Fourth Universal Definition of Myocardial Infarction (2018)

Clinical utility of preoperative stress perfusion cardiac magnetic resonance for predicting cardiovascular events in patients undergoing major noncardiac surgery

BACKGROUND

Although guidelines recommend preoperative stress testing for patients with risk factors, the appropriate indications for stress perfusion cardiac magnetic resonance (CMR) have not been clearly defined. This study aimed to investigate the value of preoperative stress perfusion CMR in predicting major adverse cardiovascular events (MACE) in patients undergoing major noncardiac surgery.

METHODS

This study included 309 patients who underwent CMR within 180 days prior to major noncardiac surgery between 2010 and 2022. Patients were categorized based on the presence or absence of inducible myocardial ischemia. The primary outcome was MACE, defined as a composite of cardiovascular death, myocardial infarction, sustained ventricular arrhythmia, heart failure, or ischemic stroke occurring during the indexed hospitalization for surgery or within 30 days post-discharge.

RESULTS

The mean patient age was 72 years (51% male), and 21% demonstrated inducible myocardial ischemia. Total MACE occurred in 4.5% of patients and was significantly higher in the inducible ischemia group compared to those without ischemia (16.9% vs. 1.3%, p < 0.001). Cox regression analysis identified inducible ischemia as the strongest predictor of MACE (hazard ratio [HR] 10.72, 95% confidence interval [95% CI] 2.91-39.60, p < 0.001). Other predictors included left ventricular ejection fraction (HR 0.94, 95% CI 0.92-0.97, p < 0.001), the number of ischemic segments (HR 1.19, 95% CI 1.07-1.31, p = 0.001), the presence of late gadolinium enhancement (LGE) (HR 6.28, 95% CI 1.93-20.44, p = 0.002), and the number of LGE segments (HR 1.21, 95% CI 1.08-1.37, p = 0.002). The predictive performance of the Revised Cardiac Risk Index score significantly improved after the addition of inducible ischemia (C-statistic 0.61 vs. 0.77; net reclassification improvement 0.58, p < 0.001; integrative discrimination index 0.07, p < 0.001).

CONCLUSIONS

In this retrospective cohort study, inducible myocardial ischemia detected by stress perfusion CMR in patients undergoing major noncardiac surgery was associated with MACE during hospitalization or within 30 days post-discharge. Larger prospective or multicenter studies are required to validate these findings and ensure generalizability.

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/.

Age and sex differences in the efficacy of early invasive strategy for non-ST-elevation acute coronary syndrome: A comparative analysis in stable patients

Objective

Previous works have struggled to clearly define sex-specific outcomes based on initial management in NSTE-ACS patients. We examined if early revascularization (<24 h) versus conservative strategy impacts differently based on sex and age in stable NSTE-ACS patients upon hospital admission.

Methods

We identified 8905 patients with diagnosis of non-ST elevation acute coronary syndromes (NSTE-ACS) in the ISACS-TC database. Patients with cardiac arrest, hemodynamic instability, and serious ventricular arrhythmias were excluded. The final cohort consisted of 7589 patients. The characteristics between groups were adjusted using inverse probability of treatment weighting models. Primary outcome measure was all-cause 30-day mortality. Risk ratios (RRs) with their 95 % CIs were employed.

Results

Of the 7589 NSTE-ACS patients identified, 2450 (32.3 %) were women. The data show a notable reduction in mortality for the older women (aged 65 years and older) undergoing early invasive strategy compared to those receiving an initial conservative (3.0 % versus 5.1 %; RR: 0.57; 95 % CI: 0.32 - 0.99) Conversely, younger women did not exhibit a significant association between early invasive strategy and mortality reduction (2.0 % versus 0.9 %; RR: 2.27; 95 % CI: 0.73 - 7.04). For men, age stratification did not markedly alter the observed benefits of an early invasive strategy over a conservative approach in the overall population, with reduced death rates in both older (3.1 % versus 5.7 %; RR: 0.52; 95 % CI: 0.34 - 0.80) and younger age groups (0.8 % versus 1.7 %; RR: 0.46; 95 % CI: 0.22 - 0.94). These age and sex-specific mortality patterns did not significantly change within subgroups stratified by the presence of NSTEMI, or a GRACE risk score>140.

Conclusion

Early coronary revascularization is associated with improved 30-day survival in older men and women and younger men who present to hospital in stable conditions after NSTE-ACS. It does not confer a survival advantage in young women. Further studies are needed to more accurately risk-stratify young women to guide treatment strategies.

Registration

ClinicalTrials.gov: NCT01218776.

Association between phenotypic age and in-hospital outcomes in patients with acute myocardial infarction: A retrospective observational study

Background

Phenotypic age (PhenoAge) has emerged as a superior predictor of age-related morbidity and mortality. This study aimed to assess the associations between PhenoAge and in-hospital outcomes in patients with acute myocardial infarction (AMI).

Methods

2896 AMI patients admitted to the First Affiliated Hospital of Xi'an Jiaotong University from 2019 to 2022 were analyzed in this retrospective study. PhenoAge was calculated by using the phenotypic age calculator, an equation for chronologic age and 9 clinical biomarkers, and Phenotypic Age Accelerate (PhenoAgeAccel) was measured using the residuals of regression PhenoAge on chronological age. Clinical outcomes were defined as in-hospital major adverse cardiovascular events (MACEs), including cardiogenic shock, malignant arrhythmia, acute heart failure, and mechanical complications.

Results

Overall, patients with high PhenoAge had a higher Gensini score and a higher likelihood of receiving supportive care, as well as worse clinical outcomes. The same results were observed in patients with positive PhenoAgeAccel. Moreover, PhenoAge and PhenoAgeAccel were significantly associated with in-hospital MACEs even after adjusting for multiple traditional risk factors. The area under the curve for PhenoAge was 0.714 (P < 0.001), which significantly outperformed chronologic age (AUC: 0.601, P < 0.001) and other cardiovascular risk factors. Re-examination of the ROC curves using different combinations of variables, PhenoAge was also able to significantly improve the predictive value of several models.

Conclusions

PhenoAge is significantly associated with clinical outcomes and reliably predicts in-hospital MACEs. Compared with chronological age, PhenoAge is a better complementary biomarker for predicting the risk of in-hospital adverse cardiovascular events in patients with AMI.

Using eosinophil response to predict cardiovascular outcomes in patients with ST- elevation myocardial infarction who undergo primary percutaneous coronary intervention

Objective

Eosinophils have been implicated in mediating the inflammatory response after ST-elevation myocardial infarction (STEMI), but its role as a biomarker predicting major adverse cardiovascular events (MACE) remains unclear. We aimed to evaluate the predictive value of eosinophil response on 30-day and 1-year MACE post primary percutaneous coronary intervention (PCI) after STEMI.

Methods

Single centre retrospective cohort study of STEMI patients undergoing PCI. Eosinophil response was defined as the change in peripherally circulating eosinophils cell count at admission minus 48 h post primary PCI. Primary endpoints were 30-day and 1-year MACE. Receiver operating characteristic (ROC) curves were created to identify optimal cut-off predicting MACE. Multivariate logistic regression analyses were used to determine if the ROC cut-off was an independent predictor of MACE.

Results

Of the 366 patients in this study (median age 61 years [53.0-71.0]; 267 males [73 %]), 41 patients (11.2 %) and 78 patients (21.3 %) developed MACE at 30-days and 1-year. The optimal ROC curve cut-off predicting MACE was an eosinophil response of greater than -0.05 × 10^9/L (ΔEos > -0.05). It had a sensitivity, specificity, and positive and negative predictive value of 83, 39, 6 and 98 % for 30-day MACE, and 74, 39, 19 and 88 % for 1-year MACE. An ΔEos > -0.05 change was associated with a threefold higher likelihood of MACE at 30-days (OR 3.1, 95 % CI 1.04-9.07, p=0.042), but not 1-year.

Conclusion

An eosinophil response of -0.05 × 10^9L at 48 h following primary PCI post STEMI is highly sensitive at predicting 30-day MACE, and in its absence, holds a high negative predictive value.

Prospective randomized single-blind multicenter study to assess the safety and effectiveness of the SELUTION SLR 014 drug eluting balloon in the treatment of subjects with in-stent restenosis: Rationale and design

BACKGROUND

Repeat drug-eluting stenting is superior to balloon angioplasty for prevention of recurrent in-stent restenosis (ISR), but carries a potential disadvantage of multiple layers of stent. The safety and effectiveness of a sirolimus drug-eluting balloon as an alternative has not been assessed.

STUDY DESIGN AND METHODS

The SELUTION4ISR trial is a prospective, multicenter, single-blinded, randomized, controlled trial. A total of 418 subjects with bare metal or drug-eluting stent (DES) ISR with up to 2 previous stent procedures at the target lesion, lesion length <26 mm and reference diameter ≥2.0 mm - ≤4.5 mm will be randomized 1:1 to treatment with either the SELUTION SLR™ DEB (SLR DEB) or standard of care (SOC), which includes either repeat DES or balloon angioplasty without drug coating. A subset of subjects will undergo planned angiographic and optical coherence tomography follow-up. The primary endpoint will be target lesion failure, defined as cardiac death, target vessel myocardial infarction, or clinically-driven target lesion revascularization at 12 months follow-up. The study will sequentially assess noninferiority of the SLR DEB to SOC in the overall cohort, followed by noninferiority then superiority of the SLR DEB to DES in the cohort with only 1 previous stent at the target lesion.

TRIAL REGISTRATION

The trial is registered at Clinicaltrials.gov (NCT04280029).

CURRENT STATUS

The trial completed enrollment in July 2024.

CONCLUSION

The SELUTION4ISR study will evaluate the safety and effectiveness of SLR DEB in a prospective, randomized, international, multicenter trial for treatment of coronary ISR.

Risk of premature cardiovascular disease and all-cause mortality in young adults, association with risk factor prevalence early in life

BACKGROUND

With the increase in risk factors and the emergence of unhealthy lifestyles in young adults, we need to pay more attention to the cardiovascular health of this group. This study aimed to assess the association of the degree of joint risk factor control with premature cardiovascular disease (CVD) and all-cause mortality in young people.

METHODS

Kailuan Study is a prospective cohort study based on a community population, which began in June 2006, and followed up every two years. A sample of 16,519 eligible participants in the Kailuan cohort was recruited in this current study and 15,948 was included in the final analysis, with an average age of 32.34 ± 5.19 years, and a male proportion of 74.76%. Based on the control status of the risk factors, participants were divided into three groups: well-controlled group (≥ 7 risk factors controlled), moderately controlled group (5-6 risk factors controlled), and poorly controlled group (≤ 4 risk factors controlled). Multivariate Cox proportional hazard model was used to analyse the relationship between the joint control of risk factors and onset of CVD and all-cause mortality.

RESULTS

During a mean follow-up period of 14.78 ± 1.33 years, we identified 285 incident CVD cases and a total of 274 deaths from all causes. Compared to the well-controlled group, the moderately controlled group and poorly controlled group exhibited progressively higher risks of CVD and all-cause mortality. The adjusted hazard ratios (HRs) for CVD in the moderately controlled group and poorly controlled group were 2.24 (95% confidence interval [CI]: 1.66-3.02) and 3.09 (95% CI: 2.04-4.68), respectively. The adjusted HRs for all-cause mortality in these two groups were 1.53 (1.15-2.04) and 2.65 (1.79-3.92), respectively.

CONCLUSIONS

We observed an inverse relationship between the degree of risk factor control and the risk of CVD and all-cause mortality in young adults, emphasizing the importance of actively controlling more risk factors in early life.

Exposure to polyethylene terephthalate micro(nano)plastics exacerbates inflammation and fibrosis after myocardial infarction by reprogramming the gut and lung microbiota and metabolome

Micro(nano)plastics (MNPs), a ubiquitous environmental pollutant, have received increasing attention for their impacts on human health. We conducted an in-depth study on the role of polyethylene terephthalate (PET) MNPs in myocardial infarction (MI). Blood from the coronary circulation of MI patients was collected to detect microplastics (MPs). Peripheral monocytes (PBMCs) and AC16 cells were used to assess inflammation, cell proliferation and apoptosis after PET nanoplastics (NPs) stimulation. The mouse MI model was established after PET NPs respiratory or oral exposure. The results showed that various types of MPs, including high levels of PET MPs, were detected in the coronary circulation. PET NPs promoted inflammatory factors secretion by PBMCs, inhibited AC16 cell proliferation and promoted hypoxia-induced AC16 cell apoptosis. PET NPs exacerbated post-MI inflammation and fibrosis through activating the NLRP3 inflammasome pathway. Through macrogenetic sequencing and metabolomics analyses, we observed that PET NPs reprogrammed the intestinal and lung microbiota and metabolome in MI mice, leading to chronic inflammation. In conclusion, PET MPs were widely present in the coronary circulation of MI patients. PET MNPs can activate the NLRP3 inflammasome pathway to exacerbate post-MI ventricular remodelling, which may be related to the reprogramming of the gut and lung microbiota and metabolome.

Psychological distress and myocardial infarction (MI): A cross-sectional and longitudinal UK population-based study

OBJECTIVE

The objective of the present research is to establish the cross-sectional and longitudinal associations between dimensions of psychological distress (i.e., social dysfunction and anhedonia, depression and anxiety, and loss of confidence) and the risk of clinically diagnosed myocardial infarction (MI).

METHODS

We analyzed valid data from 12931 participants from Wave 1 (collected from 2009 to 2010) and who continued to participate until Wave 10 (collected from 2019 to 2020, N = 5117) of the Understanding Society: the UK Household Longitudinal Study using a confirmatory factor analysis (CFA) and binary logistic regressions.

RESULTS

There were three factors including social dysfunction and anhedonia, depression and anxiety, and loss of confidence within the GHQ-12. Social dysfunction and anhedonia continued to show significant positive associations with the chance of past clinical MI diagnosis (OR = 1.24, 95% CI [1.13, 1.35], p < .001) and the risk of developing MI over the 10-year period (OR = 1.23, 95% CI [1.01, 1.49], p < .05). In addition, age showed a significant positive association with the risk of developing MI over time (OR = 1.04, 95% CI [1.01, 1.06], p < .01). Sex maintained a significant negative association (OR = 0.30, 95% CI [0.21, 0.44], p < .001). Hypertension status demonstrated a strong positive association over time (OR = 1.52, 95% CI [1.08, 2.15], p < .05).

CONCLUSION

Intervention and prevention programs may be required for individuals with high social dysfunction and anhedonia levels to reduce the prevalence of MI and the risk of developing MI over time.

Detecting cardiac injury: the next generation of high-sensitivity cardiac troponins improving diagnostic outcomes

Cardiac injury, encompassing a spectrum of heart muscle damage, requires prompt and accurate diagnosis to improve patient outcomes. Early detection using cardiac biomarkers is vital for timely intervention and reducing mortality. This review highlights the role of high-sensitivity cardiac troponins (hs-cTns) in diagnosing cardiac injury. This article offers an overview of cardiac injury, including its causes, diagnostic challenges, and the evolution of biomarkers, up to the development and commercialization of "high-sensitivity" (hs-) cTns. The molecular structure of cardiac isoforms cTnI and cTnT, release kinetics, guidelines incorporation, diagnostic performance, and clinical application will be analyzed. It is concluded that the advent of hs-cTn assays has further expanded diagnostic capabilities by enabling the detection of low-level cTn elevations, which were previously undetectable using conventional methods. This enhanced sensitivity allows earlier identification of even minor cardiac injuries, facilitating prompt intervention and improving patient outcomes. However, this increased sensitivity also introduces interpretive challenges in understanding the nature of cardiac involvement, especially in distinguishing mild cTn elevations that may signify non-ischemic cardiac injury or be associated with other non-cardiac conditions.

Cardiac biomarkers N-terminal fragment of the prohormone B-type natriuretic peptide and cardiac troponin I for characterization of the cardiac disease phenotype of the English Bull Terrier

The N-terminal fragment of prohormone B-type natriuretic peptide (NT-proBNP) and cardiac troponin I (cTnI) contribute information regarding cardiac load and function and myocardial injury, respectively, to the clinical work-up of dogs with heart disease. The English bull terrier (BT) has a predisposition to a complex cardiac phenotype. This prospective case-control study aimed to further characterize this phenotype through cardiac biomarker evaluation. Fifteen healthy BT (group 1) and 50 BT with various heart disease presentations (groups 2-4) were included. The main presentations were MVD (45 dogs) and MS (13 dogs). 16/50 dogs had echocardiographic evidence of cardiac remodeling: 7 with either increased left atrial (LA) or left ventricular (LV) volumes (group 3) and 9 with increased LA and LV volumes (group 4). Cardiac biomarkers were not significantly different between dogs with disease subtypes MVD or MS versus dogs with other disease presentations. When evaluated in relation to remodeling, median NT-proBNP and cTnI in group 4 (1004 pmol/L, 0.09 ng/mL) were significantly higher than in group 1 (257 pmol/L, 0.02 ng/mL), group 2 (300 pmol/L, 0.026 ng/mL) and group 3 (250 pmol/L, 0.02 ng/mL). There was significant discriminatory ability for both biomarkers between group 4 and groups 1, 2 or 3. Furthermore, cTnI significantly differentiated dogs with any degree of remodeling (groups 3 + 4) from those without (groups 1 + 2). The cardiac disease phenotype of the BT is not associated with a unique cardiac biomarker profile. Rather, biomarker levels are similar to those reported in other breeds with valvular heart disease.

Epicardial Adipose Tissue and Heterogeneity Parameters Combined with Inflammatory Cells to Predict the Value of Heart Failure with Preserved Ejection Fraction Patients Post Myocardial Infarction

BACKGROUND AND PURPOSE

Epicardial adipose tissue (EAT) comprises three distinct lipid components, each exerting differential effects on cardiovascular diseases. During disease progression, dynamic alterations in lipid composition and spatial distribution contribute to the inherent heterogeneity of EAT. The excessive activation of inflammatory cells may contribute to chronic inflammation, promoting atherosclerosis and cardiac diseases. However, the role of EAT in patients with myocardial infarction (MI) who develop heart failure with preserved ejection fraction (HFpEF) remains unclear. This study aims to quantify the overall and perivascular volumes of EAT using cardiac magnetic resonance (CMR) imaging and assess its heterogeneity, exploring the predictive value of EAT heterogeneity and different EAT volumes combined with inflammatory cells for the occurrence of HFpEF in MI patients with normal left ventricular ejection fraction (LVEF).

METHODS

This retrospective cohort study enrolled patients diagnosed with MI with preserved LVEF via clinical assessment and CMR at the Second Affiliated Hospital of Kunming Medical University between January 2015 and July 2023. Patients who did not undergo percutaneous coronary intervention (PCI) were followed, with the incidence of HFpEF serving as the primary endpoint. The cohort was stratified into two groups: those without HFpEF and those who developed HFpEF.Cardiac structure, function, EAT volume, and infarct volume parameters were obtained using the CMR post-processing software CVI-42, while EAT heterogeneity parameters entropy were derived using Python software. Independent sample t-tests, non-parametric tests, and chi-square tests were employed to analyze the differences in clinical baseline data and CMR metrics between the two groups. Spearman's rank correlation was utilized to analyze the associations between EAT parameters and inflammatory cells, inflammatory markers, and diastolic dysfunction indicators. Furthermore, we conducted univariate and multivariate Cox regression analyses to determine the predictive value of each parameter for the development of HFpEF in MI patients. Time-dependent ROC curves were generated to evaluate the efficacy of each parameter in predicting HFpEF, the AIC values of each parameter and the final model were calculated to evaluate the predictive performance. The optimal cut-off values were identified using time-dependent ROC curves in R software, and Kaplan-Meier event-survival curves were plotted to illustrate the event-free rates based on these optimal thresholds.The median follow-up time was calculated using the reverse Kaplan-Meier method.

RESULTS

A total of 203 MI patients with normal LVEF were included, with 74 in the HFpEF group and 129 in the non-HFpEF group. No significant differences were observed between the two groups regarding age, sex, and infarct volume; however, significant statistical differences were noted in BMI, diabetes, renal failure, leukocytes, neutrophils, monocytes, total EAT, EAT entropy, left ventricular EAT (LV EAT), left atrial end-systolic volume (LAESV), triglycerides, NHR, MHR and LACI(Left atrioventricular coupling index) (P < 0.05). Both overall and local EAT volumes showed a positive correlation with leukocytes and monocytes,as well as with the inflammatory markers MHR and SIRI. Furthermore, EAT volume exhibited a positive correlation with the LACI, a marker of diastolic dysfunction. Univariate and multivariate Cox regression analyses indicated that BMI, diabetes, monocyte, LV EAT, and EAT entropy are independent risk factors for HFpEF. And the AIC value of the multivariate regression model was the smallest.Further time-dependent ROC analysis revealed that the maximum AUC for BMI was 0.67, while the AUC for LV EAT was 0.63, and EAT entropy was 0.60, the maximum AUC for monocyte was 0.70, and the combined prediction of LV EAT and EAT entropy had a maximum AUC of 0.70. After a median follow-up of 34 months, Kaplan-Meier survival curves demonstrated that LV EAT greater than 21.23 mL was associated with the occurrence of HFpEF, whereas EAT entropy was not.

CONCLUSIONS

In patients with chronic MI, normal LVEF, and no prior PCI, the occurrence of HFpEF is not correlated with infarct volume; however, BMI, diabetes, monocyte, LV EAT, and EAT entropy are independent risk factors for HFpEF with significant predictive value, with the highest predictive efficacy observed monocyte and when combining EAT entropy and LV EAT. Additionally, both overall and local EAT volumes exhibit a moderate positive correlation with leukocytes,monocytes and inflammatory markers, and were also positively correlated with diastolic dysfunction. This suggests that, in clinical practice, beyond traditional indicators, there should be an increased focus on EAT heterogeneity and perivascular EAT in MI patients with normal LVEF who have not undergone PCI to to reduce the incidence of HFpEF.

Point-of-care troponin tests to rule out acute myocardial infarction in the prehospital environment: a protocol for a systematic review and meta-analysis

BACKGROUND

Chest pain is a major cause of emergency ambulance calls, often linked to acute myocardial infarction (AMI), a critical condition requiring immediate hospitalisation. Current diagnostic methods, such as history taking and ECG, have limitations, especially for non-ST-elevation myocardial infarction. High-sensitivity cardiac troponin (cTn) assays are more diagnostically sensitive, but the downside is that it needs hospital-based testing, which can delay diagnosis and the necessary treatment protocol. Point-of-care cTn testing, on the other hand, is much faster and done nearer to the patient; hence, it may fundamentally change the prehospital care pathway in terms of diagnostic accuracy, clinical utility and related safety.

OBJECTIVE

To present a protocol for a systematic review and meta-analysis that will assess the diagnostic accuracy, clinical utility and safety of point of care (POC) troponin tests, with or without clinical decision aids, for ruling out AMI in adults presenting with cardiac chest pain to emergency ambulance services in prehospital settings.

METHODS

This protocol follows BMJ guidelines and adheres to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2015 reporting standards. It is registered with PROSPERO (ID: CRD42024533117). A comprehensive search strategy will identify relevant studies in MEDLINE, EMBASE and CINAHL, focusing on literature from 2000 onwards. Eligibility criteria include adults with chest pain suspected of AMI, excluding those with ST-elevation myocardial infarction. The primary target is type 1 AMI, with secondary outcomes including major adverse cardiac events at 30 days. Risk of bias assessment will be performed using tools such as Quality Assessment of Diagnostic Accuracy Studies version 2, Risk of Bias 2, and Risk of Bias in Non-randomised Studies of Interventions, while the quality of the economic evaluations will be appraised using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Data items extracted will include patient demographics, test characteristics and outcomes. Where possible, meta-analyses will be conducted by fitting hierarchical models for diagnostic accuracy and random effects models for clinical and cost-effectiveness estimates. Subgroup analyses are proposed to quantify the effect of variables such as gender, ethnicity and type of troponin assay on the estimated parameters.

ETHICS AND DISSEMINATION

Ethical approval is not required. The results will be published in a peer-reviewed journal and presented at international conferences.

PROSPERO REGISTRATION NUMBER

This protocol is registered with PROSPERO, the International Prospective Register of Systematic Reviews, under the ID CRD42024533117. Any future amendments will be updated in the PROSPERO record.

Randomized comparison of the combined Sirolimus eluting and endothelial progenitor cell combo Stent vs. biolimus eluting absorbable polymer coated biomatrix alpha stent in patients undergoing percutaneous coronary intervention: Rationale and study design of the Scandinavian Organization for randomized trials with clinical outcome (SORT OUT) XI trial

RATIONALE

The biodegradable polymer Biomatrix Alpha stent contains biolimus A9 drug which is a sirolimus derivative increased in lipophicity. The biodegradable polymer sirolimus eluting Combo stent is a dual-therapy sirolimus-eluting and CD34+ antibody coated stent capturing endothelial progenitor cells (EPCs).

HYPOTHESIS

The main hypothesis of the SORT OUT XI trial was that the biodegradable polymer biolimus A9 Biomatrix Alpha stent is noninferior to the biodegradable polymer sirolimus eluting Combo stent in an all-comers population with coronary artery disease undergoing percutaneous coronary intervention (PCI).

METHODS

The SORT OUT XI study was a randomized, multicenter, single blinded, all-comer, 2-arm, noninferiority trial comparing the biodegradable polymer biolimus A9 Biomatrix Alpha stent to the biodegradable polymer sirolimus eluting Combo stent in 3 Danish University Hospitals in Western Denmark. The composite primary endpoint was target lesion failure (TLF) within 12 months. TLF was defined as composite of cardiac death, myocardial infarction not related to other than index lesion or target lesion revascularization. Clinically driven event detection was used and no planned follow up was performed. With a sample size of 1,564 patients in each treatment arm, a 2-group large-sample normal approximation test of proportions with a 1-sided 5% significance level had a 90% power to detect noninferiority with a predetermined noninferiority margin of 2.1%.

RESULTS

The trial ran from August 14, 2019 to March 19, 2023. A total of 3141 patients were enrolled and randomized 1:1 to Combo stent (n = 1,573) and Biomatrix Alpha stent (n = 1,568).

CONCLUSION

The SORT OUT XI trial will assess if the biolimus A9 eluting Biomatrix Alpha stent is noninferior to the dual-therapy Combo stent with respect to target lesion failure.

CLINICALTRIALS

GOV: NCT03952273.

Balancing privacy and health integrity: A novel framework for ECG signal analysis in immersive environments

The widespread use of immersive technologies such as Virtual Reality, Mixed Reality, and Augmented Reality has led to the continuous collection and streaming of vast amounts of sensitive biometric data. Among the biometric signals collected, ECG (electrocardiogram) stands out given its critical role in healthcare, particularly for the diagnosis and management of cardiovascular diseases. Numerous studies have demonstrated that ECG contains traits to distinctively identify a person. As a result, the need for anonymization methods is becoming increasingly crucial to protect personal privacy while ensuring the integrity of health data for effective clinical utility. Although many anonymization methods have been proposed in the literature, there has been limited exploration into their ability to preserve data integrity while complying with stringent data protection regulations. More specifically, the utility of anonymized signal and the privacy level achieved often present a trade-off that has not been thoroughly addressed. This paper analyzes the trade-off between balancing privacy protection with the preservation of health data integrity in ECG signals focusing on memory-efficient anonymization techniques that are suitable for real-time or streaming applications and do not require heavy memory computation. Moreover, we introduce an analytical framework to evaluate the privacy preservation methods alongside health integrity, incorporating state-of-the-art disease and person identifiers. We also propose a novel metric that assists users in selecting an anonymization method based on their desired trade-off between health insights and privacy protection. The experimental results demonstrate the impact of the de-identification techniques on critical downstream tasks, such as Arrhythmia detection and Myocardial Infarction detection along with identification performance, while statistical analysis reveals the biometric nature of ECG signals. The findings highlight the limitations of using such anonymization methods and models, emphasizing the need for approaches that maintain the clinical relevance of ECG data in real-time and streaming applications, particularly in memory-constrained environments.

MIO: An ontology for annotating and integrating medical knowledge in myocardial infarction to enhance clinical decision making

As biotechnology and computer science continue to advance, there's a growing amount of biomedical data worldwide. However, standardizing and consolidating these data remains challenging, making analysis and comprehension more difficult. To enhance research on complex diseases like myocardial infarction (MI), an ontology is necessary to ensure consistent data labeling and knowledge representation. This will facilitate data management and the application of artificial intelligence techniques in this field, ultimately advancing precision medicine research for MI. This study introduced the MI Ontology (MIO), which was developed using Stanford's seven-step method and Protégé. MIO aims to support precision medicine research on MI by effectively modeling and representing MI-related concepts and relationships. The validation of the MIO model involved employing Ontology Web Language (OWL) reasoners and comparing it with other disease-specific ontologies. MIO is an ontology model comprising of 3090 classes, 14 object attributes, 3494 individuals, 9415 synonyms and 49263 axioms, which encompass knowledge related to MI such as anatomical entities, clinical findings, drugs, genes, influencing factors, pathogenesis, patients-related concepts, procedures, and disease types. Furthermore, MIO has passed logical consistency validation and exhibits a broader conceptual scope and deeper knowledge structure than other disease-specific ontologies. Additionally, clinical use scenarios for MIO were developed to help address specific clinical problems. This study constructed the first comprehensive disease-specific ontology in cardiovascular diseases, named MIO, to promote precision medicine research on MI. MIO integrates and standardizes medical data, addressing complexity and standardization challenges. This promotes the use of big data analysis, explainable AI, and deep phenotype research in precision medicine. Future efforts will focus on enhancing and expanding MIO's applicability and scalability for superior services in this field.

Safety and clinical implications of coronary spasm provocation testing in patients presenting with myocardial infarction with no overt culprit lesion

BACKGROUND

Acetylcholine (ACh) provocation testing is a critical diagnostic tool for identifying coronary artery spasms in patients presenting with angina pectoris or myocardial infarction (MI) who do not exhibit obstructive coronary artery disease. Despite its utility, the use of ACh testing is limited due to concerns regarding potential life-threatening complications and a historical underrepresentation of MI populations in clinical research.

METHODS

This registry-based study analyzed 1063 patients with 115 presenting with MI and 948 without (non-MI), who underwent ACh spasm provocation testing. The primary safety endpoints include arrhythmic and other acute complications. The primary clinical endpoint was the incidence of major adverse cardiac events (MACE). The median follow-up was 2.4 years.

RESULTS

The ACh testing showed low incidences of major cardiovascular complications with no incidences of procedure-related death. Additionally, rates of fatal ventricular arrhythmia, cardiogenic shock, and procedure-related myocardial infarction showed no significant differences between the MI and non-MI patient groups. There was no significant difference in MACE between MI and non-MI groups stratified based on the ACh test responses. Multivariable analysis revealed that ST-segment elevation and diabetes mellitus were associated with a higher rate of MACE in MI patients with positive ACh tests (adjusted hazard ratio 10.98 [95 % CI: 1.14-106.07] and 8.80 [1.14-68.11], respectively).

CONCLUSIONS

The present study suggests that ACh provocation testing is safe for patients with MI, validating its expanded use in clinical settings. ST-segment elevation may serve as a prognostic marker for stratifying risk and optimizing management in patients evaluated for coronary artery spasm.

Study on the Synergistic Effect of Klotho and KRAS on Reducing Ferroptosis After Myocardial Infarction by Regulating RAP1/ERK Signaling Pathway

Myocardial infarction (MI) is a coronary artery-related disease that seriously threatens human life and is the leading cause of sudden death worldwide, where a lack of nutrients and oxygen leads to an inflammatory response and death of cardiomyocytes. Ferroptosis is a form of non-apoptotic cell death associated with metabolic dysfunction, resulting in abnormal breakdown of glutamine and iron-dependent accumulation of reactive oxygen species (ROS) during metabolism. However, the molecular mechanism of ferroptosis in the pathogenesis of MI and the function of Klotho and KRAS on ferroptosis during MI remain unclear. The MI rat model was established by LAD ligation with a 6-0 suture. H9c2 cells were placed in glucose-deficient DMEM (Thermo) and cultured in an anaerobic environment (1% CO2 and 5% CO) to establish an in vitro OGD cell model. The damage to rat heart tissue was detected by HE staining, and Klotho and KRAS were determined by RT-qPCR, Western Blot, and IHC. TUNEL staining was used to determine apoptosis in rat heart tissue samples. The interaction between Klotho and KRAS was verified by co-immunoprecipitation and Western Blot. The cardiomyocyte activity was measured by CCK-8 assay. LDH, CK-MB, cTnT, and Fe2+ markers were detected by the kits. For the assessment of ferroptosis, GSH and ROS in cardiomyocytes and serum were detected by kits, and PTSG was detected by Western Blot. IL-1β and IL-6 in cardiomyocytes and serum were determined by ELISA. Klotho was downregulated in MI. Downregulation of Klotho promoted myocardial injury; increased apoptosis of cardiomyocytes; promoted LDH, CK-MB, and cTnT concentrations; inhibited GSH; and promoted ROS levels, PTGS2 expression, and ferroptosis in rats. The same results were obtained in vitro. Klotho and KRAS had endogenous interactions. KRAS knockdown can reverse Klotho knockdown-mediated MI and ferroptosis. RAP1/ERK pathway was highly expressed in MI, and inhibiting RAP1/ERK pathway activation can reverse the promoting effect of overexpressed KRAS on MI progression and ferroptosis. Klotho interacts with KRAS and inhibits ferroptosis after MI by regulating the RAP1/ERK pathway.

Traditional Versus Dual Lumen Microcatheter-Assisted Parallel Wiring in Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From the PROGRESS-CTO Registry

BACKGROUND

The effectiveness and safety of traditional versus dual lumen microcatheter (DLMC)-assisted parallel wiring in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study.

AIMS

To compare traditional versus dual lumen microcatheter (DLMC)-assisted parallel wiring.

METHODS

We compared the clinical and angiographic characteristics and outcomes of traditional versus DLMC-assisted parallel wiring after failed antegrade wiring (AW) in a large, multicenter CTO PCI registry.

RESULTS

Among 1353 CTO PCIs with failed AW with a single wire, traditional parallel wiring (n = 1081) or DLMC-assisted parallel wiring (n = 272) were utilized at the operator's discretion. The baseline characteristics of patients were similar in both groups except for higher prevalence of diabetes mellitus, and lower prevalence of hypertension, prior heart failure, prior MI and cerebrovascular disease in DLMC patients. Lesions in the DLMC group were more likely to have proximal cap ambiguity, side branch at the proximal cap, blunt/no stump, moderate/severe calcification, and had higher J-CTO score (2.6 ± 1.0 vs. 2.1 ± 1.3, p < 0.001). Technical (87.1% vs. 74.3%, p < 0.001) and procedural (83.8% vs. 75.5%, p = 0.001) success and the incidence of in-hospital major cardiac adverse events (MACE) (4.8% vs. 2.0%, p = 0.020) were higher in the DLMC group. In propensity score matching analysis, DLMC-assisted wiring was associated with higher technical success (odds ratio [OR] 2.17, 95% confidence interval [CI] 1.33-3.54, p = 0.002) and no significant difference in MACE (OR 2.00, 95% CI 0.89-4.50, p = 0.093).

CONCLUSIONS

In lesions that could not be crossed with AW, DLMC-assisted parallel wiring was associated with a higher likelihood of technical success, without an increased risk of MACE, compared with traditional parallel wiring.

Biological variation of cardiac biomarkers in athletes during an entire sport season

OBJECTIVES

Cardiac biomarkers are useful for the diagnostic and prognostic assessment of myocardial injury (MI) and heart failure. By measuring specific proteins released into the bloodstream during heart stress or damage, these biomarkers help clinicians detect the presence and extent of heart injury and tailor appropriate treatment plans. This study aims to provide robust biological variation (BV) data for cardiac biomarkers in athletes, specifically focusing on those applied to detect or exclude MI, such as myoglobin, creatine kinase-myocardial band (CK-MB) and cardiac troponins (cTn), and those related to heart failure and cardiac dysfunction, brain natriuretic peptide (BNP) and N-terminal brain natriuretic pro-peptide (NT-proBNP).

METHODS

Thirty athletes participated, providing monthly fasting blood samples over 11 months. Samples were analyzed using chemiluminescent immunoassays and statistical analyses were conducted using the classical ANOVA method, a linear mixed model and a Bayesian approach.

RESULTS

The study observed significant gender differences in biomarker concentrations, with higher BNP and NT-proBNP in females and higher myoglobin and CK-MB in males. Physical activity within 24 h before sampling notably affected CK-MB, myoglobin, and hs-cTnI variability. The BV estimates demonstrated high individuality for most biomarkers, suggesting their potential for personalized monitoring. The study also revealed substantial heterogeneity for NT-proBNP and BNP within the population.

CONCLUSIONS

These findings underscore the importance of considering gender-specific reference intervals and the impact of recent physical activity when interpreting cardiac biomarkers in athletes. The study delivers new BV estimates for CK-MB and myoglobin while emphasizing the need for tailored clinical assessments in athlete populations.

Clinical performance validation and four diagnostic strategy assessments of high-sensitivity troponin I assays

Acute coronary syndrome (ACS) includes conditions such as unstable angina (UA), non-ST elevation myocardial infarction (NSTEMI), and ST elevation myocardial infarction (STEMI). High-sensitivity cardiac troponin I (hs-cTnI) assays have been recommended as primary biomarkers for NSTEMI diagnosis due to their high sensitivity and specificity. However, there is no consensus on the optimal diagnostic strategy for early NSTEMI detection. This study aims to evaluate the diagnostic performance of four hs-cTnI-based strategies for suspected NSTEMI: Limit of Detection (LoB), Single Cut-off, hs-cTnI 0/1 h Algorithm, and hs-cTnI 0/2 h Algorithm, in a Chinese cohort and compare the performance of assays from different manufacturers. Performance verification was conducted, including LoB, LoD, LoQ, and precision analysis. Clinical samples from 267 ACS patients were analyzed using Hybiome hs-cTnI assays. Diagnostic accuracy was assessed based on sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and F1-score. The LoB strategy demonstrated 100% sensitivity but low PPV (14.0%). Both the hs-cTnI 0/1 h Algorithm and hs-cTnI 0/2 h Algorithm showed high diagnostic performance, with the 0/2 h algorithm providing the best overall. 89.0% accuracy, 93.3% sensitivity, and 73.68% F1-score. The hs-cTnI 0/2 h Algorithm offers the most reliable diagnostic performance for early NSTEMI diagnosis.

Validation of the Prognostic Ability of Eight Risk Scores for Cardiovascular Events in NSTEMI Patients with Multi-Vessel Disease

This study compared eight risk scores regarding their predictive ability in non-ST-elevation myocardial infarction (NSTEMI) patients (n = 862) with multi-vessel disease (MVD) after percutaneous coronary intervention (PCI). The primary outcome was cardiac death. The secondary outcomes included major adverse cardiovascular event (MACE) [a composite of all-cause death, myocardial infarction (MI), and unplanned repeat revascularization], all-cause death, and MI. During a median follow-up of 4.8 years, 47 (5.5%) cardiac death, 218 (25.3%) MACE, 79 (9.2%) all-cause death, and 40 (4.6%) MI were recorded. The Synergy Between PCI With Taxus and Cardiac Surgery (SYNTAX) score II was the most accurate for cardiac death with the highest area under the receiver operating characteristic curve (AUC) (0.814, 95% CI: 0.758-0.869). The logistic SYNTAX score extended model (LSSextended) exhibited the most powerful ability in predicting MACE (AUC: 0.624, 95% CI: 0.580-0.667) and MI (AUC: 0.657, 95% CI: 0.567-0.747). The modified Age, Creatinine, and Ejection Fraction score (MAS) was the most accurate score in predicting all-cause death (AUC: 0.798, 95% CI: 0.752-0.844). The scores involving clinical variables showed better ability to predict adverse cardiovascular events among NSTEMI patients with MVD after PCI.

The effect of inflammatory markers on mortality in patients with acute myocardial infarction

Consider that inflammatory factors are associated with short-term mortality in patients with acute myocardial infarction (AMI). In this retrospective analysis of 2,784 AMI patients from the Medical Information Mart for Intensive Care-IV database, we evaluated the impact of inflammatory markers on in-hospital mortality and predicted 30-day and 90-day outcomes. Patients were divided into groups based on in-hospital survival (n = 2,364) and mortality (n = 420). Analysis of initial hospital admission laboratory data, including inflammatory factors, revealed these factors as independent predictors of in-hospital mortality (Q4 of RDW: OR 1.96, NLR: OR 1.63, SII: OR 1.85, and SIRI: OR 2.23, all P < 0.05). Cox proportional hazards models confirmed their significance for predicting 30-day (Q4 of NLR: OR 1.83, SII: OR 1.86, and SIRI: OR 2.01, all P < 0.05) and 90-day mortality (Q4 of RDW: OR 1.46, NLR: OR 1.69, SII: OR 1.73, and SIRI: OR 1.72, all P < 0.05). Increasing levels of inflammatory markers correlated with higher odds and hazard ratios, as illustrated by Restricted Cubic Spline curves. Kaplan-Meier survival analysis showed better survival rates with lower inflammatory marker levels. Receiver operating characteristic curves demonstrated good predictive performance of individual inflammatory factors, with a new composite marker showing the highest predictive ability (AUC = 0.720). This study underscores the association of inflammatory factors with both hospital and short-term mortality in AMI patients.

Cardiac arrhythmia following acute myocardial infarction: a retrospective analysis of 27,648 hospitalized patients in a tertiary heart hospital

Arrhythmia frequently complicates acute myocardial infarction (AMI) and contributes to high morbidity and mortality. We aimed to investigate the prevalence, risk factors, and impact of cardiac arrhythmias in AMI patients at a tertiary heart hospital. This retrospective observational study included AMI patients who were admitted between January 1991 and May 2022. Patients' data were analyzed and compared according to the absence or presence of cardiac arrhythmias post-AMI. We hypothesized that arrhythmias are associated with higher mortality following AMI. During the study, 27,648 patients were hospitalized with AMI, of whom 2118 (7.7%) developed arrhythmia. Patients who developed arrhythmia had a higher average age compared to those without arrhythmia (57.2 vs. 54.8 years, p=0.001), and a larger proportion were male compared to female patients (85.2% vs. 14.8%, p=0.001). Atrial fibrillation was observed in 383 patients (18.1%). Ventricular tachycardia was found in 461 (21.8%), and ventricular fibrillation occurred in 526 patients (24.8%). Complete heart block was developed in 286 (13.5%) patients, 1st-degree atrioventricular (AV) block in 36 (1.7%), 2nd-degree AV block in 138 (6.5%), left bundle branch block in 81 (3.8%), and right bundle branch block in 118 (5.6%). The rate of β-blocker use has increased in the arrhythmias group at discharge compared to the on-admission rate (55.7% vs. 32.5%). However, it remained sub-optimal. Arrhythmias were associated with longer hospital stays and five times higher hospital mortality than the non-arrhythmia group. Multivariable logistic regression analysis indicated that arrhythmia was associated with increased mortality risk three times following AMI (adjusted odds ratio 3.01; 95% confidence interval 2.42-3.75, p=0.001). Almost one-tenth of patients hospitalized with AMI in Qatar developed arrhythmia with variable outcomes; however, the in-hospital mortality remained high. Addressing the risk factors and optimizing the prevention and treatment of AMI and arrhythmias is crucial to improving clinical outcomes. This study may underestimate the incidence of arrhythmias post-AMI as it did not report all types.

Highly sensitive and reproducible SERS substrate based on ordered multi-tipped Au nanostar arrays for the detection of myocardial infarction biomarker cardiac troponin I

Acute myocardial infarction (AMI) is a severe cardiovascular disease, for which early diagnosis is critical for reducing mortality and improving patient outcomes. Cardiac troponin I (cTnI) is widely recognized as the "gold standard" biomarker for AMI due to its high specificity and sensitivity. The concentration of cTnI correlates directly with different stages of AMI. Therefore, the accurate detection of cTnI concentration is of paramount importance. However, the low concentration of cTnI in biological fluids requires ultrasensitive detection methods. In this study, we developed a sandwiched surface enhanced Raman scattering (SERS)-based biosensor composed of SERS-immune substrate, target antigen, and SERS nanotags and realized sensitive and accurate detection of cTnI. The SERS-immune substrate features an ordered, multi-tipped monolayer of Au nanostars fabricated using a three-phase interfacial self-assembly method and 4-(2-hydroxyerhyl)piperazine-1-erhanesulfonic acid (HEPES) buffer modification. Compared to Au nanosphere SERS substrates, the Au nanostar SERS substrates exhibited about a 3-fold increase in Raman enhancement and demonstrated good uniformity and batch stability. This novel SERS detection platform, leveraging dual plasmonic enhancement from both the SERS-immune substrate and SERS nanotags, achieves detection of cTnI with a limit of detection (LOD) as low as 9.09 pg mL-1 and a relative standard deviation (RSD) as low as 11.24%. Thus, the Au nanostar SERS substrates developed in this study demonstrate significant potential for rapid and accurate detection of cTnI.

Machine learning to risk stratify chest pain patients with non-diagnostic electrocardiogram in an Asian emergency department

Introduction

Elevated troponin, while essential for diagnosing myocardial infarction, can also be present in non-myocardial infarction conditions. The myocardial-ischaemic-injury-index (MI3) algorithm is a machine learning algorithm that considers age, sex and cardiac troponin I (TnI) results to risk-stratify patients for type 1 myocardial infarction.

Method

Patients aged ≥25 years who presented to the emergency department (ED) of Singapore General Hospital with symptoms suggestive of acute coronary syndrome with no diagnostic 12-lead electrocardiogram (ECG) changes were included. Participants had serial ECGs and high-sensitivity troponin assays performed at 0, 2 and 7 hours. The primary outcome was the adjudicated diagnosis of type 1 myocardial infarction at 30 days. We compared the performance of MI3 in predicting the primary outcome with the European Society of Cardiology (ESC) 0/2-hour algorithm as well as the 99th percentile upper reference limit (URL) for TnI.

Results

There were 1351 patients included (66.7% male, mean age 56 years), 902 (66.8%) of whom had only 0-hour troponin results and 449 (33.2%) with serial (both 0 and 2-hour) troponin results available. MI3 ruled out type 1 myocardial infarction with a higher sensitivity (98.9, 95% confidence interval [CI] 93.4-99.9%) and similar negative predictive value (NPV) 99.8% (95% CI 98.6-100%) as compared to the ESC strategy. The 99th percentile cut-off strategy had the lowest sensitivity, specificity, positive predictive value and NPV.

Conclusion

The MI3 algorithm was accurate in risk stratifying ED patients for myocardial infarction. The 99th percentile URL cut-off was the least accurate in ruling in and out myocardial infarction compared to the other strategies.

Cardioprotection exerted by intravenous statin at index myocardial infarction event attenuates cardiac damage upon recurrent infarction

AIMS

Recurrent acute myocardial infarction (RE-AMI) is a frequent complication after STEMI, and its association with stent thrombosis can be life-threatening. Intravenous atorvastatin (IV-atorva) administration during AMI has been shown to limit infarct size and adverse cardiac remodelling. We determined by cardiac magnetic resonance (CMR) whether the cardioprotection exerted by IV-atorva at the index AMI event translates into a better prognosis upon RE-AMI in dyslipidemic pigs.

METHODS AND RESULTS

Hypercholesterolemic pigs underwent a first AMI (90-min coronary balloon occlusion). During ongoing ischaemia, animals received IV-atorva or vehicle. Forty days later, animals underwent RE-AMI and were sacrificed on Day 43. All animals remained on p.o. atorvastatin and a high-cholesterol diet from the first AMI until sacrifice. Serial CMR analysis was performed on Day 3 post-AMI, prior- (Day 40) and post-RE-AMI (Day 43). No differences were detected in oedema formation in both animal groups during AMI and RE-AMI. Gadolinium DE-CMR revealed smaller infarcts in IV-atorva-treated animals at index event at 3 and 40 days post-AMI compared to vehicle-administered pigs (P < 0.05). CMR analyses post-RE-AMI revealed smaller infarcts in the animals treated with IV-atorva at index event than in the vehicle-administered pigs. These IV-atorva at index event benefits were associated with higher left ventricular (LV) ejection fraction and normal LV wall motion in the jeopardized myocardium at RE-AMI (P < 0.05 vs. vehicle). The scar region of RE-AMI of animals treated with IV-atorva at index event showed reduced cardiac inflammatory infiltrate, apoptosis and senescence activation, and increased reparative fibrosis and neovessel formation vs. vehicle-administered pigs. Animals treated with IV-atorva at index event also showed lower C-reactive protein and higher interleukin-10 plasma levels in the setting of RE-AMI.

CONCLUSION

The cardioprotection afforded by IV-atorva administration during an index-AMI event shows a legacy effect attenuating myocardial damage and preserving cardiac contractile function upon RE-AMI. The potential benefits of this intravenous approach should be tested in the clinical setting.

Performance Evaluation of the New High-Sensitivity Cardiac Troponin I Immunoassay on CL-2600i Mindray Analyzer

Background: International guidelines recommend the use of high-sensitivity cardiac troponin (hs-cTn) I and T methods for the detection of myocardial injury as a pre-requisite for the diagnosis of acute myocardial infarction (AMI) in patients admitted to the emergency department. Recently, Mindray (Mindray Bio-Medical Electronics Co., Ltd., Shenzhen, China) has introduced a new chemiluminescence immunoassay (CLIA) for the detection of the cTn complex. The present study aims to verify and validate the hs-cTnI Mindray assay on the new automated CL2600i analyzer compared to the routine Alinity-i series instrument by Abbott (Abbott, Chicago, IL, USA). Methods: This study evaluated linearity, precision through the 5 × 5 protocol, methodological comparison on plasma and serum matrices, hs-cTnI 99th percentile imprecision, and the hs-cTnI detection rate in a healthy population. Results: The results obtained proved that the performance of the Mindray hs-cTnI test on the CL2600i platform was closely comparable to the Abbott Alinity-i system (plasma R2: 0.974; serum R2: 0.995). The CVs were consistently low, and no significant differences were reported. Excellent analytical performance, with high sensitivity, was also observed in the healthy population (overall detection rate: 79%), as well as good linearity within the measuring range (R2: 0.994). Conclusions: The Mindray hs-cTnI test confirms its robustness and utility in routine practice as an advanced assay. The new technology, with more sensitive detection methods, may improve the accuracy and reliability of cardiac biomarker testing, ultimately leading to better outcomes in the management of patients with AMI and other cardiac conditions.

Real-World Clinical Impact of High-Sensitivity Troponin for Chest Pain Evaluation in the Emergency Department

BACKGROUND

High-sensitivity cardiac troponin (hs-cTnI) assays can quantify troponin concentrations with low limits of detection, potentially expediting and enhancing myocardial infarction diagnoses. This study investigates the real-world impact of hs-cTnI implementation on operational metrics and downstream cardiac services in patients presenting to the emergency department with chest pain.

METHODS AND RESULTS

We conducted a retrospective study of patients who presented to 3 emergency departments for chest pain and in whom ≥1 troponin concentration was measured. We compared outcomes from January 2021 to March 2022 (conventional cardiac troponin I [cTnI]) against outcomes from April 2022 to March 2023 (post-hs-cTnI implementation). The primary outcome was hospital length of stay. The study included 32 076 emergency department patient-visits (17 267 with cTnI, 14 809 with hs-cTnI). Implementation of hs-cTnI was associated with shorter median total length of stay (6.6 versus 6.0 hours, P [lt]0.001), shorter emergency department length of stay (5.5 versus 5.4 hours, P=0.039), and lower admission rates (32.6% versus 38.2%, adjusted odds ratio [aOR], 0.74 [95% CI, 0.69-0.79]; P [lt]0.0001). Hs-cTnI was also associated with lower odds of cardiology consultation (aOR, 0.91 [95% CI, 0.86-0.97]; P=0.004), echocardiography (aOR, 0.86 [95% CI, 0.82-0.91]; P [lt]0.001), stress tests (aOR, 0.74 [95% CI, 0.67-0.81]; P [lt]0.001), and invasive coronary angiography (aOR, 0.77 [95% CI, 0.70-0.83]; P [lt]0.001), but greater odds of computed tomography coronary angiography (aOR, 1.26 [95% CI, 1.01-1.56]; P=0.03) and percutaneous coronary intervention (aOR, 1.40 [95% CI, 1.20-1.63]; P [lt] 0.001) during the index encounter.

CONCLUSION

Implementation of the hs-cTnI assay was associated with reduced hospital admissions, shorter length of stay, and decreases in most downstream cardiac testing.

Outcomes and Left Ventricular Ejection Fraction in Cardiac Magnetic Resonance: Challenging the "Higher Is Better"

BACKGROUND

Contradictory evidence exists regarding the correlation between supranormal left ventricular ejection fraction (LVEF) and adverse outcomes. This study aimed to elucidate the prognostic value of supranormal LVEF.

METHODS

This retrospective cohort study analyzed patients referred for cardiac magnetic resonance imaging to assess myocardial ischemia or viability. Subjects were stratified into eig8ht LVEF groups: <20%, 20% to 30%, 30% to 40%, 40% to 50%, 50% to 60%, 60% to 70%, 70% to 80%, and ≥80%. Primary outcomes included cardiovascular death, heart failure, myocardial infarction, and stroke. The extracellular volume fraction was measured.

RESULTS

The study cohort comprised 3279 patients (mean age 68.0±12.7 years; 64.0% female). The group with 60% to 70% LVEF had the lowest risk and was used as the reference group. The median follow-up was 41.4 months (interquartile range, 33.9-49.7 months). The group with LVEF <20% exhibited the highest composite outcome risk (unadjusted hazard ratio [HR], 6.77 [95% CI, 3.81-12.03]; P<0.001; adjusted HR, 2.68 [95% CI, 1.28-5.62]; P<0.001). The groups with LVEF 70% to 80% and ≥80% showed increased risk (adjusted HR, 1.96 [95% CI, 1.23-3.08]; P=0.004; 2.16 [95% CI, 1.33-3.52]; P=0.002, respectively). A greater extracellular volume fraction was associated with an LVEF of 70% to 80% and ≥80% (adjusted odds ratios, 1.34 [95% CI, 1.03-1.74]; P=0.027; and 1.74 [95% CI, 1.30-2.34]; P<0.001, respectively).

CONCLUSIONS

LVEF >70% demonstrated increased event rates compared with an LVEF of 60% to 70%. The supranormal LVEF warrants further investigation into its pathogenesis and management.

Factors Associated with Mortality Risk in Patients with Cardiogenic Shock Post-ST-Elevation Myocardial Infarction: Insights from a Regional Centre in Northwest Romania

Background and Objectives: ST elevation myocardial infarction (STEMI), particularly when complicated by cardiogenic shock (CS), is a critical condition associated with high mortality rates. Identifying predictors of in-hospital mortality can enhance patient management and outcomes. Materials and Methods: This observational, retrospective case-control study included STEMI patients, both complicated and uncomplicated by CS. Additionally, demographics, clinical characteristics, laboratory data and in-hospital mortality rates were analysed for STEMI patients with CS and those without CS. Results: This study included a total of 101 patients with STEMI, of whom 51 (50.5%) had STEMI without CS and 50 (49.5%) had STEMI with CS. No significant differences were observed in demographic characteristics or STEMI risk factors between the two groups. Emergency coronarography was performed in 90.1% of the patients, with successful thrombolysis achieved in 24.5%. Patients with CS exhibited a significantly higher mortality (52%) than those without CS (11.76%). Univariate analysis identified white blood cell counts, CK-MB, CK levels, elevated creatinine and uric acid levels and a reduced left ventricular ejection fraction (LVEF) as predictors of mortality. Logistic regression analysis revealed that LVEF and CK-MB were independent predictors of in-hospital mortality in patients with STEMI and CS. Each 1% increase in LVEF was associated with a reduced mortality risk (HR = 0.89; 95% CI 0.81-0.98; p = 0.018), while elevated CK-MB levels were linked to an increased mortality risk (HR = 1; 95% CI 1-1.01; p = 0.014). Conclusions: Reduced systolic function and elevated CK-MB levels are key predictors of in-hospital mortality and outcomes in STEMI patients with CS. These findings underscore the importance of early identification and support the development of targeted management strategies aimed at improving outcomes in this high-risk population.

Association Between Myocardial Infarction and Quality Of Life in the ISCHEMIA Trial

BACKGROUND

The association between myocardial infarction (MI) subtypes (procedural MI [PMI] and spontaneous MI [SMI]) and subsequent quality of life (QoL) is incompletely understood.

OBJECTIVES

The authors analyzed the association between PMI and SMI and generic and disease-specific QoL in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial.

METHODS

QoL was assessed before randomization and at 1.5, 3, and 6 months, and every 6 months thereafter. European Quality of Life-5 dimensions visual analog scale (EQ-5D VAS) (generic) and Seattle Angina Questionnaire (SAQ-7) summary score (disease-specific) were used. The primary analysis was a linear, repeated-measures, multivariable-adjusted, mixed-effects model, with a random intercept for patient. QoL assessments occurring <3 months after MI were defined as early QoL and those occurring >3 months after MI were defined as late QoL.

RESULTS

4,375 randomized patients were included in the primary analysis population. The median duration of follow-up was 36.2 months (Q1-Q3: 23.8-49.5 months). In the primary analysis population, a total of 84 PMIs and 352 SMIs occurred. SMI was associated with significant decreases in both early (adjusted difference -5.7; 95% CI: -7.3 to -4.1 points) and late EQ-5D VAS (-3.1 points; 95% CI: -4.3 to -1.9 points) and in early (-7.7 points; 95% CI: -9.4 to -6.1 points) and late SAQ-7 (-1.9 points; 95% CI: -3.2 to -0.7 points). PMI was not associated with early (adjusted difference -0.8 points; 95% CI: -3.3 to 1.8 points) or late (-0.7 points; 95% CI: -2.7 to 1.2 points) changes in EQ-5D VAS, and was associated with a reduction in early (-3.0 points; 95% CI: -5.7 to -0.4) but not late SAQ-7 (-0.2 points; 95% CI -2.2 to 1.8 points).

CONCLUSIONS

In ISCHEMIA, SMI was associated with reductions in both early and late generic and disease-specific QoL, whereas PMI was only associated with a transient reduction in disease-specific QoL.

Risk of Myocardial Infarction in Patients With Aortic Stenosis: Insights From the VALVENOR Registry

BACKGROUND

A close interaction between aortic stenosis (AS) and coronary artery disease has been suggested. However, the risk of myocardial infarction (MI) in patients with AS is poorly described outside the context of aortic valve replacement.

OBJECTIVES

The purpose of this study was to assess the incidence, correlates, and impact on outcomes of MI occurrence in patients with different degrees of AS severity.

METHODS

Between 2016 and 2017, the multicenter prospective VALVENOR registry enrolled 2,830 outpatients with native valvular AS (peak aortic jet velocity [Vmax] ≥2.5 m/s). AS was defined as mild (Vmax 2.5-2.9), moderate (Vmax 3-3.9), or severe (Vmax ≥4). MI was defined using the fourth universal definition (type 2 MI were not considered).

RESULTS

The mean age was 76.0 years, 54% of the patients were men, and 18.3% had experienced prior coronary event (PCE). At 5 years, the cumulative incidence of MI (death as competing event) was only 2.5% (n = 72, one-third of ST-segment elevation MI). PCE and angina symptoms were associated with an increased risk, whereas female gender was associated with a decreased risk. By contrast, AS severity was not associated with the risk of MI. Subsequent mortality was high and at 52.8% during follow-up (median 648 days after MI occurrence). Incident MI was a powerful predictor of mortality (HR: 2.00, P < 0.001 after adjustment).

CONCLUSIONS

In patients with AS, the risk of MI is relatively low especially in patients without PCE and without angina. No association between the risk of MI and AS severity was observed. Although rare, incident MI is strongly associated with subsequent mortality.

Poor Mental Health Status as a Risk Factor and Prognosticator in SMuRF-Less Acute Myocardial Infarction

Background: The etiology of acute myocardial infarction (AMI) in patients without history of standard modifiable risk factors (SMuRFs) remains unclear. Simultaneously, evidence suggests that mental health status (MHS) contributes to the pathogenesis of AMI and worsens its outcomes. Methods: This analysis of the prospective "Beyond-SMuRFs" (NCT05535582) study included 650 consecutive patients with AMI who had available data on self-reported MHS before AMI, calculated by the SF36-Questionnaire mental component summary (MCS). Poor MHS was defined as MCS ≤ 50. Multivariable logistic-regression and Cox-regression analyses were implemented to investigate poor MHS as a potential predictor of SMuRF-less AMIs and compare all-cause mortality based on SMuRF-less and MH status, respectively. Results: Of 650 patients with AMI (mean age 62.6 ± 12.1 years), 288 (44.3%) had MCS ≤ 50 and 128 (19.7%) were SMuRF-less patients. Three out of four SMuRF-less patients reported an MCS ≤ 50 (n = 96, 75%), a significantly higher percentage than the corresponding percentage in patients with SMuRFs (n = 192, 36.8%; p < 0.01). The multivariable logistic regression model showed that MCS ≤ 50 was an independent predictor of SMuRF-less AMI [aOR = 0.95; 95% CI (0.94-0.96)]. Time-to-event analysis for all-cause mortality showed that patients with MCS > 50 had lower mortality rates than those with poor MHS (aHR, 3.61 [95% CI, 2.02 to 6.43], p < 0.01). Higher risk for all-cause mortality was also observed in SMuRF-less patients with poor MHS compared to patients with at least one SMuRF and good MHS [aHR, 4.52 (95% CI, 0.94-21.73)]. Conclusions: Poor MHS was an independent predictor of the occurrence of SMuRF-less AMI and predictive of higher mortality in patients with and without SMuRFs.

Pharmacologic agents for perioperative cardioprotection in noncardiac surgery

PURPOSE OF THE REVIEW

This review will discuss the current pharmacologic strategies for mitigation of perioperative myocardial. State-of-the-art benefits and harms of pharmacologic interventions to delineate knowledge gaps in current guidelines and clinical practice will be presented.

RECENT FINDINGS

Beta-blockers are known to reduce major adverse cardiac events but inappropriate preoperative initiation results in adverse outcomes. Renin-Angiotensin-Aldosteron System (RAAS) inhibitors once universally discontinued before surgery are now under reconsideration as continuation seems not to be associated with increased risk. Statins continue to be the cornerstone due to their pleiotropic effect. Continuation of aspirin is supported perioperatively if the bleeding risk due to surgery is low to moderate. A few studies have investigated a strategy of strict intraoperative blood pressure control but failed to observe a meaningful effect on outcome. Whether prompt intensification of treatment in case of diagnosis of myocardial injury after noncardiac surgery improves outcome remains to be established. Since the MANAGE trial, no new studies have prospectively addressed this question.

SUMMARY

New data have questioned previous ideas and suggest a more nuanced, personalized approach to perioperative management. Accordingly, future studies should address refinement in risk stratification, optimization of pharmacologic strategies, and the development of novel therapies in attempting to enhance outcomes in high-risk surgical populations.

Social Support and 10-Year Mortality Following Acute Myocardial Infarction

This study investigates social support type and long-term mortality following AMI. Demographic and clinical data were collected retrospectively from a tertiary hospital for all patients with AMI (2011-2017). Study groups based on support type were defined: (1) employed partner (served as the reference group); (2) unemployed partner; (3) no partner, family support; (4) institutional or benefit-dependent; and (5) non-kin support (caregiver). Ten-year all-cause mortality risk was assessed and compared between the groups. We identified 2652 AMI patients with recorded support type: mean age 67.6 (SD = 14) years, 66% male; 40% had no partner, followed by those with an unemployed partner (31%). Over the follow-up of (median) 7.6 years, 1471 patients died; significantly higher mortality rates were observed in patients without family support (67.9%) or receiving non-kin support (94.9%). Those with non-kin support were at the highest mortality risk, AdjHR = 2.20, 95% CI: 1.67-2.91, p < 0.001, as compared with the reference group. Subgroup analyses found women below age 75 years, Arab women, and those with higher functional status to be most vulnerable to mortality in the absence of family support. Lack of family support was associated with increased long-term mortality among AMI patients. Assessment of support status among AMI patients is integral for secondary prevention.

Subacute Cardiomyopathy Due to Statin Treatment: Can It Be True?-Case Report and Literature Review

Background and Clinical Significance: Statins are a widely used drug class associated with a plethora of muscular side effects ranging from the subclinical elevation of creatine kinase to fulminant rhabdomyolysis. Cardiac myopathy secondary to statin treatment is rare and was recently reported as a part of statin-induced necrotizing autoimmune myopathy (SINAM). Its occurrence outside of this context is still debated. Case Presentation: We present the case of a 60-year-old male who developed atorvastatin-induced rhabdomyolysis, without associated hydroxymethyl glutaryl coenzyme A reductase (HMGCR) antibodies, with clinical findings of cardiac failure and severe ECG anomalies. The symptoms slowly regressed with statin withdrawal, and the patient made a full recovery. We discuss the recently proposed statin-associated cardiomyopathy (SACM) and the possible mechanisms. We compare our case to the three other cases of statin-induced cardiac myositis found in the literature. Conclusions: We believe that in vulnerable patients, as was our case, statins can determine significant subacute cardiac toxicity. This would seem to occur in the context of severe skeletal muscle injury, probably due to higher metabolic resistance on the part of the myocardium. Also, the available evidence suggests myocardial involvement should be actively investigated in SINAM patients, preferably by cardiac MRI.

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.

Emerging Biomarkers and Electrochemical Biosensors for Early Detection of Premature Coronary Artery Disease

Coronary artery disease (CAD) is one of the primary causes of morbidity and death worldwide. Premature CAD (pCAD) is the term used to describe the 3-10% of CAD occurrences that occur in people under 45 worldwide. Diagnostic difficulties arise from the different risk factor profiles of pCAD and late-onset CAD. Better cardiovascular risk prediction in younger populations has been made possible by the development of biomarker detection tools. This can be applied to a diagnostic tool, including electrochemical biosensors, which have been predicted to be instrumental because of their adaptability for point-of-care applications for quicker diagnoses. These biosensors provide efficient, scalable, and reasonably priced solutions for the quick identification and tracking of CAD. Multiplex biomarker detection has been adopted as a viable approach for early diagnosis and risk assessment due to the constraints of using a single biomarker for pCAD diagnosis. Thus, this study looks at current developments in biosensing technology and discusses established and new cardiac biomarker panels for pCAD identification.

Myocardial Infarction with Nonobstructive Coronary Arteries (MINOCA): Current Insights into Pathophysiology, Diagnosis, and Management

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is an increasingly recognized clinical entity characterized by myocardial injury in the absence of a significant coronary artery obstruction. MINOCA encompasses a diverse range of pathophysiological mechanisms, including coronary plaque disruption, coronary vasospasm, coronary microvascular dysfunction, thromboembolism, and spontaneous coronary artery dissection. A systematic diagnostic approach is essential to identify the underlying etiology and guide appropriate management strategies. Advanced imaging techniques, particularly cardiac magnetic resonance, play a pivotal role in distinguishing ischemic from non-ischemic myocardial injury and refining prognosis. Despite growing awareness, standardized treatment protocols remain limited, with current management largely extrapolated from strategies used in obstructive coronary artery disease. Notably, MINOCA is significantly more prevalent in women, emphasizing the need to understand sex-related differences in its pathophysiology, presentation, and clinical outcomes. This narrative review offers a comprehensive and up-to-date overview of MINOCA, including a dedicated chapter on sex-related considerations. It integrates recent advancements and highlights the importance of personalized management strategies.

Motion-unrestricted dynamic electrocardiogram system utilizing imperceptible electronics

Electrocardiogram (ECG) plays a vital role in the prevention, diagnosis, and prognosis of cardiovascular diseases (CVDs). However, the lack of a user-friendly and accurate long-term dynamic electrocardiogram (DCG) device in motion has made it challenging to perform many daily cardiovascular risk screenings and assessments, such as sudden cardiac arrest, resulting in additional economic burdens on society. Here, we present a motion-unrestricted dynamic electrocardiogram (MU-DCG) system, which employs skin-conformal, imperceptible electronics for long-term, comfortable, and accurate 12-lead DCG monitoring. To facilitate assembly for use on the skin, the MU-DCG system features a pressure-activated flexible skin socket for stably soft-connecting the on-skin soft module and the off-skin stiff module during dynamic movements. Crucially, blinded cardiologist evaluations confirm minimal motion artifacts in MU-DCG-acquired ECG signals. Our results demonstrate that the MU-DCG system, with large-area, ultra-thin on-skin electrodes/leads, and an off-skin module, accomplishes anti-motion interference acquisition and in-situ analysis while retaining wearing imperceptibility.

Effectiveness of a Simplified Checklist to Overcome the Inertia of Treatment Implementation in ACS Patients with High Comorbidity Burden

Background/Objective: High-risk subsets of patients with acute coronary syndrome (ACS) experience decreased access to optimal care and have poor clinical outcomes, reflecting an inertia to the delivery of guideline-directed and evidence-based therapy and implementation of critical care pathways. We aim to investigate the clinical effectiveness of a simplified implementation checklist to counter treatment inertia in patients with high comorbidity burden. Methods: An ACS critical care pathway was simplified and reduced to a minimalistic checklist including only items on GDMT and invasive strategy. A total of 2005 consecutive patients with ACS were evaluated including 1499 patients receiving standard care and 506 patients managed with the checklist. Patients with STEMI undergoing primary percutaneous coronary interventions and patients receiving upfront cardiovascular intensive care were excluded. Multivariate regression spline models were used to study the relationship between comorbidity, expressed as the Charlson Comorbidity Index (CCI) and a management strategy including guideline-directed medical therapy (GDMT) and an early invasive approach. Inverse probability of treatment weighting (IPTW) was used to address confounding factors. The use of GDMT and early invasive therapy were compared in patients receiving standard care and checklists. The 90-day composite outcome of all-cause mortality, recurrent ACS and stroke were compared between patients receiving standard care and those receiving checklists. Results: High CCI was associated with decreased GDMT, invasive strategy and the utilization of critical care pathway. Checklist utilization was unaffected by high CCI and led to sustained and higher use of GDMT and invasive approach in patients despite high CCI. Checklist managed patients have >10% higher rates of prescription of each class of GDMT (p < 0.0001) and more than twice the rate of early invasive approach (51.0% vs. 20.7%, (p < 0.0001) compared to patients receiving standard care. The 90-day composite outcome was lower in checklist management patients compared to patients receiving standard care, adjusted hazard ratio 0.61 (95% CI 0.46-0.81), log-rank p = 0.0006, especially in patients with high CCI, adjusted hazard ratio 0.60 (95% CI 0.38-0.97), log-rank p = 0.035 for CCI 5-6; adjusted hazard ratio 0.53 (95% CI 0.35-0.84), log-rank p = 0.0057 for CCI 7 or more. Conclusions: The use of a simplified checklist is associated with better implementation of GDMT and invasive strategy as well as better 90-day clinical outcomes in ACS patients with high comorbidity burden.

Targeting Investigation and Treatment in Type 2 Myocardial Infarction: A Pilot Randomized Controlled Trial

BACKGROUND

Type 2 myocardial infarction occurs in the absence of atherothrombosis, due to myocardial oxygen supply or demand imbalance, often during another acute illness. It is common and associated with poor clinical outcomes. No randomized controlled trials are available to guide investigation or treatment.

OBJECTIVES

The authors assessed the feasibility of implementing a complex intervention of investigation and treatment for coronary and structural heart disease in patients with type 2 myocardial infarction.

METHODS

A pilot phase of a prospective randomized controlled trial was conducted. Process outcomes included the proportion of eligible patients approached, consented, and randomized. Adherence was defined as the number of recommended investigations and treatments administered at 90 days. Qualitative interviews explored reasons for participation and patient experience.

RESULTS

Between November 2022 and November 2023, 4,127 patients with increased cardiac troponin concentrations were screened across 3 sites, and 403 patients (10%) met inclusion criteria. One hundred and forty-three patients (35%) were eligible, 119 patients (83%) were approached, and 60 patients (42%, age 70 ± 10 years, 38% women) consented and randomized to the intervention (n = 28) or standard care (n = 32). Follow-up was complete in all participants. Adherence to recommendations was 90.7% (95% CI: 85.3%-96.1%). Patients highlighted variation in communication of the diagnosis and in trial investigation and management recommendations were potential barriers to participation.

CONCLUSIONS

It is feasible to recruit and randomize patients with type 2 myocardial infarction to a complex intervention targeting coronary or structural heart disease. A multicenter trial with an optimized intervention is now required to inform practice.

Lipoprotein(a) Levels and Adverse Outcomes in Heart Failure

BACKGROUND

Although lipoprotein(a) [Lp(a)] level elevation is associated with new-onset heart failure (HF), it is unclear if elevated Lp(a) levels predict cardiovascular events in patients with chronic HF. Thus, we examined the association between Lp(a) levels and adverse cardiovascular outcomes in patients with HF.

METHODS AND RESULTS

A total of 1088 patients with HF undergoing cardiac catheterization at Emory-affiliated hospitals from 2004 to 2022 were divided into low (<30 mg/dL), intermediate (30-49 mg/dL), and high (≥50 mg/dL) Lp(a) groups. The primary outcome was the composite of cardiovascular death and HF hospitalization. Outcomes were assessed by Lp(a) group with competing risk modeling accounting for noncardiovascular death after adjustment for demographics, traditional cardiovascular risk factors, ejection fraction, ischemic HF etiology, and N-terminal prohormone of brain natriuretic peptide. Sensitivity analyses were performed to explore for heterogeneity of effect. The median age was 67 years, 34% were women, 18% were Black, 74% had ischemic HF, and 60% had an ejection fraction of ≤40%. During a median follow-up time of 4.3 years, 474 composite events (44%) occurred. When compared with participants with Lp(a) <30 mg/dL after multivariable adjustment, those with Lp(a) 30-49 mg/dL (subdistribution hazard ratio [sHR] 1.35, 95% confidence interval 1.04-1.76, P = .025) and Lp(a) ≥50 mg/dL (sHR 1.38, 95% confidence interval 1.11-1.72, P = .004) had a significantly higher risk of cardiovascular death or HF hospitalization. This relationship seemed to diminish over time and was nominally stronger in those with ischemic versus nonischemic HF (Pinteraction = .06), but did not meet significance after adjustment for multiple hypothesis testing.

CONCLUSIONS

In patients with HF, Lp(a) ≥30 mg/dL independently predicts the risk of cardiovascular death or HF hospitalization.

Angiography-Derived Microcirculatory Resistance in Detecting Microvascular Obstruction and Predicting Heart Failure After STEMI

BACKGROUND

Microvascular obstruction (MVO) is associated with heart failure (HF) following ST-segment-elevation myocardial infarction. Angiography-derived microcirculatory resistance (AMR), a wire- and adenosine-free measure, may facilitate early assessment of microvascular function post-primary percutaneous coronary intervention. This study aimed to evaluate the ability of AMR to detect MVO and its prognostic value for predicting HF in patients with ST-segment-elevation myocardial infarction post-primary percutaneous coronary intervention.

METHODS

Patients with consecutive ST-segment-elevation myocardial infarction undergoing primary percutaneous coronary intervention with a cardiac magnetic resonance examination 2 to 7 days post-procedure between April 2016 and February 2023 were retrospectively reviewed. AMR was computed from coronary angiography. MVO was identified and quantified via cardiac magnetic resonance. The end point was new-onset HF during follow-up.

RESULTS

Overall, 475 patients (aged 56.8±11.7 years; 399 males) were included. The area under the curve for AMR to detect MVO was 0.821 (95% CI, 0.782-0.859), with an optimal cutoff value of 2.7 mm Hg*s/cm. During a median follow-up of 37.3 months, 121 (25.5%) patients developed HF. AMR, whether as a continuous (per 0.5-mm Hg*s/cm increase; hazard ratio, 1.29 [95% CI, 1.10-1.52]; P=0.002) or categorical (AMR >2.7 mm Hg*s/cm; hazard ratio, 2.15 [95% CI, 1.43-3.22]; P<0.001) variable, was independently associated with HF after adjusting for traditional risk factors (age, symptom-to-balloon time, left anterior descending coronary artery, and ejection fraction) and late gadolinium enhancement-cardiac magnetic resonance parameters. AMR improved prognostication over traditional risk factors and late gadolinium enhancement-cardiac magnetic resonance parameters (net reclassification improvement, 0.533; P<0.001; integrative discrimination index, 0.023; P=0.005).

CONCLUSIONS

AMR showed good diagnostic performance in detecting MVO and was an independent and incremental predictor of HF in patients with ST-segment-elevation myocardial infarction post-primary percutaneous coronary intervention.

ST-Segment Elevation Myocardial Infarction Following Left Internal Thoracic Artery-to-Coronary Bypass Secondary to Arterial Steal Phenomenon

BACKGROUND

In the post-left internal thoracic artery (LITA)-to-coronary artery bypass graft (CABG) setting, anginal symptoms are associated with the presence of large, unligated LITA side branches. These symptoms are mediated by a variable arterial steal phenomenon.

CASE SUMMARY

This report describes an atypical case of ST-segment elevation myocardial infarction (STEMI) following LITA-CABG secondary to a variable arterial steal phenomenon induced by both a branch variant of the LITA and an intercostal artery. Angiography-guided embolization of the branch vessels successfully resolved the patient's ischemia.

DISCUSSION

STEMI secondary to LITA branch-mediated steal has not been previously reported. This case demonstrates that large LITA side branches can lead to myocardial infarction and that embolization of the relevant side branches is an effective treatment strategy.

TAKE-HOME MESSAGES

Providers should be aware that LITA side branches, if not ligated during surgery, may lead to threatening coronary ischemia. If such side branches cannot be ligated intraoperatively, then intravascular embolization is an effective treatment strategy.

Comparing the Efficacy of Sirolimus and Paclitaxel-Eluting Balloon Catheters in the Treatment of Coronary In-Stent Restenosis: A Prospective Randomized Study (TIS 2 Study)

BACKGROUND

Current therapy for in-stent restenosis (ISR) is based on drug-eluting stents (DES) or drug-eluting balloon catheters. This prospective randomized study compared the efficacy of a novel sirolimus-eluting balloon (SEB) catheter to that of a paclitaxel-eluting balloon (PEB) catheter for the treatment of bare-metal stent (BMS-ISR) or DES-ISR restenosis.

METHODS

A total of 145 patients with 158 BMS or DES-ISR lesions were randomly assigned to the treatment with either SEB or PEB. The in-segment late lumen loss at 12 months, the 12-month incidence of binary ISR, and major adverse cardiac events (cardiac death, nonfatal acute myocardial infarction, or target lesion revascularization) were compared between groups.

RESULTS

The noninferiority of SEB compared with PEB in the treatment of BMS/DES-ISR with respect to late lumen loss was not demonstrated (Δlate lumen loss, -0.024 mm [95% CI, -0.277 to 0.229]; for a noninferiority margin of 0.20 mm), except in the post hoc subanalysis for the BMS-ISR group (-0.203 mm [95% CI, -0.584 to 0.178]). No significant differences in the incidence of repeated binary ISR (31.6% versus 30.4%, P=0.906) or 12-month major adverse cardiac events (31% for both; P>0.999) between the SEB and PEB groups were observed.

CONCLUSIONS

The noninferiority of SEB relative to PEB in the treatment of BMS/DES-ISR with respect to late lumen loss was not confirmed.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03672656.

Association between mild renal insufficiency, inflammatory status on initial admission, and 1-year mortality following ST-segment elevation myocardial infarction

The systemic inflammation tends to increase progressively as kidney function deteriorates. However, it remains unknown whether mild renal insufficiency affects inflammatory response at admission and subsequent clinical outcomes following ST-segment elevation myocardial infarction (STEMI). This study aimed to evaluate the joint, interactive, and mediating effects of estimated glomerular filtration rate (eGFR) and neutrophil-lymphocyte ratio (NLR) at admission on 1-year mortality in STEMI patients. Data were collected from 5,594 consecutive STEMI patients at seven centers (NCT04996901). Mildly reduced eGFR (60-89 mL/min/1.73m2) was associated with both elevated NLR and increased 1-year mortality (β 0.55, 95%CI [0.07-1.02], P = 0.024; HR 2.18, 95%CI [1.55-3.08], P < 0.001; respectively). Inflammation at admission mediated a small but significant proportion of the association between mildly reduced eGFR and mortality risk (1.7%, P = 0.030). Incorporating eGFR and NLR into a predictive model significantly improved mortality prediction following STEMI compared with clinical risk factors alone (C-index, 0.799 vs. 0.730, P < 0.001; net reclassification index 0.334, P < 0.001). These findings support the identification of patients at risk who may benefit from intensive kidney function monitoring and early adjuvant intervention, while also highlighting the need for developing anti-inflammatory therapies for STEMI patients with renal insufficiency.