Management of Acute Coronary Syndrome in the Older Adult Population: A Scientific Statement From the American Heart Association

The impact of uric acid on acute coronary syndrome prognosis in elderly patients

BACKGROUND

Uric acid (UA) plays an important role in cardiovascular diseases, yet its implications in elderly patients remains incompletely understood. This study aimed to explore the impact of UA on the prognosis in advanced-age patients with acute coronary syndrome (ACS).

METHODS

We included 526 patients aged 80 and older who were diagnosed with ACS. The UA levels were measured at admission, and patients were divided into four groups based on quartiles of UA levels. Major adverse cardiovascular events (MACE) during follow-up were recorded.

RESULTS

The median UA level was 344.09 μmol/L, while the median follow-up duration was 64 months. Kaplan-Meier curves demonstrated a higher cumulative incidence of MACE during long-term follow-up in the Q4 group (Log-rank p < 0.05). Cox regression analysis revealed an independent correlation between UA levels and an increased risk of MACE (HR 1.002, 95%CI 1.000-1.003, p = 0.021). The ROC curve indicated that the optimal UA value for predicting MACE was 324.25 μmol/L. After matching through PSM, the MACE-free survival rate was lower in both hyperuricemia group (UA> 420.00 μmol/L) and high UA group (324.25 μmol/L < UA≤ 420.00 μmol/L) compared to the control group. Both hyperuricemia and high UA levels were independent risk factors for long-term MACE in advanced-age ACS patients, with HR values of 1.546 (1.049-2.280, p = 0.028) and 1.491 (1.011-2.198, p = 0.044), respectively.

CONCLUSION

Elevated UA levels were identified as independent risk factors for MACE in elderly patients with ACS. The optimal predictive value of UA for poor cardiovascular prognosis was significantly lower than the traditional definition of hyperuricemia.

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.

Identification and Initial Resuscitation of Critically Unwell Older Patients in the Emergency Department

Identifying and managing critically unwell older patients in emergency departments are challenging for all clinicians. Physiologic changes, multiple comorbidities, and medications often mask or confound serious conditions in older people, and vital signs can be misleading. Because standard triage methods may be inadequate for this population, enhanced triage systems that incorporate frailty assessments and tailored scoring systems are useful. Serial assessments tailored to the patient, biomarkers, and advanced imaging are also important to better detect and manage critical illness in older adults and improve outcomes. Here, the authors discuss diagnosis and management of critically ill older adults.

Characteristics and Outcomes of Older Patients Undergoing Protected Percutaneous Coronary Intervention With Impella

BACKGROUND

In patients undergoing high-risk percutaneous coronary intervention, Impella has become an important adjunctive tool to support revascularization. The impact of age on the outcomes of patients undergoing high-risk percutaneous coronary intervention is limited. The aim of this study is to describe the characteristics and outcomes of patients ≥75 years of age undergoing Impella-supported high-risk percutaneous coronary intervention.

METHODS AND RESULTS

Baseline characteristics and outcomes of patients ≥75 years of age versus those of patients <75 years of age in patients enrolled in the cVAD PROTECT III (Catheter-Based Ventricular Assist Device Prospective, Multi-Center, Randomized Controlled Trial of the IMPELLA RECOVER LP 2.5 System Versus Intra Aortic Balloon Pump in Patients Undergoing Non Emergent High Risk Percutaneous Coronary Intervention) study (NCT04136392). Major adverse cardiovascular and cerebral events (composite of all-cause death, nonfatal myocardial infarction, stroke/transient ischemic attack, and repeat revascularization) were assessed at 30 and 90 days and all-cause death at 1 year. Out of 1237 patients, 493 (39.9%) patients were ≥75 years of age. Patients ≥75 years of age had less diabetes and prior myocardial infarction, more hypertension and dyslipidemia, worse renal function, more severe valvular heart disease, but higher left ventricular ejection fraction (P<0.05 for all comparisons). Baseline Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery scores were similar between groups. Older patients underwent more left main percutaneous coronary intervention (58% versus 39%; P<0.0001), atherectomy (32% versus 22%; P<0.0001), and femoral access (87% versus 79%, P=0.0003) as compared with younger patients. In-hospital vascular complications did not differ, but rates of respiratory failure, pericardial tamponade, and cardiogenic shock were higher in older patients. Rates of all-cause death and major adverse cardiovascular and cerebral events did not differ between groups at 30 and 90 days. Rates of all-cause death at 1 year were higher in patients ≥75 years (adjusted hazard ratio, 1.99 [95% CI, 1.24-3.18], P=0.004).

CONCLUSIONS

Impella-supported high-risk percutaneous coronary intervention in older patients is feasible with an acceptable safety profile. However, age ≥75 years remained a statistically significant predictor for all-cause death at 1 year.

REGISTRATION

URL: https://clinicaltrials.gov; Unique Identifier: NCT04136392.

Invasive Versus Conservative Strategies in Older Adults With Non-ST Elevation Acute Coronary Syndrome: An Updated Meta-Analysis of Randomized Controlled Trials

Non-ST-elevation acute coronary syndrome (NSTE-ACS) is a common condition among older adults. However, due to frailty and comorbidities, older adults are often underrepresented in clinical trials, making the decision between an invasive or conservative approach for optimal management controversial. Our meta-analysis seeks to address this issue by focusing exclusively on randomized controlled trials (RCTs). A systematic database literature search was conducted via PubMed, the Cochrane Central Register of Controlled Trials, Embase, and ClinicalTrials.gov to identify RCTs comparing invasive and conservative management strategies in older adults with NSTE-ACS. Data on unplanned revascularization, myocardial infarction (MI), bleeding, all-cause mortality, composite of major adverse outcomes, and stroke were extracted and pooled. Random-effects models to calculate pooled risk ratios (RR) with 95% confidence intervals (CI) were analyzed using the Review Manager software. A total of seven RCTs and a total of 2997 patients were included in the meta-analysis. The invasive approach demonstrated a lower risk of unplanned revascularization (RR: 0.36; 95% CI: 0.23, 0.55; p < 0.00001; I² = 28%) and MI (RR: 0.72; 95% CI: 0.56, 0.94; p = 0.01; I² = 34%). No significant differences were found for major bleeding episodes (RR: 1.40; 95% CI: 0.93, 2.14; p = 0.11), all-cause mortality (RR: 1.01; 95% CI: 0.91, 1.12; p = 0.49), composite of major adverse events (RR: 0.87; 95% CI: 0.73, 1.05; p = 0.14) and risk of stroke (RR: 0.84; 95% CI: 0.59, 1.20; p = 0.34) between the two strategies. Our findings reveal that, in older adults with NSTE-ACS, an invasive strategy reduces the risk of subsequent MI and unplanned revascularization. However, no significant differences in mortality, bleeding, or stroke were observed between the two groups.

Cephalosporin triggered Kounis syndrome: Pathophysiological and clinical insights

BACKGROUND

Acute coronary syndrome triggered by hypersensitivity to various natural, chemical, or pharmaceutical allergens is known as Kounis syndrome. Kounis syndrome is classified in three subtypes based on its pathophysiological mechanism and outcome. Among pharmaceuticals, cephalosporins are frequently implicated in allergic illnesses, with ceftriaxone being one of the most frequently reported causes. Based on literature reports and our own experience, we focused on the main clinical features regarding ceftriaxone triggered KS (CTKS).

METHODS

Medical records from all CTKS cases, as published by the end of December 2024, were retrieved and analyzed, including a patient admitted to our hospital after inadvertent twice ceftriaxone administration.

RESULTS

Clinical findings from 10 CTKS patients, mean aged 61 ± 18 (range 24-85) years, 5 males, were studied. Type-I KS (coronary vasospasm) was found in 8 cases (80 %), whereas 2 more patients showed a type-II variant (atheromatous plaque thrombosis), with the right artery as the most involved coronary vessel. Apart from transient hemodynamic instability in 2 patients on admission, everyone was discharged in a good clinical condition.

CONCLUSIONS

CTKS is a rare, but likely underrecognized, clinical condition that may occur regardless of gender, age, history of allergy or preexisting coronary artery disease. The predominant type-I variant indicates a transient coronary asospasm (and/or microcirculatory impairment) as the most likely pathogenic mechanism. Key pathophysiological, clinical, and prognostic aspects are discussed.

Gender differences in patient-reported outcomes and cardiac symptoms in patients with acute coronary syndrome in Riyadh, Saudi Arabia

OBJECTIVES

To measure the gender differences in patient-reported outcomes and cardiac symptoms in patients with acute coronary syndrome (ACS) at King Khalid University Hospital in Riyadh, Saudi Arabia.

METHODS

A cross-sectional study was conducted on 240 randomly selected ACS patients aged ≥18 years. Data were collected using validated questionnaires, including Patient-reported outcomes measures, the Rose Dyspnea Scale, Patient Health Questionnaire, and Seattle Angina Questionnaire. Multiple linear regression analysis was conducted to identify factors associated with quality of life (QoL).

RESULTS

The study included 60% males and 40% females. Females reported significantly lower global physical health scores (11.62 [±2.49] versus (vs) 13.68 [±2.68], p=0.00), higher dyspnea symptoms (2.61 [±1.41] vs 1.55 [±1.51], p=0.00), and more physical limitation (43.2 [±31.8] vs 55.19 [±33.96], p=0.02). Multiple linear regression analysis showed female gender was associated with a decline in physical health (-0.33 [-2.42, -1.00]), increased dyspnea symptoms (0.30 [0.55, 1.37]), higher depression scores (0.14 [0.004, 0.87]), a decline in SAQ physical activity [-0.19 (-23.68, -2.60)] and summary scores [-0.14 (-11.34, -.04)]. Older age and lower income were also significantly associated with poorer QoL outcomes.

CONCLUSION

Female gender, advanced age, and lower income were associated with worse patient-reported outcomes in ACS patients. Healthcare providers should consider these disparities to improve management strategies and QoL in this population.

Geriatric conditions and invasive management in frail patients with NSTEMI. A subgroup analysis of a randomized clinical trial

INTRODUCTION AND OBJECTIVES

Invasive management in frail patients with non-ST-segment elevation myocardial infarction (NSTEMI) remains controversial. We investigated the impact of various geriatric conditions.

METHODS

The MOSCA-FRAIL trial included 167 adults aged ≥ 70 years with frailty (Clinical Frailty Scale [CFS] ≥ 4 points) and NSTEMI, who were randomized to either an invasive (n=84) or conservative (n=83) strategy. In addition to frailty, we measured activities of daily living (Barthel index), cognitive impairment (Pfeiffer test), and comorbidities (Charlson index). The primary endpoint was the difference (invasive minus conservative) in restricted mean survival time (RMST) for all-cause mortality at a median follow-up of 3.9 years.

RESULTS

A total of 93 patients died. The RMST difference favored invasive management at the CFS 25th percentile (CFS=4; 157 days, 95%CI, 18-295; P=.027), which changed to a nonsignificant effect at the 50th and 75th percentiles. The RMST difference remained nonsignificant, irrespective of the severity of other geriatric assessments. In time-to-event analysis, invasive management was associated with an initially lower life expectancy, peaking at around 1 year, among all subgroups. However, patients with CFS=4 experienced a benefit at the end of follow-up (181 days, 95%CI, 19-343), whereas those with CFS >4 did not (-16 days, 95%CI, -217 to 186; interaction P=.16). Subgroups defined by other geriatric markers showed a similar time-dependent trend, albeit with weaker statistical interaction.

CONCLUSIONS

Among adults with frailty and NSTEMI, the CFS might be useful for evaluating the relative risks and benefits of invasive management. A CFS >4 could serve as a valuable threshold for decision-making.

Development of a package on the management of acute myocardial infarction for healthcare professionals at Jordan University Hospital

BACKGROUND

Acute myocardial infarction (AMI), commonly known as a heart attack, is one of the leading causes of death globally. While healthcare professionals possess fundamental knowledge of managing AMI, there are key areas that require improvement or where basic knowledge is lacking. Timely decision-making, collaboration with the healthcare team, and continuous patient monitoring are imperative for optimizing outcomes in AMI cases. This study aimed to determine the current knowledge level and educational needs of healthcare professionals at Jordan University Hospital regarding AMI management to develop a targeted training program.

MATERIALS AND METHODS

To understand the current knowledge and educational needs of these healthcare professionals in managing AMI, a quantitative analysis was conducted using a sample of 309 internship doctors and registered nurses at Jordan University Hospital. Data were collected through questionnaire surveys, exploratory factor analysis, and hypothesis testing.

RESULTS

The data analysis revealed that a significant majority of the internship doctors and registered nurses (over 90%) have an excellent understanding and adequate knowledge concerning the management of AMI. However, there are gaps in certain areas of AMI management. Additionally, a significant relationship was found between the occupational category (registered nurses and internship doctors) and the management of AMI.

CONCLUSION

This study highlights the importance of focused educational interventions in improving healthcare workers' skills in managing AMI. By addressing knowledge gaps through customized training content tailored to different professional roles, Jordan University Hospital can enhance the standard of care provided to AMI patients.

Remnant Cholesterol Levels at Diagnosis May Predict Acute Coronary Syndrome Occurrence During Follow-Up in Patients with Antineutrophil Cytoplasmic Antibody-Associated Vasculitis

Background/Objectives: Previous studies have revealed the predictive potential of remnant cholesterol (RC) for acute coronary syndrome (ACS) occurrence in the general population. However, whether this association applies to patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV), in which a lipid paradox exists, remains unclear. We investigated whether RC levels at diagnosis could predict ACS occurrence during follow-up in patients with AAV. Methods: This study included 139 patients with AAV. ACS was defined as ST-elevation myocardial infarction (STEMI), non-STEMI, or unstable angina occurring after AAV diagnosis. RC levels were calculated as (total cholesterol)-(low-density lipoprotein cholesterol)-(high-density lipoprotein cholesterol). Patients were categorised into three groups by RC tertiles: highest (≥26.2 mg/dL), middle (19.1-26.1 mg/dL), and lowest (≤19.0 mg/dL) tertile groups. Results: The median age of the 139 patients (male, 31.7%) was 58.0 years. During follow-up, six, two, and one patients were diagnosed with ACS in the highest, middle, and lowest tertile groups, respectively. Patients in the highest tertile group exhibited a significantly lower ACS-free survival rate than those in the lowest tertile (p = 0.030). In the multivariable Cox hazards model, male sex (hazard ratio [HR] 9.054, 95% confidence interval [CI] 1.786-45.910), Birmingham vasculitis activity score (HR 1.147, 95% CI 1.033-1.274), and the highest tertile of RC levels (HR 10.818, 95% CI 1.867-62.689) were significantly and independently associated with ACS occurrence during follow-up in patients with AAV. Conclusions: Our findings indicate that RC levels at diagnosis may predict ACS occurrence during follow-up in patients with AAV, regardless of the traditional cardiovascular risk factors.

GLP-1 Receptor Agonists and Myocardial Perfusion: Bridging Mechanisms to Clinical Outcomes

Coronary microvascular dysfunction (CMD) is a key contributor to myocardial ischemia and adverse cardiovascular outcomes, particularly in individuals with metabolic disorders such as type 2 diabetes (T2D). While conventional therapies primarily target epicardial coronary disease, effective treatments for CMD remain limited. Glucagon-like peptide-1 receptor (GLP-1R) agonists have emerged as promising agents with cardiovascular benefits extending beyond glycemic control. Preclinical and clinical evidence suggests that GLP-1R activation enhances coronary microvascular function through mechanisms including improved endothelial function, increased nitric oxide bioavailability, attenuation of oxidative stress, and reduced vascular inflammation. Moreover, GLP-1R agonists have been shown to improve myocardial blood flow, myocardial perfusion reserve, and coronary endothelial function, particularly in high-risk populations. Despite these promising findings, inconsistencies remain across studies due to variability in patient populations, study designs, and imaging methodologies. This review summarizes current evidence on the role of GLP-1R agonists in myocardial perfusion, bridging mechanistic insights with clinical outcomes. Further large-scale, well-designed trials are needed to clarify their long-term impact on coronary microcirculation and explore their potential as targeted therapies for CMD.

Direct economic burden of acute coronary syndromes in the Portuguese National Health Service-facts and trends between 2002 and 2022

Aim

We estimated the average direct cost per Acute Coronary Syndromes (ACS) in-patient episodes by diagnosis, namely ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), unstable angina (UA), and undetermined AMI (Acute Myocardial Infarction). We also analyzed the changes in direct costs over time between 2002 and 2022, and the total direct economic burden of ACS hospitalizations for the Portuguese National Health Service (NHS).

Methods

We used the Portuguese Registry of Acute Coronary Syndromes (61,440 ACS hospitalizations), a cohort of people with ACS, recruited and followed from first hospitalization. A direct cost analysis was conducted. As resources, we considered health professional working hours, non-medical resources used during in-patient stays, laboratory and diagnostic tests, interventional cardiology procedures, pharmaceuticals, hospitalization-related complications, rehabilitation services, and death costs. A multivariate analysis was performed to identify the main cost determinants.

Results

The average cost per ACS patient from 2002 to 2022 was 6,280.79 €. A significantly higher average cost was observed among patients diagnosed with STEMI of 3,853.26€ (95% confidence interval [CI] 3,690.87 to 4,015.65€), among NSTEMI patients of 1,308.91 € (95% CI 1,173.52 € to 1,444.30 €), and among patients who died during the hospitalization of 12,017.64€ (95% CI 11,232.21 € to 12,803.08 €). Over time, cost trends fluctuated, increasing until 2011 and then gradually decreasing until 2022, apart from 2020. Considering the total universe of 294,307 ACS-hospitalizations, the Portuguese NHS incurred a direct economic burden of 1,831 million euros over the complete period, with total annual costs averaging 87,203,851 €, representing on average 0.93% of the NHS annual health expenditure.

Conclusion

ACS represent a significant direct cost and economic burden for the NHS.

Age-related differences in coronary artery lesions and short-term prognosis in acute coronary syndrome patients

OBJECTIVE

To explore age-related differences in coronary artery lesions, lesion characteristics, and short-term prognosis in acute coronary syndrome (ACS) patients.

METHODS

A retrospective analysis was conducted on 198 ACS patients (February 2019-January 2024). Patients were grouped by age: < 40 years (low-age), 40-60 years (middle-age), and > 60 years (high-age). We compared clinical data, coronary angiography results, lesion characteristics, and short-term major adverse cardiac event (MACE) occurrence across the groups. Pearson or Spearman correlation was used to assess relationships, and ROC curves were employed to evaluate the predictive ability for MACE.

RESULTS

The high-age group had significantly higher Gensini scoring and Global Registry of Acute Coronary Events (GRACE) scores (both P < 0.001), more diseased branches, and a higher proportion of non-calcified plaques. MACE incidence was highest in the high-age group. Age correlated positively with hypertension, hyperlipidemia, triglycerides, Gensini score, GRACE score, and the number of diseased branches, and negatively with hemoglobin levels (all P < 0.05). Age showed the strongest predictive ability for short-term MACE (AUC: 0.673, sensitivity: 71.0%).

CONCLUSION

Elderly ACS patients exhibit more severe coronary lesions and a higher incidence of MACE. Age is a significant predictor of short-term MACE and correlates with various clinical and angiographic indicators.

Absence of chest discomfort in type 1 NSTEMI patients: predictors and impact on outcome

BACKGROUND

The absence of chest discomfort has been hypothesized to delay treatment and consequently result in worse outcomes in patients with non-ST-elevation myocardial infarction (NSTEMI).

METHODS

In 888 consecutive patients with type 1 NSTEMI, symptoms were systematically classified as chest discomfort defined as chest pain or pressure, dyspnea or other symptoms, e.g. epigastric pain. Patient characteristics predictive for the absence of chest discomfort and the impact of the symptom type on adverse in-hospital events (all-cause mortality, cardiogenic shock, and mechanical ventilation) were analyzed.

RESULTS

Chest discomfort was reported in 81.0%, dyspnea without chest discomfort in 12.2%, and only other symptoms in the remaining 6.9% of patients. In a multivariable regression analysis, female sex (p = 0.035), diabetes mellitus (p = 0.003), the absence of any family history of coronary artery disease (CAD) (p = 0.002), anemia (p < 0.001), and atrial fibrillation or flutter at presentation (p = 0.017) were independent predictors for the absence of chest discomfort. The absence of chest discomfort was associated with a higher rate of in-hospital adverse events (10.6% for chest discomfort vs. 29.6% for dyspnea and 27.9% for other symptoms, p < 0.001), which appeared partially mediated (p = 0.044) by longer times from diagnosis to invasive management (p < 0.001).

CONCLUSIONS

In type 1 NSTEMI, the absence of chest discomfort is associated with a higher rate of adverse in-hospital events. Women, diabetics, patients without a family history of CAD, patients with anemia, and patients with atrial fibrillation are more likely to present without chest discomfort and special attention may be required to avoid delayed invasive management in these patients.

Establishment and validation of post-PCI nomogram in elderly patients with acute coronary syndromes

Objective

The objective of this study was to create and validate a clinical prediction model for the incidence of major adverse cardiovascular events (MACE) within one year after percutaneous coronary intervention (PCI) in elderly patients diagnosed with acute coronary syndromes (ACS).

Methods

The study will use 70% of the 738 patients for model training and the remaining 30% for model validation. The feature recursive elimination algorithm (RFE) and the least absolute shrinkage selection operator (LASSO) regression technique will be used to identify the best combination of features. We compare the clinical prediction model we constructed with GRACE in terms of discrimination, calibration, recall, and clinical impact.

Results

We used the RFE and LASSO regression technique to select 8 key variables from 44 candidates for our predictive model. The predictive model was found to have a good fit based on the Hosmer-Lemeshow test results (χ 2 = 6.245). Additionally, the Brier score of the clinical prediction model was 0.1502, confirming its accuracy. When comparing our clinical prediction model to the widely used GRACE scoring system, the results showed that our model had slightly better predictive efficacy for the dataset involved in this study. The NRI was 0.6166, NRI + was 0.2262, NRI- was 0.3904, and IDI was 0.1272, with a P value of <0.001. The validation set's AUC was 0.787, indicating the prediction model has high differentiation and discriminative ability.

Conclusion

This model assists in the early identification of the risk of MACE within one year after PCI for ACS in elderly patients.

RURUS SURYAWAN Score: A Novel Scoring System to Predict 30-Day Mortality for Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Background/Objectives: It is essential to identify acute myocardial infarction patients with greater risk of deterioration following primary percutaneous coronary intervention. Due to an inconsistent result about predictors of 30-day outcomes regarding scoring systems for the first episode of acute myocardial infarction, the objective of this study is to develop novel scoring systems to predict 30-day mortality among patients with a first episode of acute myocardial infarction who underwent primary percutaneous coronary intervention. Methods: This retrospective study was conducted with total sampling for all patients with first-time acute myocardial infarction who underwent primary percutaneous coronary intervention between 2021 and 2024 at Dr. Soetomo Hospital, Indonesia. We performed a total sampling and collected 1714 patients, of which 1535 patients were included. Our primary outcomes included 30-day mortality. Results: The analysis included 1535 patients: 926 in the derivation set and 609 in the validation set. In our study, the 30-day mortality rate was 20.7%. Multivariate logistic regression analysis was used to build prediction models in the derivation group and then validated in the validation cohort. The area under the ROC curve of the RURUS SURYAWAN score to predict 30-day mortality was 0.944 (0.906-0.972) in the derivation set and 0.959 (0.921-0.983) in the validation set, with 94.6% sensitivity and 97.3% specificity (p < 0.001). Conclusions: After adjusting for potential confounders, we developed RURUS SURYAWAN, a novel scoring system to identify predictors of 30-day mortality among acute myocardial infarction before primary percutaneous coronary intervention.

Elderly patients treated with Onyx versus Orsiro drug-eluting coronary stents in a randomized clinical trial with long-term follow-up

BACKGROUND

Percutaneous coronary intervention (PCI) with new-generation drug-eluting stents is increasingly performed in elderly patients, who generally have more comorbidities and more technically challenging target lesions. Nevertheless, there is a paucity of reported data on the long-term safety and efficacy of PCI with contemporary stents in elderly all-comers.

METHODS

This prespecified secondary analysis of a large-scale randomized clinical trial (BIONYX; clinicaltrials.gov:NCT02508714) compared in elderly all-comers (≥ 75 years) the 5-year outcome after PCI with the novel, more radiopaque Onyx zotarolimus-eluting stent (ZES) versus the Orsiro sirolimus-eluting stent (SES). We assessed the main composite endpoint target vessel failure (TVF: cardiac death, target vessel myocardial infarction, or target vessel revascularization) and several secondary endpoints.

RESULTS

Of 2,488 trial participants, 475(19.1%) were elderly (79.5 ± 3.5 years), including 165(34.7%) women. There was a significant between-stent difference in the main endpoint TVF in favor of the Onyx ZES (14.4% vs. 24.2%, HR: 0.60, 95% CI 0.39-0.93, plog-rank = 0.02). The time-to-event curves displayed between-stent dissimilarities across all components of TVF, yet not statistically significant. Landmark analysis between 1- and 5-year follow-up showed in Onyx ZES-treated patients significantly lower rates of TVF (7.8% vs.8.9%, p = 0.002) and target vessel revascularization (3.0% vs.8.3%, p = 0.029). In addition, the 5-year rates of all-cause mortality and several composite endpoints were lower (p < 0.03) in Onyx ZES-treated patients.

CONCLUSIONS

In elderly all-comer patients, those treated with Onyx ZES showed a lower 5-year incidence of the main endpoint of safety and efficacy, as well as several secondary endpoints, than patients treated with Orsiro SES. Further research on this issue is warranted.

CLINICAL TRIAL REGISTRATION INFORMATION

https://clinicaltrials.gov/study/NCT02508714.

Physical activity, frailty, and kinesiophobia among older adult patients with coronary heart disease in China

BACKGROUND

Physical activity (PA) offers advantages in the secondary prevention of coronary heart disease (CHD). However, in older adults, frailty and kinesiophobia may exert negative influences on PA engagement.

OBJECTIVE

To investigate PA, frailty, and kinesiophobia among older adult patients with CHD in China.

METHODS

This cross-sectional study enrolled older adult patients with CHD in the cardiac outpatient care unit of the *** University. The International Physical Activity Questionnaire, the Frailty Phenotype Scale, and the Tampa Scale of Kinesiophobia were used to evaluate PA, frailty, and kinesiophobia, respectively.

RESULTS

A total of 239 participants (mean age: 72.0 ± 7.5 years, 148 males) were enrolled. The rates of frailty and pre-frailty were 20.5 % and 46.4 %, respectively. The mean kinesiophobia score was 43.13±5.48. The median metabolic equivalent of task of PA was 2784 MET-min/week, and 25.1 % of the patients did not reach the minimum recommended by AHA (150 mins/week). Spearman rank correlation analysis showed that PA was negatively correlated with frailty (r = -0.559, P < 0.001) and kinesiophobia (r = -0.463, P < 0.001). Multivariable logistic regression analysis showed that frailty [OR = 0.412, 95 % confidence interval (CI): 0.304-0.559, P < 0.001] and kinesiophobia (OR=0.936, 95 % CI: 0.879-0.997, P = 0.040) were independently associated with PA after adjustment for age, cardiovascular adverse events, comorbidities, Barthel index, and history of dizziness.

CONCLUSIONS

Older adult patients with CHD had low levels of PA. Frailty and kinesiophobia were independently associated with PA in older adult patients with CHD. Reversing frailty and reducing kinesiophobia in older adult patients with CHD may increase PA levels.

Frailty as a Prognostic Indicator for In-Hospital Mortality and Clinical Outcomes in Acute Coronary Syndrome: A Systematic Review and Meta-Analysis

BACKGROUND & AIMS

Frailty is a significant predictor of adverse outcomes in patients with acute coronary syndrome (ACS). However, its impact on short-term clinical outcomes remains unclear. We conducted a systematic review and meta-analysis to investigate the associations between frailty and adverse clinical outcomes in patients with ACS.

METHODS

We systematically searched the Embase, MEDLINE, and CENTRAL databases from inception to 1 August 2023 for observational cohort studies, cross-sectional studies, or clinical trials involving hospitalised adults with ACS. Studies utilising validated frailty screening tools and examining the associations between frailty and clinical endpoints, such as in-hospital mortality, length of hospital stay, major bleeding, and stroke, were included. The meta-analysis was performed via random effects models and meta-regression analyses.

RESULTS

Among the 4,458 records identified, 42 were deemed eligible, and data from 14 studies were included in the analysis. Frailty was significantly associated with increased in-hospital all-cause mortality (relative risk [RR] 2.89; 95% confidence interval [CI] 2.49-3.34) and prolonged length of hospitalisation (standardised mean difference [SMD] 2.01; 95% CI 1.48-2.46), with frail patients with ACS spending an average of 3.5 more days in the hospital. Furthermore, frail patients with ACS presented a significantly greater risk of adverse outcomes than non-frail patients with ACS did (RR 1.86; 95% CI 1. 41-2.46). Subgroup analysis revealed a significant increase in major bleeding events (RR 2.03; 95% CI 1.51-2.73) among frail patients with ACS, whereas the incidence of stroke showed a nonsignificant trend towards elevation (RR 1.23; 95% CI 0.56-2.72).

CONCLUSIONS

Frailty is strongly associated with in-hospital all-cause mortality, prolonged length of hospitalisation, and adverse clinical outcomes such as major bleeding in patients with ACS.

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

AIMS

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

METHODS AND RESULTS

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

CONCLUSIONS

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

The Prognostic Role of Residual SYNTAX Score in Older Patients with Acute Coronary Syndrome

Background

Approximately half of the patients presenting with acute coronary syndrome have multivessel disease. There has been conflicting data regarding the residual coronary artery disease (CAD) burden and its impact on mortality, especially in older people. Therefore, we aimed to assess all-cause mortality and residual CAD burden in older patients with acute coronary syndrome.

Methods

Patients over 75 years of age who presented with acute coronary syndrome and underwent percutaneous coronary intervention were retrospectively included in the study. After the index procedure, residual The Synergy Between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery (SYNTAX) scores were calculated and the patients were divided into two groups as residual SYNTAX > 8 and < 8. In-hospital and long-term all-cause mortality were defined as the endpoints of the study.

Results

Overall, 352 patients were included in the study. The mean age was 82.0 ± 4.8 years and 188 (53.4%) patients were female. The median follow-up was 35 (3-57) months. Both in-hospital and long-term mortality were significantly higher in the patients with residual SYNTAX sore > 8 (33.9% vs. 12.0% and 70.1% vs. 48.4% both p < 0.01, respectively). Kaplan-Meier analysis survival curves continued to separate showing increased mortality in the patients with residual SYNTAX score > 8 (p < 0.01). In multivariate Cox regression analysis, high residual CAD burden [residual Syntax score > 8, hazard ratio: 1.83 (1.30-2.56 95% confidence interval), p < 0.01], age, diabetes mellitus, left ventricular ejection fraction and renal insufficiency were associated with long-term all-cause mortality.

Conclusions

Elderly patients with residual SYNTAX score > 8 had higher in-hospital and long-term all-cause mortality rates. Strategies aiming to reduce residual CAD burden by revascularization seem reasonable.

Updated evidence on selection and implementation of an invasive treatment strategy for older patients with non-ST-segment elevation myocardial infarction

Non-ST-segment elevation myocardial infarction (NSTEMI) is the most common acute coronary syndrome diagnosis in older patients. In the UK, there are ~20 000 NSTEMI cases annually in patients aged ≥75 years. Despite therapeutic advances in pharmacological and invasive management, studies show that older patients with NSTEMI experience worse in-hospital and long-term outcomes than younger patients, suggesting a clear need for robust evidence in this cohort.The European Society of Cardiology guidelines recommend that invasive management should be considered holistically with no specified age cut-offs. However, older patients are less likely to receive invasive management due to a paucity of evidence from trials that represent contemporary clinical characteristics of older adults. Recruiting older patients realistic of those encountered in clinical practice is hugely challenging. Chronological age alone does not reflect the heterogeneity of the older population; ~30% of older patients with NSTEMI are frail, ~65% are cognitively impaired and most live with at least two additional comorbidities that can influence risk. Weighing the risk of an NSTEMI in an older adult against competing risks attributable to underlying frailty, comorbidities and cognitive impairment poses a key challenge.Recently, the SENIOR-RITA trial showed that invasive management in older patients with NSTEMI is safe and reduces non-fatal myocardial infarction and subsequent revascularisation but does not improve mortality. Individualised risk assessment and shared decision-making is necessary to guide these nuanced decisions. This review discusses the latest evidence regarding invasive management in the older population with NSTEMI, including the impact of geriatric syndromes on clinical outcomes.

ESICM consensus-based recommendations for the management of very old patients in intensive care

PURPOSE

The heterogeneity of very old patients (age ≥ 80 years) and the prevalence of complex geriatric syndromes in this cohort constitute major challenges for the classical methods of evidence-based medicine to inform clinical practice. The lack of robust guidance for the management of critical conditions in these patients contributes to considerable uncertainty among practitioners and unwarranted variations of care. The European Society of Intensive Care Medicine (ESICM) initiated a Delphi study to translate the empirical knowledge of experts in this field into consensus-based recommendations for clinical practice.

METHODS

A multi-national group of specialists in intensive care, emergency, and geriatric medicine provided opinions on managing very old patients with critical conditions. Strong or moderate consensus was defined as having at least 90% or 80% of experts, respectively, expressing agreement or disagreement on the three highest or lowest levels of a 9-points Likert scale.

RESULTS

Twenty-eight members of the expert steering group and 82 additional experts completed two Delphi rounds. After discussing the results, the steering group issued recommendations for 48 statements and 2 checklists for which consensus was achieved. In addition to determining fundamental principles, they include advice on goals of care and the decision-making about admission to and treatment of patients in intensive care and the management after discharge.

CONCLUSION

A multi-disciplinary group of experts achieved consensus on recommendations concerning intensive care for very old patients, which were approved and endorsed by ESICM. The implementation requires a careful analysis of available healthcare resources and should proceed in a stepwise fashion.

Frailty prevalence, invasive treatment frequency, and in-hospital outcome in patients hospitalized for acute coronary syndrome in Germany (2005-2022): a nationwide registry study

Background

Frailty is a significant predictor for adverse outcomes. Yet, data on prevalence and treatment of frail patients with acute coronary syndrome (ACS) remains limited. We aimed to investigate frailty prevalence, interventional treatment frequency, and in-hospital outcome for all patients hospitalized for ACS in Germany from 2005 to 2022 and validate the Hospital Frailty Risk Score (HFRS) in this population.

Methods

Data for 2005-2022 from the Statistical Federal Office included all cases with primary diagnosis of ACS treated in Germany. Patients were categorized into low, intermediate, and high frailty by HFRS. Diagnoses, procedures, and in-hospital outcomes were analyzed. Univariable and multivariable logistic regressions as well as sensitivity analyses were performed.

Findings

Between 2005 and 2022, 5,889,972 ACS patients were hospitalized in Germany. Mean age was 69 years (standard deviation (SD) ± 12.85 years) and 2,060,224 (34.98%) were female. In-hospital mortality was 6.2%. Among all, 5,001,812 (84.9%) had a low, 784,106 (13.3%) an intermediate, and 104,054 (1.8%) a high HFRS. High-frailty patients were less likely to undergo coronary intervention than low-frailty patients (47.0% vs. 70.6%, p < 0.001), had longer hospital stays (21.6 days SD 19.4 ± vs. 5.6 days SD ± 5.2, p < 0.001), and higher in-hospital mortality (adjusted odds ratio (OR) 3.34 [confidence interval (95% CI) 3.29-3.4]).

Interpretation

Nearly one-sixth of ACS-patients were frail according to HFRS. Frail patients had longer hospital stays, less often received interventional procedures, and showed substantially increased in-hospital mortality. In our aging population, frailty will play an increasing role in patient management. Frailty scores based on electronic patient records, like the HFRS, offer clinicians a tool for assessing in-hospital outcome in ACS patients, potentially enabling more individualized treatment approaches.

Funding

None.

One-year clinical events according to frailty in older patients with non-ST elevation acute coronary syndrome undergoing coronary angiography: an analysis of the IMPACT-TIMING-GO study

Objective

To evaluate the prevalence and one-year prognosis associated with frailty in a contemporary cohort of older patients with non-ST-elevation acute coronary syndrome (NSTEACS).

Methods

The IMPACT-TIMING-GO registry (IMPACT of Time of Intervention in patients with Myocardial Infarction with Non-ST seGment elevation. ManaGement and Outcomes) prospectively included 1020 patients with NSTEACS undergoing invasive coronary angiography between April and May 2021. For this sub-study, patients ≥ 65 years were selected. Frailty was assessed according to FRAIL scale. We studied all-cause mortality and the composite of all-cause mortality or all-cause hospitalizations at one-year follow-up after discharge.

Results

Five hundred and sixty seven patients (mean age: 75.8 ± 6.7 years, 28.2% women) were included: 316 (55.7%) were robust, 183 (32.3%) prefrail, and 68 (12.0%) frail. Frail patients were significantly older, more often women, and presented a worse baseline clinical profile. There were no differences among groups regarding pretreatment with a P2Y12 inhibitor. An urgent angiography (< 24 h) was less frequently performed in frail patients, with no differences regarding revascularization approach or in main in-hospital adverse events, although acute kidney disease occurred more frequently in frail patients. At 1-year follow-up, 20 patients died (3.6%). Chronic kidney disease was independently associated with 1-year all-cause death, although a trend towards higher mortality was observed in frail patients (HR = 3.01; 95% CI: 0.93-9.78; P = 0.065). Frailty was independently associated with higher 1-year all-cause mortality or all-cause rehospitalizations (HR = 2.23; 95% CI: 1.43-3.46; P < 0.001).

Conclusions

In older patients with NSTEACS, frailty independently associates higher all-cause mortality or all-cause hospital admissions at one-year follow-up.

Association between triglyceride-glucose index and all-cause mortality in critically ill patients with acute myocardial infarction: analysis of the MIMIC-IV database

Background

Currently, the clinical evidence regarding the prognostic significance of the TyG index in acute myocardial infarction (AMI) patients remains unclear. Our research analyzed the correlation between the TyG index and the risk of mortality in patients with AMI, in order to evaluate the influence of the TyG index on the prognosis of this population.

Methods

1205 ICU patients with AMI were analyzed in this retrospective cohort analysis, and the necessary data were obtained from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. The study conducted Kaplan-Meier analysis to compare all-cause mortality rates across four groups of patients. The study included logistic regression and Cox regression analysis to examine the correlation among the TyG index and the risk of in-hospital, 28-day, and 90-day mortality.

Results

In our study, 176 (14.61%) patients experienced in-hospital deaths, 198 (16.43%) patients died within 28 days of follow-up, and 189 (23.98%) patients died within 90 days of follow-up. Logistic regression and Cox proportional hazard analyses revealed that the TyG index was an independent predictor of in-hospital, 28-day, and 90-day mortality (OR: 1.406, 95% CI 1.141-1.731, p = 0.001; HR: 1.364, 95% CI 1.118-1.665, p = 0.002; HR: 1.221, 95% CI 1.024-1.445, p = 0.026, respectively). The restricted cubic spline regression model showed that the risk of in-hospital, 28-day, and 90-day mortality increased linearly with increasing TyG index.

Conclusions

The TyG index was significantly associated with an increased risk of mortality in AMI patients. Our findings suggested that the TyG index may be instrumental in identifying patients at high risk for adverse outcomes following AMI.

Impact of geriatric nutritional risk index on clinical outcomes in acute coronary syndrome patients: a comprehensive meta-analysis

BACKGROUND

The Geriatric Nutritional Risk Index (GNRI), derived from serum albumin levels and body weight relative to ideal body weight, is a novel tool for assessing nutritional status. This meta-analysis explored the association between GNRI and the clinical outcomes in patients with acute coronary syndrome (ACS).

METHODS

We systematically searched PubMed, Embase, and Web of Science for studies evaluating the GNRI in patients with ACS. Inclusion criteria were observational studies reporting all-cause mortality or major adverse cardiovascular events (MACEs) among ACS patients categorized by low versus normal GNRI. Data extraction and quality assessment were independently performed by two authors, utilizing a random-effects model to account for potential heterogeneity.

RESULTS

Eleven cohort studies, encompassing 18 616 patients with ACS, were included. A low GNRI was associated with significantly increased risks of all-cause mortality (RR, 1.95; 95% CI, 1.63-2.34; P < 0.001; I² = 32%) and MACEs (RR, 1.93; 95% CI, 1.62-2.29; P < 0.001; I² = 25%). Subgroup analyses for the all-cause mortality outcome showed consistent findings across varied study designs, patient demographics, and follow-up periods (P for subgroup differences all >0.05). Sensitivity analyses conducted by sequentially excluding individual studies confirmed the stability of these results.

CONCLUSION

A low GNRI at the time of admission is a significant predictor of increased all-cause mortality and MACEs in patients with ACS.

The nonlinear association between lipoprotein(a) and major adverse cardiovascular events in acute coronary syndrome patients with three-vessel disease

Lipoprotein(a) [Lp(a)] is a lipoprotein with potent atherogenic and thrombogenic potential. Its role in patients with acute coronary syndrome (ACS) combined with three-vessel disease (TVD) remains unclear. This study aimed to investigate the correlation between Lp(a) levels and the occurrence of major adverse cardiovascular events (MACE) in patients with ACS combined with TVD. Patients who underwent coronary angiography and were diagnosed with ACS combined with TVD were selected for the study. Patients were divided into three groups based on their Lp(a) levels. The correlation between Lp(a) and MACE was evaluated using univariate and multivariate Cox regression analysis, subgroup analysis, sensitivity analysis, Kaplan-Meier survival curve, receiver operating characteristic curve (ROC), and restricted cubic spline plot (RCS). A total of 1504 patients were included, with a median follow-up time of 38 months. Univariate Cox regression analysis showed that patients with higher Lp(a) levels had a significantly increased incidence of MACE (P < 0.001). After adjusting for confounding factors, multivariate Cox regression analysis indicated that high Lp(a) levels remained an independent predictor of MACE (P < 0.05). Subgroup analysis revealed that higher Lp(a) levels were significantly associated with a higher risk of MACE in subgroups including patients aged ≥ 60 years, males, those with hypertension, CKD, without diabetes, without hyperlipidemia, and without stroke (P < 0.05). Sensitivity analysis further confirmed the close correlation between Lp(a) and MACE (P < 0.05). Kaplan-Meier survival curve showed that the cumulative incidence of MACE in the high Lp(a) group was significantly higher than in the low-level group (P < 0.001). The ROC curve analysis indicated that Lp(a) had some predictive value for the occurrence of MACE (AUC: 0.623, 95% CI: 0.593-0.653, P < 0.001). The RCS plot demonstrated that after transforming Lp(a) to a normal distribution as Log10Lp(a), there was an approximately U-shaped nonlinear association between Log10Lp(a) and the risk of MACE (P nonlinear < 0.001). Lp(a) levels were significantly associated with the risk of MACE in patients with ACS combined with TVD.

Downregulation of serum miR-30c-5p serves as a biomarker to predict disease onset and short-term prognosis in acute coronary syndrome patients

BACKGROUND & OBJECTIVE

Timely intervention for Acute coronary syndrome (ACS) could effectively reduce the mortality rate of ACS patients. This study aimed to investigate the clinical significance of miR-30c-5p for ACS and to provide a convenient biomarker for diagnosing of ACS.

METHODS

Baseline information was collected from a total of 173 subjects (98 ACS subjects and 65 healthy subjects). The miR-30c-5p expression was evaluated by the Polymerase chain reaction (PCR). The predictive value of miR-30c-5p for ACS was assessed by Receiver Operating Characteristic (ROC) curve and multivariate logistic regression analysis. The relationship between miR-30c-5p expression and ACS severity was assessed by correlation analysis. Furthermore, the prognostic value of miR-30c-5p on Major Adverse Cardiovascular Events (MACE) occurrence was assessed by the Kaplan-Meier (K-M) curve to evaluate its prognostic significance.

RESULTS

Downregulation of miR-30c-5p was observed in ACS subjects and its diagnostic value on ACS was confirmed by the ROC curve. MiR-30c-5p could also discriminate acute myocardial infarction (AMI) from unstable angina pectoris (UAP) subjects in ACS. The expression of miR-30c-5p was negatively correlated with the cardiac troponin I (cTnI) levels and the Gensini score. A lower miR-30c-5p expression was observed in ACS subjects who developed MACE (P = 0.020), and the K-M curve further confirmed the close correlation between miR-30c-5p expression and MACE occurrence in ACS. MiR-30c-5p was also identified as an independent prognostic factor for MACE in ACS.

CONCLUSIONS

Serum miR-30c-5p expression was correlated with the severity of ACS, and downregulated miR-30c-5p expression showed a diagnostic and prognostic value in ACS.

Bridging Care Gaps for Older Women Undergoing Percutaneous Coronary Intervention

This paper reviews the distinct clinical, pathophysiological, and therapeutic challenges faced by older women undergoing percutaneous coronary intervention (PCI). Older women present with a greater comorbidity burden, smaller coronary vessels, and post-menopausal hormonal changes, which increase procedural complexity and adverse cardiovascular outcomes. Despite these challenges, older women are less likely to receive evidence-based therapies, resulting in higher risks of major adverse cardiovascular events (MACE) and bleeding. The paper further discusses the limitations of current risk stratification tools and outlines strategies for improving outcomes through tailored procedural techniques and patient-centered care approaches in this underrepresented population.

A novel radiomics-based technique for identifying vulnerable coronary plaques: a follow-up study

BACKGROUND

Previous reports have suggested that coronary computed tomography angiography (CCTA)-based radiomics analysis is a potentially helpful tool for assessing vulnerable plaques. We aimed to investigate whether coronary radiomic analysis of CCTA images could identify vulnerable plaques in patients with stable angina pectoris.

METHODS

This retrospective study included patients initially diagnosed with stable angina pectoris. Patients were randomly divided into either the training or test dataset at an 8 : 2 ratio. Radiomics features were extracted from CCTA images. Radiomics models for predicting vulnerable plaques were developed using the support vector machine (SVM) algorithm. The model performance was assessed using the area under the curve (AUC); the accuracy, sensitivity, and specificity were calculated to compare the diagnostic performance using the two cohorts.

RESULTS

A total of 158 patients were included in the analysis. The SVM radiomics model performed well in predicting vulnerable plaques, with AUC values of 0.977 and 0.875 for the training and test cohorts, respectively. With optimal cutoff values, the radiomics model showed accuracies of 0.91 and 0.882 in the training and test cohorts, respectively.

CONCLUSION

Although further larger population studies are necessary, this novel CCTA radiomics model may identify vulnerable plaques in patients with stable angina pectoris.

Disturbed shear stress promotes atherosclerosis through TRIM21-regulated MAPK6 degradation and consequent endothelial inflammation

RATIONALE

Coronary artery plaques often develop in regions subjected to disturbed shear stress (DSS), yet the mechanisms underlying this phenomenon remain poorly understood. Our study aimed to elucidate the unknown role of MAPK6 in shear stress and plaque formation.

METHODS

In vitro and in vivo experiments, RNA-seq, CO-IP and proteomic analysis, combined with single-cell RNA-seq datasets were used to reveal the upstream and downstream mechanisms involved. AAV-MAPK6, ApoE-/-MAPK6flox/floxTEKCre mice and the CXCL12 neutraligand were used to confirm the beneficial effects of MAPK6 against atherosclerosis.

RESULTS

Our study revealed a substantial decrease in MAPK6 protein levels in endothelial cells in response to DSS, both in vivo and in vitro, which was contingent on the binding of the ubiquitin ligase TRIM21 to MAPK6. Endothelium-specific MAPK6 overexpression exerts antiatherosclerotic effects in ApoE-/- mice, elucidating the unexplored role of MAPK6 in atherosclerosis. Comprehensive RNA-seq, integrated single-cell mapping and further experiments unveiled the involvement of MAPK6 in inflammation through the EGR1/CXCL12 axis. ApoE-/-MAPK6flox/floxTEKCre mice finally confirmed that conditional MAPK6 knockout resulted in endothelial inflammation and significant increases in plaque areas. Notably, these effects could be reversed through the neutralization of CXCL12.

CONCLUSIONS

Our study illuminates the advantages of MAPK6 in decelerating plaque progression, highlighting the potential of safeguarding MAPK6 as a novel therapeutic strategy against atherosclerosis.

KEY POINTS

Disturbed flow activates the ubiquitin‒proteasome degradation pathway of MAPK6 in endothelial cells, which is contingent on the binding of the ubiquitin ligase TRIM21 to MAPK6. Endothelial MAPK6 has an advantageous impact on decelerating plaque progression. MAPK6 regulates endothelial inflammation via the EGR1/CXCL12 axis.

In adults aged ≥75 y with NSTEMI, an invasive vs. conservative strategy did not improve a composite outcome at a median 4.1 y

CLINICAL IMPACT RATINGS

GIM/FP/GP: [Formula: see text] Cardiology: [Formula: see text] Geriatrics: [Formula: see text].

Latest evidence on assessment and invasive management of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in the older population

INTRODUCTION

Invasive management of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) should be considered regardless of age, but a key challenge is deciding which patients are most likely to benefit from an invasive approach in the older population. In addition to assessment of the clinical signs and symptoms, a holistic assessment of geriatric syndromes such as frailty, multimorbidity and cognitive impairment is of increasing importance. Recent trials have validated the roles of physiological assessment and intracoronary imaging to guide revascularisation.

AREAS COVERED

This review focuses on the comparison between invasive and conservative management in the older population with NSTE-ACS, the clinical characteristics of the older population with NSTE-ACS, and the role of physiological assessment and intracoronary imaging to guide revascularisation in this cohort.

EXPERT OPINION

Invasive management in the older population with NSTE-ACS may not improve mortality but reduces the risk of non-fatal myocardial infarction and repeat revascularisation. Decisions surrounding invasive versus conservative management should be individualized to each patient, depending on patient preference, clinical features, comorbidities and frailty. In patients where invasive management is indicated, a combination of physiological assessment and intracoronary imaging is likely to improve revascularisation outcomes, especially in the context of complex anatomical characteristics like multivessel disease.

Associations of cognitive decline with outcomes of cardiovascular rehabilitation in patients with cardiovascular disease

BACKGROUND

Patients with cardiovascular disease (CVD) are often contending with various comorbidities including cognitive decline. Cognitive decline is a risk marker for adverse outcomes in these patients. On the other hand, cardiovascular rehabilitation (CVR) improves clinical outcomes. However, it remains uncertain whether CVR is associated with favorable outcomes in patients with CVD and cognitive decline. Therefore, the present study aimed to investigate whether CVR is associated with favorable outcomes in patients with CVD and cognitive decline.

METHODS

We reviewed 4232 patients admitted for CVD. Cognitive function was assessed using the Mini-Cog at hospital discharge, and a score of <3 was defined as cognitive decline. We measured the 6-min walking distance (6MWD) at discharge and 5 months after CVR prescription for participants in outpatient CVR. The primary outcome was change in exercise tolerance (Δ6MWD), and the secondary outcome was composite events (all-cause death and/or re-admission due to CVD). We compared Δ6MWD between patients with and without cognitive decline and examined the association between outpatient CVR participation and composite events.

RESULTS

Of all patients, 768 had cognitive decline. There was no significant difference in Δ6MWD between the cognitive decline and non-cognitive decline groups, even after adjusting for confounders [estimated mean difference: 2.20 m; 95 % confidence interval (CI): -0.60-5.00 m]. Additionally, participation in outpatient CVR was associated with lower rate of composite events, regardless of cognitive decline [adjusted hazard ratio (aHR): 0.589; 95 % CI: 0.552-0.627 in the cognitive decline group and aHR: 0.767; 95 % CI: 0.742-0.793 in the non-cognitive decline group]. An interaction was observed based on the presence of cognitive decline (p = 0.011).

CONCLUSION

Regardless of cognitive decline, participation in outpatient CVR was associated with increased exercise tolerance. Furthermore, outpatient CVR was linked to reduced composite events in both, with particularly potent association in cognitively impaired patients.

Mechanisms of a mindfulness psyCho-behAvioRal intErvention (MCARE) on depression and anxiety symptoms in patients with acute coronary syndrome: A longitudinal mediation analysis

OBJECTIVE

This study aimed to explore the mediating roles of mindfulness and illness perception in the effects of a social media-based Mindfulness psyCho-behAvioRal intErvention (MCARE) on depressive and anxiety symptoms among patients with ACS.

METHODS

This study conducted a secondary longitudinal mediation analysis using data from a randomized controlled trial of the MCARE grogram in patients with ACS. Participants were recruited at two tertiary hospitals in Jinan, China. The MCARE program consisted of six weekly sessions addressing mindfulness training and disease management to facilitate understanding and management of emotions and illness. The analytical sample included participants who completed measures of the primary outcomes, i.e., depression (PHQ-9) and anxiety (GAD-7) and potential mediators, i.e., mindfulness (CAMS-R) and illness perception (Brief-IPQ) at baseline (T0), immediate post-intervention (T1), and 12-week after the commencement of the intervention (T2).

RESULTS

This study included 146 participants (mean age 58.9 years (SD = 8.9), 69.2 % male), including both intervention and control groups. The mediation analysis revealed a significant mediating effect of T1 mindfulness in the relationship between the group and T2 depression symptoms (indirect effect: -0.109, 95 % CI: -0.191, -0.041; P = 0.004), accounting for 26 % of the effect. For T2 anxiety symptoms, T1 illness perception exhibited a significant mediating effect (indirect effect: -0.055, 95 % CI: -0.110, -0.005; P = 0.035), accounting for 22 % of the effect.

CONCLUSIONS

This study found that mindfulness and illness perception played a mediating role in the effects of the MCARE program on depressive and anxiety symptoms among patients with ACS.

Trends and Disparities in CAD and AMI in the United States From 2000 to 2020

Background

Coronary artery disease (CAD) and acute myocardial infarction (AMI) still pose a significant burden to the health care system, affecting population subgroups differently.

Objectives

The purpose of the study was to describe age, sex, and racial disparities in mortality rates for CAD and AMI in the United States between 2000 and 2020.

Methods

This was an ecological study with trend analysis of mortality rates using data from the National Centers for Disease Control and Prevention surveillance databases.

Results

Between 2000 and 2020, there was a significant decrease in the age-standardized mortality rates of both CAD (from 249.4 to 118 per 100,000 cases [P < 0.001]) and AMI (from 93.4 to 34.1 per 100,000 cases [P < 0.001]), with deceleration in the decline of mortality rates after 2011. CAD and AMI mortality rates were both significantly higher in males (P < 0.001), the 75+ years age group (P < 0.001), and in non-Hispanic Blacks (NHBs) and non-Hispanic Whites (NHWs) compared to Hispanics (P < 0.001). While CAD mortality rates were higher in NHB compared to NHW (P = 0.037), there was no significant difference in AMI mortality rates between NHB and NHW (P = 0.144). There was also no difference in both CAD and AMI mortality rates between the 25 to 44 years and 45 to 64 years age groups (P = 0.051 and P = 0.072).

Conclusions

While a significant reduction in mortality rates is evident, the notable deceleration in this decline in recent years reflects a plateauing of earlier gains and highlights the need to identify new targets. The persistent disparities in the identified population subgroups necessitate further exploration to inform targeted interventions and policies.

Prospective Association of the Mediterranean Diet with the Onset of Cardiometabolic Multimorbidity in a UK-Based Cohort: The EPIC-Norfolk Study

BACKGROUND

Cardiometabolic multimorbidity (CMM), defined as the co-occurrence of 2 or more cardiometabolic diseases, including myocardial infarction (MI), stroke, and type 2 diabetes (T2D), is an increasing public health challenge. Although poor diet is a known risk factor for a first cardiometabolic disease (FCMD), the relationship with subsequent occurrence of CMM is less studied.

OBJECTIVES

This study aims to investigate the prospective association between baseline adherence to the Mediterranean diet and the onset of CMM across various follow-up durations.

METHODS

We used data from the European Prospective Investigation into Cancer-Norfolk cohort study of 21,900 adults, aged 40-79 free of prevalent MI, stroke, and T2D at baseline (1993-1997). A median-based Mediterranean diet score and a pyramid-based MDS (pyr-MDS) were used to measure baseline adherence to the Mediterranean diet. Multistate modeling was employed to investigate associations with the FCMD and the subsequent CMM event.

RESULTS

Over the entire follow-up period of 21.4 y (median), we observed 5028 FCMD and 734 CMM events. Multistate analysis indicated that the association between baseline Mediterranean diet and the risk of CMM may be stronger in shorter follow-up durations. Particularly, baseline pyr-MDS was significantly associated with the risk of subsequent CMM transitioning from FCMD when follow-up durations were limited to 10 and 15 y, with hazard ratio (95% confidence interval) being 0.67 (0.53, 0.84) and 0.80 (0.70, 0.92) per SD increase in pyr-MDS, respectively. Additionally, we observed that the risk of CMM transitioning from FCMD was modified by social class across shorter to longer follow-ups, where the impact of baseline Mediterranean diet was only significant in nonmanual workers.

CONCLUSIONS

Baseline adherence to the Mediterranean diet was potentially associated with a lower risk of CMM transitioning from FCMD, particularly during shorter follow-up periods.

Long-term Survival in Elderly Patients after Coronary Artery Bypass Grafting Compared to the Age-matched General Population: A Meta-analysis of Reconstructed Time-to-Event Data

BACKGROUND

 Coronary artery disease (CAD) limits life expectancy compared to the general population. Myocardial infarctions (MIs) are the primary cause of death. The incidence of MI increases progressively with age and most MI deaths occur in the population older than 70 years. Coronary artery bypass grafting (CABG) may prevent the occurrence of new MIs by bypassing most CAD lesions, providing downstream "collateralization" to the diseased vessel, and consequently prolonging survival. We systematically assessed the survival-improving potential of CABG by comparing elderly CABG patients to the age-matched general population.

METHODS

 Three databases were assessed. The primary and single outcome was long-term all-cause mortality. Time-to-event data of the individual studies were extracted and reconstructed in an overall survival curve. As a sensitivity analysis, summary hazard ratios (HRs) and 95% confidence intervals (CIs) for all individual studies were pooled and meta-analytically addressed. The control group was based on the age-matched general population of each individual study.

RESULTS

 From 1,352 records, 4 studies (4,045 patients) were included in the analysis. Elderly patients (>70 years) who underwent CABG had a significantly lower risk of death in the follow-up compared to the general age-matched population in the overall survival analysis (HR: 0.88; 95% CI: 0.83, 0.94; p < 0.001: mean follow-up was 7 years).

CONCLUSION

 Elderly patients who undergo CABG appear to have significantly better long-term survival compared to the age-matched general population. This advantage becomes visible after the first year and underscores the life-prolonging effect of bypass surgery, which may eliminate the expected reduction in life expectancy through CAD.

Cardiogenic shock

Cardiogenic shock is a complex syndrome defined by systemic hypoperfusion and inadequate cardiac output arising from a wide array of underlying causes. Although the understanding of cardiogenic shock epidemiology, specific subphenotypes, haemodynamics, and cardiogenic shock severity staging has evolved, few therapeutic interventions have shown survival benefit. Results from seminal randomised controlled trials support early revascularisation of the culprit vessel in infarct-related cardiogenic shock and provide evidence of improved survival with the use of temporary circulatory support in selected patients. However, numerous questions remain unanswered, including optimal pharmacotherapy regimens, the role of mechanical circulatory support devices, management of secondary organ dysfunction, and best supportive care. This Review summarises current definitions, pathophysiological principles, and management approaches in cardiogenic shock, and highlights key knowledge gaps to advance individualised shock therapy and the evidence-based ethical use of modern technology and resources in cardiogenic shock.

Fatal rhabdomyolysis and fulminant myocarditis with malignant arrhythmias after one dose of ipilimumab and nivolumab

Immune checkpoint inhibitors (ICIs) related myocarditis is a rare complication of modern immunotherapy. It can present as an asymptomatic subclinical condition or full-blown fulminant myocarditis with malignant arrythmias and cardiogenic shock. Myositis/rhabdomyolysis and/or myasthenic symptoms can be present concomitantly. We present a case of fatal fulminant myocarditis presenting with cardiac arrythmias and severe systolic dysfunction, with accompanying rhabdomyolysis after the first dose of ipilimumab and nivolumab immunotherapy. First working diagnosis of subacute late presenting acute myocardial infarction (ACS) was incorrect and the correct diagnosis was established only after additional testing and consultation. Treatment consisted of high-dose corticosteroids, intravenous immunoglobulins, sedation with mechanical ventilation, antibiotic coverage, hemodialysis, and sustained low-efficiency daily diafiltration (SLEDD) with CytoSorb or TheraNova membranes, and intra-aortic balloon pump mechanical cardiac support. No tangible improvement in the condition was observed during the whole treatment period and the patient died on the sixth day of intensive care treatment.

Different levels of lipids, Hb1Ac and cytokines among patients with coronary artery disease

Background

Different risk factors are responsible for the occurrence of coronary artery disease (CAD). Among these, the main factors are dyslipidemia, dysglycaemia, and endothelial inflammation. The aim of the study was to analyze the levels of lipids, glucose, and cytokine in patients with different coronary heart diseases.

Methods

A total of 2147 patients diagnosed with coronary atherosclerosis, stable angina, unstable angina, acute non-ST-segment elevation infarction (NSTEMI) and acute ST-segment-elevation myocardial infarction (STEMI) at the Cardiovascular Center of Beijing Tongren Hospital from February 2022 to April 2023. The data were gathered from the medical record system.Nonparametric Wilcoxon test was used for statistical analysis of continuous variables, and chi-square test was used for statistical analysis of categorical variables among multiple groups.

Results

Compared with coronary atherosclerosis group, acute myocardial infarction group showed a significant increase in IL-6 level (p < 0.001). Compared with stable angina group, acute myocardial infarction group showed a significant increase in IL-6 and decrease in INF-γlevels (p < 0.001). Compared with unstable angina group, acute myocardial infarction group showed a significant increase in IL-6 level and decrease in IL-17, as well as INF-γlevels (p < 0.001). Compared with NSTEMI group, the proportion of younger, males, glycemic-lowering drugs, as well as the levels of TC, LDL-C in STEMI group increased significantly, while the proportion of hypertension, IFG/IGT/DM, hyperlipidemia and Hb1Ac level decreased significantly. STEMI group showed a significant increase in IL-2 and IL-6 levels (p < 0.05).

Conclusions

The levels of lipids, Hb1Ac, IL-2 and IL-6 were varying in patients with different stages of coronary heart diseases.The data would contribute to a deeper understanding of the roles of lipids, glucose, and inflammation in the occurrence and development of CAD.

Complete Versus Culprit-Only Revascularization in Older Patients With ST-Segment-Elevation Myocardial Infarction: An Individual Patient Meta-Analysis

BACKGROUND

Complete revascularization is the standard treatment for patients with ST-segment-elevation myocardial infarction and multivessel disease. The FIRE trial (Functional Assessment in Elderly Myocardial Infarction Patients With Multivessel Disease) confirmed the benefit of complete revascularization in a population of older patients, but the follow-up is limited to 1 year. Therefore, the long-term benefit (>1 year) of this strategy in older patients is debated. To address this, an individual patient data meta-analysis was conducted in patients with ST-segment-elevation myocardial infarction ≥75 years of age enrolled in randomized clinical trials investigating complete versus culprit-only revascularization strategies.

METHODS

PubMed, Embase, and the Cochrane database were systematically searched to identify randomized clinical trials comparing complete versus culprit-only revascularization. Individual patient-level data were collected from the relevant trials. The primary end point was death, myocardial infarction, or ischemia-driven revascularization. The secondary end point was cardiovascular death or myocardial infarction.

RESULTS

Data from 7 randomized clinical trials encompassing 1733 patients (917 randomized to culprit-only and 816 to complete revascularization) were analyzed. The median age was 79 [interquartile range, 77-83] years. Of the patients, 595 (34%) were female. Follow-up ranged from a minimum of 6 months to a maximum of 6.2 years (median, 2.5 [interquartile range, 1-3.8] years). Complete revascularization reduced the primary end point up to 4 years (hazard ratio, 0.78 [95% CI, 0.63-0.96]) but not at the longest available follow-up (hazard ratio, 0.83 [95% CI, 0.69-1.01]). Complete revascularization significantly reduced the occurrence of cardiovascular death or myocardial infarction at the longest available follow-up (hazard ratio, 0.76 [95% CI, 0.58-0.99]). This was observed even when censoring the follow-up at each year. Long-term rate of death did not differ between complete and culprit-only revascularization arms.

CONCLUSIONS

In this individual patient data meta-analysis of older patients with ST-segment-elevation myocardial infarction and multivessel disease, complete revascularization reduced the primary end point of death, myocardial infarction, or ischemia-driven revascularization up to 4 years. At the longest follow-up, complete revascularization reduced the composite of cardiovascular death or myocardial infarction but not the primary end point.

REGISTRATION

URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: CRD42022367898.