2 and 4UDMI criteria were 4.34 %, 2.05 %, and 4.94 % respectively, with higher rates seen for all definitions when using cTnI versus cTnT (SCAI: 9.84 % vs. 1.91 %, p < 0.001; ARC 2: 3.15 % vs. 1.56 %, p = 0.136; and 4UDMI 5.91 % vs. 4.51 %, p = 0.391). Minor and major periprocedural myocardial injury was respectively observed in 58.31 % and 27.10 % of patients, with rates of both significantly higher when using cTnI versus cTnT (Minor: 69.29 % vs. 53.47 %, p < 0.001, Major: 49.21 % vs. 17.36 %, p < 0.001).

CONCLUSIONS

Among patients with CCS and unstable angina, PPMIs defined by SCAI occurred more frequently when using cTnI as opposed to cTnT, whereas the type of troponin had no impact on the incidence of PPMIs according to the ARC-2 and 4UDMI.

Performance of computerized self-reported medical history taking and HEAR score for safe early rule-out of cardiac events in acute chest pain patients: the CLEOS-CPDS prospective cohort study

Aims

A simplified version of the history, electrocardiogram, age, risk factors, troponin (HEART) score, excluding troponin, has been proposed to rule-out major adverse cardiac events (MACEs). Computerized history taking (CHT) provides a systematic and automated method to obtain information necessary to calculate the HEAR score. We aimed to evaluate the efficacy and diagnostic accuracy of CHT in calculating the HEAR score for predicting MACE.

Methods and results

Prospective study including clinically stable adults presenting with chest pain at the emergency department (ED) of Danderyd University Hospital (Stockholm, Sweden), in 2017-19. Participants entered their medical histories on touchscreen tablets using CHT software. The HEAR and HEART scores were calculated from CHT data. Thirty-day MACE and acute coronary syndrome (ACS) outcomes were retrieved, and the diagnostic accuracy was assessed. Logistic regression was used to determine the most predictive components of the HEAR score. Among 1000 patients, HEART and HEAR scores could be calculated from CHT data in 648 and 666 cases, respectively, with negative predictive values [95% confidence interval (CI)] of 0.98 (0.97-0.99) and 0.99 (0.96-1.00). Two patients with HEAR score <2 experienced a 30-day MACE. The age [odds ratio (OR) 2.75, 95% CI 1.62-4.66] and history (OR 2.38, 95% CI 1.52-3.71) components of the HEAR score were most predictive of MACE. Acute coronary syndrome outcomes provided similar results.

Conclusion

The HEAR score acquired by CHT identifies very-low-risk patients with chest pain in the ED, safely ruling out ACS and MACE. This highlights the value of computerized history taking by patients, which may reduce unnecessary tests and hospital admissions.

Trial Registration

ClinicalTrials.gov NCT03439449.