Long-term mortality of patients undergoing cardiac catheterization for ST-elevation and non-ST-elevation myocardial infarction

Relationship between abdominal visceral adipose tissue and cardiovascular events in patients with acute coronary syndrome

Abdominal visceral adipose tissue (AVAT) is associated with the incidence of cardiovascular events (CVEs). We retrospectively evaluated the association between AVAT and the incidence of CVEs in 602 patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI). Patients were divided into four groups according to the quartiles of AVAT areas using computed tomography. The incidence of CVEs (cardiovascular death, ACS recurrence and stroke) during the follow-up period (median 49.5 months) was evaluated. Cox analysis adjusting for cardiovascular risk factors revealed that the AVAT quartile classification exhibited a significant association with the incidence of CVEs. The risk in quartile 3 (moderate AVAT areas, ≥ 106.0 to < 142.6 cm2) was significantly lower than in quartiles 1 (low AVAT areas, < 71.0cm2; P < 0.01; hazard ratio [HR], 5.06), 2 (mild AVAT areas, ≥ 71.0 to < 106.0 cm2; P < 0.01; HR, 4.25) and 4 (severe AVAT areas, ≥ 142.6 cm2; P < 0.01; HR, 4.52). Polynomial analyses revealed that quadratic model was the most appropriate to illustrate the relationship between AVAT area and the hazard ratios for CVEs (corrected Akaike's information criterion, 49.2; R2, 0.47). The AVAT area and the incidence of CVEs exhibited a U-shaped relationship in patients with ACS undergoing PCI independent of conventional cardiovascular risk factors. The risk of CVEs was the lowest in patients with moderate AVAT areas. Evaluating AVAT may provide additional information for the assessment of long-term prognosis in patients with ACS.

Efficacy and safety of oral anticoagulants in patients with atrial fibrillation and acute myocardial infarction: a systematic review and meta-analysis

BACKGROUND

The optimal antithrombotic therapy strategies for patients with atrial fibrillation (AF) and acute myocardial infarction (AMI) remain uncertain. We aimed to evaluate the efficacy and safety of oral anticoagulants (OAC) among patients with AF and AMI.

METHODS

PubMed, Embase, and Web of Science were searched from inception till 5 February 2025. The primary outcome was any stroke.

RESULTS

Eleven studies with 83 549 patients were included. OAC therapy was associated with lower risks of any stroke (odds ratio [OR]: 0.68; 95% confidence interval [CI]: 0.60-0.77; P < .001), ischemic stroke (OR: 0.64; 95% CI: 0.57-0.73; P < .001), and all-cause mortality (OR: 0.81; 95% CI: 0.74-0.89; P < .001). Additionally, OAC therapy was associated with a higher risk of any bleeding (OR: 1.24; 95% CI: 1.06-1.46; P = .009), but not for major bleeding (OR: 1.28; 95% CI: 0.87-1.90; P = .21).

CONCLUSIONS

OAC therapy is effective for patients with AF and AMI, but should be administered cautiously in those at high bleeding risk.

Screening for Dyslipidemia Among Patients Admitted With Acute Coronary Syndrome at the Jakaya Kikwete Cardiac Institute, Tanzania: A Retrospective Cohort Study

INTRODUCTION

 Dyslipidemia remains a significant risk factor for atherosclerosis and the development of acute coronary syndrome (ACS). Consistent data have demonstrated challenging lipid control according to the European Society of Cardiology (ESC) guideline-directed target low-density lipoprotein cholesterol (LDL-C) level. The exact prevalence of dyslipidemia in Tanzania remains unclear, although it is known to be quite high, and higher in urban than in rural areas. This study aimed to evaluate the current practice of lipid assessment in patients admitted with ACS and compliance with national and international guidelines.

METHODOLOGY

 This retrospective hospital-based cohort study aimed to determine the current practice of dyslipidemia screening in patients with ACS admitted to the Jakaya Kikwete Cardiac Institute (JKCI) and evaluate their adherence to national and international recommended guidelines, such as ESC and American Heart Association guidelines. All patients admitted to the JKCI from June 2023 to June 2024, aged 18 years or older, and presenting with ACS, were included in this study. Data were collected using a prestructured tool created with Google Forms (Google, Mountain View, CA). Data extraction was performed in MS Excel (Microsoft Corporation, Redmond, WA) and then transferred to R software (R Foundation for Statistical Computing, Vienna, Austria) for analysis. This information is summarized in tables, graphs, and frequencies.

RESULTS

 This study included 124 patients diagnosed with ACS admitted to the JKCI center. Of this cohort, 58 (47%) patients had their LDL-C levels checked within 48 hours of presentation. The follow-up of lipids after admission was documented in 10% of the patients. Only 9.5% achieved the guideline-recommended LDL-C goal. Most patients were initiated on and maintained on a high-intensity statin, with no data on the use of nonstatin therapy.

CONCLUSION

 The findings of this study have mirrored many irregularities in the current practice of dyslipidemia screening among patients with ACS admitted to JKCI. This study also highlighted the local nonadherence to national and international recommended guidelines, which, in turn, undermines secondary prevention of cardiovascular events. Further larger multicentered studies are recommended to assess the scope of the problem to reduce the burden and risk of future events.

Impact of Revascularization on Major Adverse Cardiovascular Events in Patients Without ST-Elevation Myocardial Infarction in the Arabian Gulf

Objectives: The study evaluated the impact of revascularization procedures, including percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG), during the index hospitalization on major adverse cardiovascular events (MACE) in patients with non-ST-elevation myocardial infarction (NSTEMI) in the Arabian Gulf. Methods: Data were analyzed from 1820 consecutive patients diagnosed with NSTEMI, admitted to 29 hospitals in four Arabian Gulf countries from January 2012 to January 2013, and who were discharged alive. Results: Of the patients, 29.1% (n = 529) underwent either PCI (89.8%; n = 475) or CABG (10.2%; n = 54). The matching method (288 PCI/CABG patients were matched with 762 controls that did not undergo PCI/CABG) revealed significant reductions in MACE events among patients who had undergone PCI/CABG (25% vs. 43%; p < 0.001). This decrease was consistent across individual MACE components, including stroke/transient ischemic attack (TIA) (2.4% vs. 7.0%; p = 0.005), all-cause mortality (4.5% vs. 7.0%; p < 0.001) and cardiac-related readmissions (20% vs. 31%; p = 0.001) but not reinfarction (1.7% vs. 1.4%; p = 0.73). Conclusions: The revascularization procedures, PCI/CABG, were associated with significant reductions in annual MACE event rates, specifically lower stroke/TIA, all-cause mortality and cardiac-related readmissions.

Why have temporal trends in STEMI and NSTEMI incidence and short-term mortality changed in recent years? A nationwide 35-year cohort study in Iceland

OBJECTIVES

Temporal trends in the incidence of ST-elevation myocardial infarction (STEMI) have been declining in many countries, while the incidence of non-ST elevation myocardial infarction (NSTEMI) has reached a plateau or even increased. The reasons for these changing trends have yet to be explained. We analysed these trends and short-term mortality from acute coronary syndromes in a nationwide cohort study over 35 years in Iceland.

DESIGN

Retrospective cohort study using a national MI registry.

SETTING

Iceland.

PARTICIPANTS

All cases of myocardial infarction in individuals aged 25-74 years in Iceland 1981-2015.

METHODS

Each case was classified as STEMI, NSTEMI or no ECG taken. ECG recordings were classified according to Minnesota criteria.

OUTCOME MEASURES

Trends of STEMI and NSTEMI incidence and 1-day and 28-day mortality were obtained from the National Death Registry.

RESULTS

A total of 10 348 cases were identified (mean age 61 years, 76.4% male). These were categorised as STEMI (32.7%), NSTEMI (45.8%) and no ECG taken (21.5%). We detected a significant 3.7% annual decline in the incidence of first MI. The age-adjusted incidence of STEMI showed an 83.2% decline, most pronounced after 1994, while for NSTEMI the decline was 66.5%, reaching a plateau from the year 1989 onwards. In Iceland, the uptake of highly sensitive biomarkers was initiated in 1997 (cardiac troponin T) and 2012 (high-sensitive troponin T), respectively.

CONCLUSIONS

The different temporal trends in the incidence of STEMI and NSTEMI cannot be explained only by the uptake of highly sensitive biomarkers in 1997 and 2012. The change in population-level risk factor exposure is likely to have influenced atherosclerotic plaque burden and thrombotic mechanisms. Finally, increasing uptake of cardioprotective pharmacological and interventional therapy may have resulted in a primary preventive effect on plaque rupture and thrombosis and thus on the rates of STEMI and NSTEMI disproportionally.

Systemic immune inflammatory response index (SIIRI) in acute myocardial infarction

BACKGROUND

Different treatment approaches exist for non-ST elevation acute coronary syndrome (ACS) patients. This study assessed the systemic immune inflammatory response index (SIIRI) for its prognostic value and incremental clinical utility in determining optimal timing for percutaneous coronary intervention (PCI) in non-ST elevation myocardial infarction (NSTEMI) patients, particularly when troponin levels are initially negative.

METHODS

This study included 1270 ACS patients: 437 STEMI, 422 NSTEMI, and 411 unstable angina. Patients were stratified by SIIRI levels measured at admission, and coronary artery disease severity was evaluated using the SYNTAX score. The primary endpoint was major adverse cardiovascular events (MACE), including cardiovascular death, non-fatal myocardial infarction, stroke, and revascularization. Secondary endpoints encompassed individual MACE components and heart failure hospitalisations.

RESULTS

The mean age was 54.93 years (83% male). SIIRI levels were significantly higher in STEMI patients (6.83 ± 6.43 × 10 5 ) compared to NSTEMI (4.5 ± 5.39 × 10 5 ) and unstable angina (3.48 ± 2.83 × 10 5 ) ( P  < 0.001). Area under the curve for SIIRI distinguished NSTEMI and unstable angina from STEMI (0.81 and 0.80), with optimal cut-off points of 4.80 × 10 5 and 4.25 × 10 5 . In NSTEMI, 24.6% presented within 2 h of symptom onset, were troponin-negative, yet had elevated SIIRI. Post-PCI, SIIRI > 4.93 × 10 5 correlated with increased MACE at 1 year (17.2% vs 5%).

CONCLUSION

NSTEMI and unstable angina patients with SIIRI values >4.80 × 10 5 and 4.25 × 10 5 respectively, may require urgent intervention (<2 h). SIIRI can be of significant utility in patients of NSTEMI who present earlier with negative troponins. SIIRI can also aid in identifying high-risk individuals post-PCI, providing a valuable tool for early and accurate assessment.

Time-Point Clinical Outcomes in Patients With Acute Myocardial Infarction: One Step for Personalized Medicine

Limited data exist regarding time-point risk stratification models after acute coronary syndrome. This study aimed to investigate time-point mortality rates in patients with acute myocardial infarction, focusing on comparison by type of myocardial infarction, in a real-world cohort. A total of 12,836 patients from a nationwide Korean registry were analyzed. Mortality rates at yearly, monthly, and weekly time points after admission were calculated by dividing the number of deaths during a specific period by the number of patients at risk in the same period for ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) groups. In the first week after admission, patients with STEMI had a significantly higher mortality rate than patients with NSTEMI (4.62% vs 1.79%, p <0.001). However, this trend was inverted since the second week. The higher mortality rate in patients with STEMI versus NSTEMI was inverted since the second week for male patients but only since the tenth week for female patients. Temporal assessment of correlates of mortality revealed that several baseline variables, including Killip class, systolic blood pressure, total cholesterol, and STEMI diagnosis, had significantly different effects on deaths over time. In conclusion, temporal assessment of time-point outcomes from the Korean registry revealed that an initially higher mortality rate in patients with STEMI versus NSTEMI was inverted in the second week. This outcome assessment could be a step toward developing an advanced risk prediction model for time-course personalized medicine. Further studies are needed to clarify this issue.

High-risk plaques in non-culprit lesions and clinical outcome after NSTEMI vs. STEMI

AIMS

Complete non-culprit (NC) revascularisation may help reduce recurrent events after non-ST-segment elevation myocardial infarction (NSTEMI), especially if NC lesions would harbour high-risk plaque (HRP) features similar to ST-segment elevation myocardial infarction (STEMI). This study aimed to assess differences in fractional flow reserve (FFR)-negative NC plaque morphology in patients presenting with NSTEMI vs. STEMI and assess the association of HRP morphology and clinical outcome.

METHODS AND RESULTS

In the prospective PECTUS-obs study, 438 patients presenting with myocardial infarction (MI) underwent optical coherence tomography (OCT) of all FFR-negative intermediate NC lesions. The primary endpoint was the occurrence of major adverse cardiovascular events (MACE, composite of all-cause mortality, non-fatal MI or unplanned revascularisation) at 2-year follow-up. Four hundred and twenty patients had at least one analysable OCT, including 203 (48.3%) with NSTEMI and 217 (51.7%) with STEMI. The prevalence of HRPs, including thin-cap fibroatheromas, plaque rupture, and thrombus, was comparable between groups. MACE occurred in 29 (14.3%) NSTEMI patients and 16 (7.4%) STEMI patients (Puni-variable = 0.025 and Pmulti-variable = 0.270). Incidence of MACE was numerically higher among patients with HRP, irrespective of the clinical presentation at index (Pinteraction = 0.684). Among HRP criteria, plaque rupture was associated with MACE in both NSTEMI (P < 0.001) and STEMI (P = 0.020).

CONCLUSION

Presence of NC HRP is comparable between NSTEMI and STEMI and leads to numerically higher event rates in both. These results call for additional research on complete revascularisation in NSTEMI and treatment of HRP.

CLINICAL TRIAL REGISTRATION

NCT03857971.

Impact of symptom-to-balloon time in patients with non-ST-segment elevation myocardial infarction and complex lesions

AIMS

Considering the limited data regarding clinical outcomes of patients with non-ST-segment on the ECG elevation myocardial infarction (NSTEMI), this study compared the outcomes of patients undergoing percutaneous coronary intervention with newer-generation drug-eluting stents stratified by the presence/absence of complex lesions and symptom-to-balloon time (SBT; <48 h or ≥48 h).

METHODS

We enrolled 4373 patients with NSTEMI from the Korea Acute Myocardial Infarction Registry-National Institute of Health dataset and stratified them into the complex group (2106 patients; SBT < 48 h, n  = 1365; SBT ≥48 h, n  = 741) and the noncomplex group (2267 patients; SBT < 48 h, n  = 1573; SBT ≥48 h, n  = 694). The primary outcome was the 3-year all-cause mortality rate. The secondary outcomes were any major adverse cardiac events (MACE), including cardiac death (CD), recurrent myocardial infarction, and stroke.

RESULTS

The incidence of all-cause mortality (adjusted hazard ratio, 0.656; P  = 0.009), CD ( P  = 0.037), and MACE ( P  = 0.047) in the complex group and of stroke in the noncomplex group ( P  = 0.020) were significantly lower in patients with SBT < 48 h than in those with SBT ≥48 h. Among patients with SBT < 48 h, the stroke incidence ( P  = 0.019) was higher in the complex group than in the noncomplex group, while among patients with SBT ≥48 h, the MACE incidence ( P  = 0.011) was higher in the former than in the latter.

CONCLUSION

SBT reduction effectively decreased the 3-year mortality in patients with NSTEMI in the complex group compared with the noncomplex group.

Comparison of Outcomes Between ST-Segment Elevation and Non-ST-Segment Elevation Myocardial Infarctions Based on Left Ventricular Ejection Fraction

Background: This study was conducted to address the lack of reports comparing the clinical outcomes of non-ST-segment elevation myocardial infarction (NSTEMI) and STEMI based on left ventricular ejection fraction (LVEF). Methods: A total of 9854 patients from the Korea Acute Myocardial Infarction Registry-National Institute of Health dataset were classified into three LVEF categories: heart failure (HF) with reduced ejection fraction (EF) (HFrEF, n = 1250), HF with mildly reduced EF (HFmrEF, n = 2383), and HF with preserved EF (HFpEF, n = 6221). Each group was further divided into NSTEMI and STEMI groups. The primary clinical outcome was the incidence of patient-oriented composite outcomes, defined as all-cause death, recurrent myocardial infarction, any repeat coronary revascularization, hospitalization for HF, and stroke. Results: Following adjustment, in-hospital mortality rates were comparable between the NSTEMI and STEMI groups in the HFrEF and HFmrEF groups. However, 3-year mortality rates were higher in the NSTEMI group. In contrast, in the HFpEF group, the STEMI group had higher rates of in-hospital all-cause death (p = 0.001) and cardiac death (p < 0.001) compared to the NSTEMI group, which was associated with increased 3-year all-cause death (p = 0.026) and cardiac death (p < 0.001) in the STEMI group. When in-hospital mortality was excluded, no difference in 3-year mortality rates was observed between the NSTEMI and STEMI groups in the HFpEF group. Conclusions: In-hospital mortality and 3-year outcomes varied across LVEF groups. Therefore, comparing NSTEMI and STEMI based on LVEF provides valuable insights into the differences in patient outcomes.

Prognostic Impact of Anemia and Hemoglobin Levels in Unselected Patients Undergoing Coronary Angiography

Background/Objectives: This study investigates the prevalence and prognostic impact of concomitant anemia in unselected patients undergoing invasive coronary angiography (CA). The spectrum of patients undergoing CA has significantly changed during the past decades, related to ongoing demographic changes and improved treatment strategies for patients with cardiovascular disease. Methods: Consecutive patients undergoing invasive CA from 2016 to 2022 were retrospectively included at one institution. Patients with anemia (i.e., hemoglobin < 13.0 g/dL for males and <12.0 g/dL for females) were compared with patients without anemia (i.e., nonanemics). The primary endpoint was rehospitalization for heart failure (HF) at 36 months. Secondary endpoints comprised the risk of rehospitalization for acute myocardial infarction (AMI) and coronary revascularization. Statistical analyses included Kaplan-Meier, multivariable Cox proportional regression analyses, and propensity score matching. Results: From 2016 to 2022, 7645 patients undergoing CA were included with a median hemoglobin level of 13.2 g/dL. Anemics had a higher prevalence of coronary artery disease (CAD) (76.3% vs. 74.8%; p = 0.001), alongside an increased need for percutaneous coronary intervention (PCI) (45.3% vs. 41.5%; p = 0.001). At 36 months, the risk of rehospitalization for HF was higher in anemic patients (27.4% vs. 18.4%; p = 0.001; HR = 1.583; 95% CI 1.432-1.750; p = 0.001), which was still evident after multivariable adjustment (HR = 1.164; 95% CI 1.039-1.304; p = 0.009) and propensity score matching (HR = 1.137; 95% CI 1.006-1.286; p = 0.040). However, neither the risk of AMI (8.4% vs. 7.4%, p = 0.091) nor the risk of coronary revascularization at 36 months (8.0% vs. 8.5%, p = 0.447) was higher in anemic compared with nonanemic patients. Conclusions: In consecutive patients undergoing CA, concomitant anemia was independently associated with an increased risk of rehospitalization for HF, but not AMI or coronary revascularization. Patients with LVEF ≥ 35% and multivessel disease were especially susceptible to anemia-induced HF-related rehospitalization.

Three-year outcomes following non-ST-segment elevation myocardial infarction and new-generation drug-eluting stent implantation, stratified by patient age (under and over 75 years) and left ventricular ejection fraction: A prospective cohort study

Due to limited published data, we investigated 3-year outcomes according to left ventricular ejection fraction (LVEF) in patients older and younger than 75 years with non-ST-segment elevation myocardial infarction (NSTEMI) who underwent successful newer-generation drug-eluting stent (DES) implantation. This research analyzed the data of 4558 patients (1032 older adults [≥75 years] and 3526 younger adults [<75 years]) from the Korea Acute MI Registry-NIH. We further divided the older group based on LVEF: heart failure (HF) with reduced EF (HFrEF, ≤40%, n = 196; group A), HF with mildly reduced EF (HFmrEF, 41-49%, n = 228; group B), and HF with preserved EF (HFpEF, ≥50%, n = 608; group C). Similarly, the younger group was divided into HFrEF (group D, n = 353), HFmrEF (group E, n = 577), and HFpEF (group F, n = 2596). The primary outcome was a composite of major adverse cardiac events (MACE) at 3 years, including all-cause death, recurrent MI, any repeat revascularization, or hospitalization for HF. MACE rates were highest in the HFrEF groups (A and D), followed by the HFmrEF groups (B and E), and lowest in the HFpEF groups (C and F) for both age groups. All-cause death, cardiac death (CD), all-cause death or MI, and hospitalization for HF rates were higher in group A than in groups B and C, and higher in group D than in groups E and F. Across all LVEF categories, MACE, all-cause death, CD, and non-CD, and all-cause death or MI rates were higher in the older group. This multicenter cohort study demonstrates that older patients have higher mortality rates compared to younger patients. Additionally, MACE rates were highest in the HFrEF group, followed by the HFmrEF group, and lowest in the HFpEF group across both age groups. Further research is needed to confirm these findings.

The impact of sex differences on 3-year outcomes of patients with non-ST-segment elevation myocardial infarction after successful stent implantation according to symptom-to-balloon time

BACKGROUND

Because no data are available, we compared the 3-year outcomes of patients with non-ST-elevation myocardial infarction (NSTEMI) based on sex and symptom-to-balloon time (SBT).

METHODS

This study included 4910 patients who were divided into two groups based on SBT: SBT <48 h (n = 3,293, 67.1%) and SBT ≥48 h (n = 1,617, 32.9%). The primary outcome was all-cause death during the 3-year follow-up period. The secondary outcome was major adverse cardiac events (MACE), defined as all-cause death, recurrent myocardial infarction, or repeat coronary revascularization.

RESULTS

After adjustment, the in-hospital mortality rates for males and females in the SBT <48 h and SBT ≥48 h groups were similar. During a 3-year follow-up period, females in the SBT <48 h group had significantly higher rates of all-cause death (adjusted hazard ratio [aHR], 1.482; P = 0.006), cardiac death (CD, aHR, 1.617; P = 0.009), and MACE (aHR, 1.268; P = 0.024) than those males in the same groups. Females and males in the SBT ≥48 h group did not differ significantly in the primary and secondary outcomes. In males, the rates of all-cause death (P = 0.008) and CD (P = 0.024) were significantly higher in the SBT ≥48 h group than in the SBT <48 h group.

CONCLUSIONS

This study has identified a higher 3-year mortality rate in female patients with NSTEMI and SBT <48 h compared to their male counterparts. As such, a more preventive approach may be required to reduce mortality in these female patients.

Renin-angiotensin system inhibitors and non-ST-elevation myocardial infarction outcomes based on left ventricular ejection fraction

BACKGROUND

We assessed left ventricular ejection fraction (LVEF) to compare the effects of renin-angiotensin system inhibitors (RASI) in patients with non-ST-segment elevation myocardial infarction (NSTEMI).

METHODS

We categorized 4558 patients with NSTEMI as either RASI users (3752 patients) or non-users (806 patients). The 3-year patient-oriented composite outcome (POCO), which included all-cause death, recurrent myocardial infarction, any repeat revascularization, or hospitalization for heart failure (HF), was the primary outcome. To compare clinical outcomes, a multivariable-adjusted hazard ratio (aHR) was calculated after performing multicollinearity tests on all significant confounding variables (P < 0.05).

RESULTS

Among RASI users, the aHRs for POCO, all-cause death, and cardiac death were significantly higher in the HF with reduced EF (HFrEF) subgroup than in the HF with mildly reduced EF (HFmrEF) (1.610, 2.120, and 2.489; P < 0.001, <0.001, and <0.001; respectively) and HF with preserved EF (HFpEF) (2.234, 3.920, and 5.215; P < 0.001, <0.001, and <0.001; respectively) subgroups. The aHRs for these variables were significantly higher in the HFmrEF subgroup than the HFpEF subgroup (1.416, 1.843, and 2.172, respectively). Among RASI non-users, the aHRs for these variables were significantly higher in the HFrEF subgroup than the HFmrEF (2.573, 3.172, and 3.762, respectively) and HFpEF (2.425, 3.805, and 4.178, respectively) subgroups. In three LVEF subgroups, RASI users exhibited lower aHRs for POCO and all-cause death than RASI non-users.

CONCLUSION

In the RASI users group, the aHRs for POCO and mortality were highest in the HFrEF subgroup, intermediate in the HFmrEF subgroup, and lowest in the HFpEF subgroup.

Clinical predictors and outcomes of ST-elevation myocardial infarction related cardiogenic shock in the Asian population

Background

Cardiogenic shock (CS) complicating myocardial infarction is associated with poor outcomes. Data among Asian populations are scarce. We aimed to investigate the long-term outcomes, prognostic factors, and predictors of CS among Asian ST elevation myocardial infarction (STEMI) patients.

Methods

This was a retrospective cohort study of consecutive patients undergoing primary percutaneous coronary intervention (PPCI) for STEMI within our regional STEMI network between 2015 and 2019. The long-term outcomes of those with and without CS were compared. Clinical predictors of outcomes and development of CS were investigated.

Results

A total of 1791 patients who underwent PPCI were included. Patients completed at least 2 years' follow-up with a median follow-up period of 2.6 years (IQR 1.0, 3,9). Overall, 208/1791 (11.6 %) STEMI patients developed CS. These patients were older (61.1 ± 12.5 vs 57.8 ± 12.2, P < 0.001) and mostly men (87.0 %). All-cause mortality (59.9 % vs 4.7 % P < 0.001), cardiac mortality (43.8 % vs 2.2 %, P < 0.001) and major adverse cardiovascular events (MACE) was significantly higher in the CS group (59.1 % vs 14.0 %, P < 0.001). Independent predictors of survival were higher index LVEF (adjusted hazards ratio [aHR] 0.967, 95 %CI 0.951-0.984, p < 0.001) and higher arterial pH at onset of shock (aHR 0.750, 0.626-0.897, p = 0.002). Increased serum lactate concentration independently predicts poor prognosis (aHR 1.084, 95 % CI 1.046-1.124, p < 0.001).

Conclusion

In Asian STEMI patients who underwent PPCI, CS was associated with poor outcomes. Higher LVEF on index admission was associated with better outcomes; while lactic acidosis independently predicted mortality.

Predictive Value of CHADS2, CHA2DS2-VASc and R2-CHADS2 Scores for Short- and Long-Term Major Adverse Cardiac Events in Non-ST-Segment Elevation Myocardial Infarction

BACKGROUND

Non-ST-elevation myocardial infarction (NSTEMI) carries a poor prognosis, and accurately prognostication has significant clinical importance. In this study, we analyzed the predictive value of the CHADS2, CHA2DS2-VASc, and R2-CHADS2scores for major adverse cardiac events (MACE) following percutaneous coronary intervention (PCI) in patients with NSTEMI using data from a prospective multicenter registry.

METHODS AND RESULTS

The registry included 440 consecutive patients with NSTEMI and coronary artery disease who underwent successful PCI. Patients were clinically followed for up to 3 years or until the occurrence of MACE. MACE was defined as a composite of all-cause death and nonfatal MI. During the follow-up period, 55 patients (12.5%) experienced MACE. Risk analysis of MACE occurrence, adjusted for the multivariable model, demonstrated a significant increase in risk with higher CHADS2, CHA2DS2-VASc, and R2-CHADS2scores. Kaplan-Meier analysis showed a higher incidence of MACE in patients with higher CHADS2, CHA2DS2-VASc, and R2-CHADS2scores, both in the short- and long-term periods.

CONCLUSIONS

Patients with NSTEMI and higher CHADS2, CHA2DS2-VASc, and R2-CHADS2scores displayed a greater incidence of MACE.

Safety and efficacy of PCSK9 inhibitor (evolocumab) in patients with non-ST segment elevation acute coronary syndrome and non-culprit artery critical lesions: a randomised controlled trial protocol (SPECIAL study)

INTRODUCTION

Patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) and concomitant multivessel coronary artery disease (CAD) are considered patients with extremely high-risk atherosclerotic cardiovascular disease (ASCVD), and current guidelines specify a lower low-density lipoprotein cholesterol (LDL-C) target for this population. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have been shown to effectively reduce LDL-C levels on a statin background. Additionally, several studies have confirmed the role of PCSK9 inhibitors in plaque regression and reducing residual cardiovascular risk in patients with ACS. However, those studies included coronary lesions with a degree of stenosis <50%. Whether the application of PCSK9 inhibitors in patients with NSTE-ACS with non-culprit artery critical lesions (stenosis degree between 50% and 75%) has a similar effect on plaque regression and improvement of cardiovascular outcomes remains unknown, with a lack of relevant research. This study aims to further investigate the safety and efficacy of evolocumab in patients with NSTE-ACS and concomitant multivessel CAD (non-culprit artery stenosis between 50% and 75%).

METHODS AND ANALYSIS

In this single-centre clinical randomised controlled trial, 122 patients with NSTE-ACS and concomitant multivessel CAD (non-culprit artery stenosis between 50% and 75%) will be randomly assigned to either the evolocumab treatment group or the standard treatment group after completing culprit vessel revascularisation. The evolocumab treatment group will receive evolocumab in addition to statin therapy, while the standard treatment group will receive standard statin therapy. At baseline and week 50, patients in the evolocumab treatment group will undergo coronary angiography and OCT imaging to visualise pre-existing non-lesional vessels. The primary end point is the absolute change in average minimum fibrous cap thickness (FCT) from baseline to week 50. Secondary end points include changes in plaque lipid arc, lipid length, macrophage grading, lipid levels and major adverse cardiovascular events during the 1-year follow-up period.

ETHICS AND DISSEMINATION

Ethics: this study will adhere to the principles outlined in the Helsinki Declaration and other applicable ethical guidelines. This study protocol has received approval from the Medical Research Ethics Committee of the First Affiliated Hospital of the University of Science and Technology of China (Anhui Provincial Hospital), with approval number 2022-ky214.

DISSEMINATION

we plan to disseminate the findings of this study through various channels. This includes publication in peer-reviewed academic journals, presentation at relevant academic conferences and communication to the public, policymakers and healthcare professionals. We will also share updates on the research progress through social media and other online platforms to facilitate the exchange and application of scientific knowledge. Efforts will be made to ensure widespread dissemination of the research results and to have a positive impact on society.

TRIAL REGISTRATION NUMBER

ChiCTR2200066675.

Patient Comments and Patient Experience Ratings Are Strongly Correlated With Emergency Department Wait Times

BACKGROUND AND OBJECTIVES

Hospitals and clinicians increasingly are reimbursed based on quality of care through financial incentives tied to value-based purchasing. Patient-centered care, measured through patient experience surveys, is a key component of many quality incentive programs. We hypothesize that operational aspects such as wait times are an important element of emergency department (ED) patient experience. The objectives of this paper are to determine (1) the association between ED wait times and patient experience and (2) whether patient comments show awareness of wait times.

METHODS

This is a cross-sectional observational study from January 1, 2019, to December 31, 2020, across 16 EDs within a regional health care system. Patient and operations data were obtained as secondary data through internal sources and merged with primary patient experience data from our data analytics team. Dependent variables are (1) the association between ED wait times in minutes and patient experience ratings and (2) the association between wait times in minutes and patient comments including the term wait (yes/no). Patients rated their "likelihood to recommend (LTR) an ED" on a 0 to 10 scale (categories: "Promoter" = 9-10, "Neutral" = 7-8, or "Detractor" = 0-6). Our aggregate experience rating, or Net Promoter Score (NPS), is calculated by the following formula for each distinct wait time (rounded to the nearest minute): NPS = 100* (# promoters - # detractors)/(# promoters + # neutrals + # detractors). Independent variables for patient age and gender and triage acuity, were included as potential confounders. We performed a mixed-effect multivariate ordinal logistic regression for the rating category as a function of 30 minutes waited. We also performed a logistic regression for the percentage of patients commenting on the wait as a function of 30 minutes waited. Standard errors are adjusted for clustering between the 16 ED sites.

RESULTS

A total of 50 833 unique participants completed an experience survey, representing a response rate of 8.1%. Of these respondents, 28.1% included comments, with 10.9% using the term "wait." The odds ratio for association of a 30-minute wait with LTR category is 0.83 [0.81, 0.84]. As wait times increase, the odds of commenting on the wait increase by 1.49 [1.46, 1.53]. We show policy-relevant bubble plot visualizations of these two relationships.

CONCLUSIONS

Patients were less likely to give a positive patient experience rating as wait times increased, and this was reflected in their comments. Improving on the factors contributing to ED wait times is essential to meeting health care systems' quality initiatives.

Value of ACEF-II Score in Predicting Major Adverse Cardiac Events in Patients With Non-ST-Segment Elevation Myocardial Infarction and Unstable Angina

Background

A score based on age, creatinine level, and ejection fraction as well as hematocrit value and the presence of emergency surgery (ACEF-II) has been proposed to have predictive value for risk stratification in cardiac surgery. This study aimed to evaluate its utility in patients with non-ST-segment elevation myocardial infarction and unstable angina (NSTEMI-ACS) to predict 1-year major adverse cardiac events (MACE).

Methods

In all, 768 patients with NSTEMI-ACS were enrolled in the study. After propensity score matching, the MACE and control groups comprised 168 patients each. Blood samples were drawn from patients during emergency department admission and hospitalization. The Global Registry of Acute Coronary Events, Acute Coronary Treatment and Intervention Outcome Network Intensive Care Unit risk, ACEF, and ACEF-II scores of each patient were evaluated.

Results

Mean (SD) age of the study population was 63.07 (12.39) years; 547 (71.2%) patients were male. After propensity score matching for 7 variables, a comparison of the matched groups revealed that patients with MACE had higher heart rates and rates of ST-segment deviation, cardiac arrest, and creatinine levels and lower left ventricular ejection fraction and albumin, hemoglobin, hematocrit, systolic blood pressure, and oxygen saturation values. Multivariate logistic regression analysis revealed that ACEF-II score had the highest odds ratio of the evaluated scores, at 1.41 (95% CI, 1.12-1.81; P = .005). The ACEF score did not reach statistical significance for the prediction of 1-year MACE according to multivariate analysis. In addition to type of risk score, left ventricular ejection fraction and heart rate had predictive value for 1-year MACE. An ACEF-II score cutoff of 1.82 predicted 1-year MACE, with a sensitivity of 61.2% and a specificity of 76.2%.

Conclusion

ACEF-II score, which is easy to calculate, could be used to predict 1-year MACE in patients with NSTEMI-ACS.

Development and validation of a machine learning-based readmission risk prediction model for non-ST elevation myocardial infarction patients after percutaneous coronary intervention

To investigate the factors that influence readmissions in patients with acute non-ST elevation myocardial infarction (NSTEMI) after percutaneous coronary intervention (PCI) by using multiple machine learning (ML) methods to establish a predictive model. In this study, 1576 NSTEMI patients who were hospitalized at the Affiliated Hospital of North Sichuan Medical College were selected as the research subjects. They were divided into two groups: the readmitted group and the non-readmitted group. The division was based on whether the patients experienced complications or another incident of myocardial infarction within one year after undergoing PCI. Common variables selected by univariate and multivariate logistic regression, LASSO regression, and random forest were used as independent influencing factors for NSTEMI patients' readmissions after PCI. Six different ML models were constructed using these common variables. The area under the ROC curve, accuracy, sensitivity, and specificity were used to evaluate the performance of the six ML models. Finally, the optimal model was selected, and a nomogram was created to visually represent its clinical effectiveness. Three different methods were used to select seven representative common variables. These variables were then utilized to construct six different ML models, which were subsequently compared. The findings indicated that the LR model exhibited the most optimal performance in terms of AUC, accuracy, sensitivity, and specificity. The outcome, admission mode (walking and non-walking), communication ability, CRP, TC, HDL, and LDL were identified as independent predicators of readmissions in NSTEMI patients after PCI. The prediction model constructed by the LR algorithm was the best. The established column graph model established proved to be effective in identifying high-risk groups with high accuracy and differentiation. It holds a specific predictive value for the occurrence of readmissions after direct PCI in NSTEMI patients.

Calcium signaling from sarcoplasmic reticulum and mitochondria contact sites in acute myocardial infarction

Acute myocardial infarction (AMI) is a serious condition that occurs when part of the heart is subjected to ischemia episodes, following partial or complete occlusion of the epicardial coronary arteries. The resulting damage to heart muscle cells have a significant impact on patient's health and quality of life. About that, recent research focused on the role of the sarcoplasmic reticulum (SR) and mitochondria in the physiopathology of AMI. Moreover, SR and mitochondria get in touch each other through multiple membrane contact sites giving rise to the subcellular region called mitochondria-associated membranes (MAMs). MAMs are essential for, but not limited to, bioenergetics and cell fate. Disruption of the architecture of these regions occurs during AMI although it is still unclear the cause-consequence connection and a complete overview of the pathological changes; for sure this concurs to further damage to heart muscle. The calcium ion (Ca2+) plays a pivotal role in the pathophysiology of AMI and its dynamic signaling between the SR and mitochondria holds significant importance. In this review, we tried to summarize and update the knowledge about the roles of these organelles in AMI from a Ca2+ signaling point of view. Accordingly, we also reported some possible cardioprotective targets which are directly or indirectly related at limiting the dysfunctions caused by the deregulation of the Ca2+ signaling.

Long-term outcomes of titanium-nitride-oxide coated stents and drug-eluting stents in acute coronary syndrome: A systematic review and meta-analysis

BACKGROUND

In severe cases of coronary artery disease, percutaneous coronary intervention provide promising results. The stent used could be a drug-eluting stent (DES) or a titanium-nitride-oxide coated stent (TiNOS).

AIM

To compare the 5-year effectiveness and safety of the two stent types.

METHODS

The following systematic review and meta-analysis was conducted in accordance with the preferred reporting items for systematic reviews and meta-analysis guidelines, and PubMed/MEDLINE, Scopus, and Cochrane Central were searched from inception till August 2023. Primary outcomes were major adverse cardiac events (MACE), cardiac death, myocardial infarction (MI), cardiac death or MI, and ischemia-driven total lesion revascularization (ID-TLR).

RESULTS

Four randomized controlled trials (RCT), which analyzed a sum total of 3045 patients with acute coronary syndrome (ACS) after a median follow-up time of 5 years were included. Though statistically insignificant, an increase in the ID-TLR was observed in patients receiving TiNOSs vs DESs. In addition, MI, cardiac death and MI, and definite stent thrombosis (DST) were significantly decreased in the TiNOS arm. Baseline analysis revealed no significant results with meta-regression presenting non-ST elevated MI (NSTEMI) as a statistically significant covariate in the outcome of MACE.

CONCLUSION

TiNOS was found to be superior to DES in terms of MI, cardiac death or MI, and DST outcomes, however, the effect of the two stent types on ID-TLR and MACE was not significant. A greater number of studies are required to establish an accurate comparison of patient outcomes in TiNOS and DES.

Evaluating Cardiovascular Risks: The Platelet Lymphocyte Ratio and the Neutrophil Lymphocyte Ratio As High-Risk Heart Score Predictors in Non-ST Elevation Myocardial Infarction (NSTEMI) and Unstable Angina Patients

Introduction Acute coronary syndromes (ACS), encompassing non-ST elevation myocardial infarction (NSTEMI) and unstable angina (UA), present significant challenges in risk assessment and management, particularly in resource-constrained environments like India. The burden of cardiovascular diseases in such regions necessitates cost-effective and readily accessible tools for risk stratification. Previous research has emphasized the role of inflammatory markers in coronary artery disease (CAD), prompting investigations into simple and affordable biomarkers for risk assessment. Platelet lymphocyte ratio (PLR) and neutrophil lymphocyte ratio (NLR) have emerged as potential biomarkers for thrombotic activity in cardiac illnesses, offering simplicity, accessibility, and cost-effectiveness in risk assessment making them particularly valuable in resource-poor settings like India, where advanced diagnostic tools may be limited. Objective This study aims to evaluate the effectiveness of PLR and NLR as predictors of high-risk HEART (history, ECG, age, risk factors, and troponin) scores in patients with NSTEMI and UA. Methods A prospective cross-sectional study was conducted at the Saveetha Medical College and Hospitals in Chennai, India, from March 2021 to September 2022. The study included 288 adults diagnosed with NSTEMI or UA, aged 18 years and above. The inclusion criteria comprised patients with confirmed diagnoses of NSTEMI or UA based on clinical symptoms, electrocardiographic findings, and cardiac biomarker elevation. The exclusion criteria encompassed patients with active infections, acute traumatic injuries, end-stage renal disease, malignant neoplasms, and ST-elevation myocardial infarction (STEMI). In addition to the HEART score, PLR, and NLR were computed to assess the prognosis of patients admitted to the Saveetha Medical College and Hospitals. Results The statistical analysis revealed significant correlations between PLR, NLR, and HEART score risk categories. The Pearson's correlation coefficient indicated strong associations between PLR/NLR values and HEART score risk groups, suggesting their potential as predictive markers for adverse clinical outcomes. Additionally, analysis of variance (ANOVA) demonstrated significant differences in PLR/NLR values across different HEART score risk categories, further highlighting their relevance in risk stratification. The effect sizes for these correlations were moderate to large, indicating clinically meaningful associations between PLR/NLR and cardiovascular risk. Conclusion In cases of NSTEMI and UA, PLR and NLR show potential as simple and inexpensive indicators of high-risk patients. By leveraging these inexpensive biomarkers, healthcare providers can enhance risk assessment and prognostication in patients presenting with ACS, facilitating timely interventions and tailored management strategies.

Prognostic implications of non-infarct-related territory unrecognized myocardial infarction in patients with non-ST-segment-elevation acute coronary syndrome

BACKGROUND

Prognostic value of non-infarct-related territory (non-IR) unrecognized myocardial infarction (UMI) in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) remains to be elucidated. We sought to evaluate the prognostic impact of non-IR UMI in patients with first NSTE-ACS presentation.

METHODS

This retrospective single-center analysis was conducted in patients with NSTE-ACS without prior history of coronary artery disease, who underwent uncomplicated urgent percutaneous coronary intervention (PCI) within 48 h of admission between August 2014 and January 2018. All patients underwent postprocedural cardiac magnetic resonance imaging (CMR) within 30 days after PCI. Non-IR UMI was defined as the presence of non-IR delayed gadolinium enhancement with an ischemic distribution pattern. We investigated the association of non-IR UMI, other CMR findings and baseline clinical characteristics with major adverse cardiac events (MACE), defined as death, non-fatal myocardial infarction, stroke, late revascularization, and hospitalization for congestive heart failure.

RESULTS

A total of 168 NSTE-ACS patients were included [124 men (73.8 %); 66 ± 11 years]. Non-IR UMI was detected in 28 patients (16.7 %). During a median follow-up of 32 (15-58) months, MACE occurred in 10 (35.7 %) patients with non-IR UMI, and 20 (14.3 %) patients without (p = 0.013). Cox's proportional hazards analysis showed that the presence of non-IR UMI was an independent predictor of MACE (hazard ratio [HR], 2.37, 95 % confidence interval [CI], 1.09-5.18, p = 0.030). In patients with NSTE-ACS undergoing urgent PCI, the prevalence of non-IR UMI was 16.7 %.

CONCLUSIONS

Non-IR UMI provided prognostic information independent of conventional risk factors and the extent of myocardial injury caused by NSTE-ACS.

The everolimus eluting Synergy MegatronTM drug-eluting stent platform: Early outcomes from the European Synergy MegatronTM Implanters' Registry

BACKGROUND

The Synergy MegatronTM is an everolimus-drug eluting stent that may offer advantages in the treatment of aorto-ostial disease and large proximal vessels.

AIMS

To report the short- to medium-term clinical outcomes from the European Synergy MegatronTM Implanters' Registry.

METHODS

This registry was an investigator-initiated study conducted at 14 European centers. The primary outcome was target lesion failure (TLF), defined as the composite of cardiovascular death, target vessel myocardial infarction (MI), and target lesion revascularisation.

RESULTS

Five hundred seventy-five patients underwent PCI with MegatronTM between 2019 and 2021. Patients were 69 ± 12 years old, 26% had diabetes mellitus, 24% had moderate-severe left ventricular impairment and 59% presented with an acute coronary syndrome. 15% were deemed prohibitively high risk for surgical revascularisation. The target vessel involved the left main stem in 55%, the ostium of the RCA in 13% and was a true bifurcation (Medina 1,1,1) in 50%.  At 1 year, TLF was observed in 40 patients, with 26 (65%) occurring within the first 30 days. The cumulative incidence of TLF was 4.5% at 30 days and 8.6% (95% CI 6.3-11.7) at 1 year. The incidence of stent thrombosis was 0.5% with no late stent thromboses. By multivariate analysis, the strongest independent predictors of TLF were severe left ventricular impairment (HR 3.43, 95% CI: 1.67-6.76, p < 0.001) and a target vessel involving the left main (HR 4.00 95% CI 1.81-10.15 p = 0.001).

CONCLUSIONS

Use of the Synergy MegatronTM everolimus eluting stent in a 'real-world' setting shows favorable outcomes at 30 days and 1 year.

Mortality in Patients with Acute Coronary Syndrome-A Prospective 5-Year Follow-Up Study

Our objective was to compare long-term outcomes in patients with non-ST-elevation myocardial infarction (NSTEMI) and ST-elevation myocardial infarction (STEMI) between two time periods in Southern Norway. There are limited contemporary data comparing long-term follow-up after revascularization in the last decades. This prospective follow-up study consecutively included both NSTEMI and STEMI patients during two time periods, 2014-2015 and 2004-2009. Patients were followed up for a period of 5 years. The primary outcome was all-cause mortality after 1 and 5 years. A total of 539 patients with acute myocardial infarction (AMI), 316 with NSTEMI (234 included in 2014 and 82 included in 2007) and 223 with STEMI (160 included in 2014 and 63 included in 2004). Mortality after NSTEMI was high and remained unchanged during the two time periods (mortality rate at 1 year: 3.5% versus 4.9%, p = 0.50; and 5 years: 11.4% versus 14.6%, p = 0.40). Among STEMI patients, all-cause mortality at 1 year was reduced in 2014 compared to 2004 (1.3% versus 11.1%, p < 0.001; and 5 years: 7.0% versus 22.2%, p = 0.004, respectively). Time to coronary angiography in NSTEMI patients remained unchanged between 2014 and 2007 (28.2 h [IQR 18.1-46.3] versus 30.3 h [IQR 18.0-48.3], p = 0.20), while time to coronary angiography in STEMI patients was improved in 2014 compared with 2004 (2.8 h [IQR 2.0-4.8] versus 21.7 h [IQR 5.4-27.1], p < 0.001), respectively. During one decade of AMI treatment, mortality in patients with NSTEMI remained unchanged while mortality in STEMI patients decreased, both at 1 and 5 years.

Spontaneous coronary artery dissection and ST-segment elevation myocardial infarction: Does clinical presentation matter?

BACKGROUND

Some patients with spontaneous coronary artery dissection (SCAD) present as ST-segment-elevation myocardial infarction (STEMI). This study evaluates the characteristics, management and outcomes of SCAD patients presenting as STEMI compared to non-ST-segment elevation myocardial infarction (NSTEMI).

METHODS

We analysed data from consecutive patients included in the prospective Spanish Registry on SCAD. All coronary angiograms were centrally reviewed. All adverse events were adjudicated by an independent Clinical Events Committee.

RESULTS

Between June 2015 to December 2020, 389 patients were included. Forty-two percent presented with STEMI and 56% with NSTEMI. STEMI patients showed a worse distal flow (TIMI flow 0-1 38% vs 19%, p < 0.001) and more severe (% diameter stenosis 85 ± 18 vs 75 ± 21, p < 0.001) and longer (42 ± 23 mm vs 35 ± 24 mm, p = 0.006) lesions. Patients with STEMI were more frequently treated with percutaneous coronary intervention (PCI) (31% vs 16%, p < 0.001) and developed more frequently left ventricular systolic dysfunction (21% vs 8%, p < 0.001). No differences were found in combined major adverse events during admission (7% vs 5%, p = 0.463), but in-hospital reinfarctions (5% vs 1.4%, p = 0.039) and cardiogenic shock (2.6% vs 0%, p = 0.019) were more frequently seen in the STEMI group. At late follow-up (median 29 months) no differences were found in the incidence of major adverse cardiac and cerebrovascular events (13% vs 13%, p-value = 0.882) between groups.

CONCLUSIONS

Patients with SCAD and STEMI had a worse angiographic profile and were more frequently referred to PCI compared to NSTEMI patients. Despite these disparities, both short and long-term prognosis were similar in STEMI and NSTEMI SCAD patients.

Comparative Effectiveness of Ticagrelor, Prasugrel, and Clopidogrel for Secondary Prophylaxis in Acute Coronary Syndrome: A Propensity Score-Matched Cohort Study

Comparative effectiveness evaluation of newer P2Y12 inhibitors (prasugrel and ticagrelor) compared with clopidogrel after acute coronary syndrome (ACS) is limited in real-world US populations. The objective of this study was to evaluate cardiovascular events based on ticagrelor, prasugrel, and clopidogrel use in a real-world patient setting. This retrospective cohort study used the IBM MarketScan database (January 1, 2013, to December 31, 2018) to create three propensity score-matched pairs: ticagrelor vs. clopidogrel (N = 21,719), prasugrel vs. clopidogrel (N = 11,513), and prasugrel vs. ticagrelor (N = 11,065). The primary outcome was a composite of myocardial ischemia, unstable angina, stroke, and heart failure hospitalization. These groups were compared in a time-to-event analysis for the primary outcome at 30, 90, and 180 days following P2Y12 inhibitors initiation after percutaneous coronary intervention. Compared with clopidogrel, ticagrelor use suggested a 10% reduction in the primary outcome at 90 days (hazard ratio (HR): 0.90, 95% confidence interval (CI): 0.82-0.99). There were no differences for all other matched pairs or follow-up combinations. In the subgroup analysis of females, the results suggested a risk reduction of 27% for prasugrel at 30 days (HR: 0.73, 95% CI: 0.53-1.00) and 17% for ticagrelor at 90 days (HR: 0.83, 95% CI: 0.70-0.98) when compared with clopidogrel. Among patients treated with bare-metal stents, the results suggested that prasugrel vs. ticagrelor was associated with a 55% and 33% reduced risk for the primary outcome at 30 days and 180 days, respectively. With limited evidence in the United States comparing these drugs, this study helps inform clinicians when choosing P2Y12 inhibitors after ACS.

Impact of pre-existing vascular disease on clinical outcomes

AIMS

Little is known about the outcomes and processes of care of patients with non-ST-segment myocardial infarction (NSTEMI) who present with 'polyvascular' disease.

METHODS AND RESULTS

We analysed 287 279 NSTEMI patients using the Myocardial Ischaemia National Audit Project registry. Clinical characteristics and outcomes were analysed according to history of affected vascular bed-coronary artery disease (CAD), cerebrovascular disease (CeVD), and peripheral vascular disease (PVD)-with comparison to a historically disease-free control group, comprising 167 947 patients (59%). After adjusting for demographics and management, polyvascular disease was associated with increased likelihood of major adverse cardiovascular events (MACEs) [CAD odds ratio (OR): 1.06; 95% confidence interval (CI): 1.01-1.12; P = 0.02] (CeVD OR: 1.19; 95% CI: 1.12-1.27; P < 0.001) (PVD OR: 1.22; 95% CI: 1.13-1.33; P < 0.001) and in-hospital mortality (CeVD OR: 1.24; 95% CI: 1.16-1.32; P < 0.001) (PVD OR: 1.33; 95% CI: 1.21-1.46; P < 0.001). Patients without vascular disease were less frequently discharged on statins (PVD 88%, CeVD 86%, CAD 90%, and control 78%), and those with moderate [ejection fraction (EF) 30-49%] or severe left ventricular systolic dysfunction (EF < 30%) were less frequently discharged on angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) (CAD 82%, CeVD 77%, PVD 77%, and control 74%). Patients with polyvascular disease were less likely to be discharged on dual antiplatelet therapy (DAPT) (PVD 78%, CeVD 77%, CAD 80%, and control 87%).

CONCLUSION

Polyvascular disease patients had a higher incidence of in-hospital mortality and MACEs. Patients with no history of vascular disease were less likely to receive statins or ACE inhibitors/ARBs, but more likely to receive DAPT.

Differences in Revascularization Strategy and Outcomes by Clinical Presentations in Spontaneous Coronary Artery Dissection

BACKGROUND

Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction (MI). However, the role of revascularization for SCAD according to presentation remains unclear.

METHODS

We analyzed patients with SCAD who presented acutely and were participating in the Canadian SCAD Cohort Study. We compared revascularization strategy and clinical outcomes (in-hospital major adverse events and major adverse cardiovascular event [MACE] including recurrent MI at 1-year) in patients with SCAD presenting with ST-elevation MI (STEMI) vs unstable angina or non-STEMI (UA-NSTEMI).

RESULTS

Among 750 patients with SCAD (mean 51.7 ± 10.5years; 88.5% were women; median follow-up was 373 days), 234 (31.2%) presented with STEMI. More patients with SCAD-STEMI (27.8%) were treated with revascularization (98.5% percutaneous coronary intervention [PCI]) compared with 8.7% of patients with UA-NSTEMI (93.3% PCI). For patients with SCAD and STEMI, 93.9% were planned procedures vs 71.1% for UA-NSTEMI. Successful or partially successful PCI was 65.5% for STEMI and 76.9% for UA-NSTEMI (P < 0.001). In revascularized patients, 1-year MACE was not different between STEMI and UA-NSTEMI. Revascularization was associated with higher in-hospital major adverse events and its association was more prominent in UA-NSTEMI (STEMI: 26.2% vs 10.7%, P < 0.001; UA-NSTEMI: 37.8% vs 3.6%, P < 0.001). The difference in adverse events according to revascularization diminished over time and was not evident at 1 year.

CONCLUSIONS

Despite higher in-hospital events with revascularization in patients with SCAD, and higher revascularization with SCAD-STEMI, 1-year MACE was not different compared with UA-NSTEMI. This is reassuring, as revascularization may be required for ongoing ischemia at the time of initial presentation in STEMI-SCAD, and emphasizes the need for careful patient selection for revascularization in UA-NSTEMI.

The impact of ST-segment elevation on the prognosis of patients with Takotsubo cardiomyopathy

INTRODUCTION

Takotsubo cardiomyopathy (TC) has a variety of electrocardiographic expressions such as ST-segment elevation (STE), T-wave inversion, QTc-prolongation, left bundle branch block, presence of anterior Q waves and rarely ST-segment depression. In contrast to acute myocardial infarction, the impact of STE on the initial electrocardiogram (EKG), on TC outcomes, remains largely unknown.

OBJECTIVE

To evaluate the significance of STE on the index EKG of patients with takotsubo cardiomyopathy (TC) in terms of prognosis.

METHODS

We examined retrospectively the data of 436 patients diagnosed with TC who were admitted to the Minneapolis Heart Institute between August 2001 and November 2019.

RESULTS

Of 436 patients, 145 (33%) presented with STE on the index EKG. Typical apical ballooning pattern was encountered more frequently in the STE group (66% vs 51%; p = 0.005), on the contrary to the mid-ventricular ballooning which was more common in the non-STE group (31% vs 45%; p = 0.005) while initial left ventricular ejection fraction was similar between the two groups (31% ± 9 vs 33% ± 11; p = 0.163). The composite endpoint of TC-related complications, defined as left ventricular outflow tract obstruction (LVOTO), left ventricular (LV) thrombus, hemodynamic instability requiring mechanical or intravenous vasopressor support, cardiac arrest or in-hospital death, was higher for the STE group (37% vs 24%; p = 0.006). Left ventricular outflow obstruction (LVOTO) was more frequent in patients with STE (13% vs 3%; p < 0.001) while there was a trend toward higher rates of LV thrombus formation in the same group (5% vs 1%; p = 0.057). On multivariable analysis, STE remained an independent predictor of TC-related complications. In-hospital mortality (2.8% vs 3.4%; p = 1.000) and five-year mortality were similar between the two groups (23% vs 20%; p = 0.612).

CONCLUSION

Patients with TC presenting with STE on the initial EKG, were more likely to develop disease related complications, thus, careful in-hospital monitoring including imaging evaluation for LVOTO and LV thrombus may be warranted for these patients. Nevertheless, both groups had similar in-hospital and five-year mortality.

Differences in incident and recurrent myocardial infarction among White and Black individuals aged 35 to 84: Findings from the ARIC community surveillance study

BACKGROUND

No previous study has examined racial differences in recurrent acute myocardial infarction (AMI) in a community population. We aimed to examine racial differences in recurrent AMI risk, along with first AMI risk in a community population.

METHODS

The community surveillance of the Atherosclerosis Risk in Communities Study (2005-2014) included 470,000 people 35 to 84 years old in 4 U.S. communities. Hospitalizations for recurrent and first AMI were identified from ICD-9-CM discharge codes. Poisson regression models were used to compare recurrent and first AMI risk ratios between Black and White residents.

RESULTS

Recurrent and first AMI risk per 1,000 persons were 8.8 (95% CI, 8.3-9.2) and 20.7 (95% CI, 20.0-21.4) in Black men, 6.8 (95% CI, 6.5-7.0) and 14.1 (95% CI, 13.8-14.5) in White men, 5.3 (95% CI, 5.0-5.7) and 16.2 (95% CI, 15.6-16.8) in Black women, and 3.1 (95% CI, 3.0-3.3) and 8.8 (95% CI, 8.6-9.0) in White women, respectively. The age-adjusted risk ratios (RR) of recurrent AMI were higher in Black men vs White men (RR, 1.58 95% CI, 1.30-1.92) and Black women vs White women (RR, 2.09 95% CI, 1.64-2.66). The corresponding RRs were slightly lower for first AMI: Black men vs White men, RR, 1.49 (95% CI, 1.30-1.71) and Black women vs White women, RR, 1.65 (95% CI, 1.42-1.92) CONCLUSIONS: Large disparities exist by race for recurrent AMI risk in the community. The magnitude of disparities is stronger for recurrent events than for first events, and particularly among women.

Racial and Ethnic Disparities in Acute Coronary Syndrome: A Nationally Representative Sample

Background

Disparities in acute coronary syndrome (ACS) outcomes exist between racial and ethnic groups. We aimed to evaluate disparities in resource utilization and inpatient outcomes across multiple ethnic and racial groups using contemporary data.

Methods

We identified hospital discharges for ACS in the United States using the National Inpatient Sample from 2015 to 2018. The International Classification of Diseases, Tenth Revision, Clinical Modification codes were used to identify variables of interest. The primary outcomes were in-hospital complications, length of stay, and total hospital charge. Statistical analysis was performed using STATA version 17.

Results

Our analysis included 1,911,869 ACS discharges. Our sample was made up of 78.6% White, 12.1% Black, and 9.3% Hispanic patients. Hispanic and Black patients presenting with ACS were younger and had more cardiometabolic comorbidities than their White counterparts, especially hypertension, diabetes mellitus, and obesity. Despite social determinants of health being more likely to be unfavorable for Hispanics than their White counterparts, they were more likely to incur higher total hospital charges than their White counterparts. Black patients were the least likely to undergo revascularization procedures. Despite these differences, White patients had higher in-hospital mortality rates than Black and Hispanic patients.

Conclusions

In this nationally representative study, despite having higher cardiometabolic comorbidity burden, lower socioeconomic status, and percutaneous intervention, Black and Hispanic patients experienced lower mortality rates than their White counterparts. Hispanic patients incurred the highest amount of total hospital charges for an ACS admission.

Relationship Between Body Mass Index and Outcomes in Acute Myocardial Infarction

Background

The prevalence of obesity in the United States is high. Obesity is one of the leading risk factors in the development of acute myocardial infarction (AMI). Nevertheless, how obesity impacts AMI in-hospital outcomes remains controversial.

Methods

Using National Inpatient Sample (NIS) database, we identified patients diagnosed with AMI from the year 2015 to 2018. We divided these patients into five subgroups based on their body mass index (BMI). We compared outcomes such as mortality, length of inpatient stay, and inpatient complications between our subgroups. Statistical analysis was done using the program STATA. Our nationally representative analysis included 561,535 patients who had an AMI event across various weight classes.

Results

Most of our sample was obese (BMI > 30 kg/m2) and male. Obese patients were significantly younger than the rest. Length of stay (LOS) for AMI was highest for those with a BMI of less than 24 kg/m2. In-hospital mortality is highest for those with a BMI of < 30 kg/m2 and lowest for those with a BMI of 30 - 40 kg/m2. Inpatient complications are highest in the lower BMI population (BMI < 24 kg/m2).

Conclusion

The current analysis of a nationally representative sample showed the clinical implications of BMI in patients with AMI. Patients with a BMI of 30 - 40 kg/m2 had more favorable LOS, inpatient complications, and in-hospital mortality when compared to those with an ideal body weight. Hence, this supports and expands on the concept of the "obesity paradox". Further studies are needed to further investigate the possible mechanism behind this.

Timing of angiography and outcomes in patients with non-ST-segment elevation myocardial infarction: Insights from the evaluation and management of patients with acute chest pain in China registry

Objective

Although an invasive strategy has been recommended within 24 h for patients with non-ST-segment elevation myocardial infarction (NSTEMI), the optimal timing of the invasive strategy remains controversial. We sought to investigate the association between the different timings of invasive strategies and clinical outcomes in patients with NSTEMI.

Materials and methods

Patients admitted with NSTEMI from the Evaluation and Management of Patients with Acute ChesT pain in China (EMPACT) registry between January 2016 and September 2017 were included. The primary outcomes were major adverse cardiac events (MACEs) within 30 days. Multivariable logistic regression was performed to assess independent risk factors for MACEs.

Results

A total of 969 patients with NSTEMI from the EMPACT Registry were eligible for this study. Coronary angiography (CAG) was performed in 501 patients [<24 h, n = 150 (15.5%); ≥ 24 h, n = 351 (36.2%)]. The rate of MACEs at 30 days in all patients was 9.2%, including 54 (5.6%) deaths. Patients who underwent CAG had a lower rate of MACEs and mortality than those who did not receive CAG (MACEs: 5.6% vs. 13.0%, P < 0.001; mortality: 1.6% vs. 9.8%, P < 0.001). Nonetheless, no statistically significant difference was found in the rates of MACEs and mortality between the early (< 24 h) and delayed (≥ 24 h) CAG groups. Older age (OR: 1.036, 95% CI: 1.007, 1.065, P = 0.014), and acute heart failure (OR: 2.431, 95% CI: 1.244, 4.749, P = 0.009) increased the risk of MACEs and protective factors were underwent CAG (OR: 0.427, 95% CI: 0.219, 0.832, P = 0.012) or PCI (OR: 0.376, 95% CI: 0.163, 0.868, P = 0.022). In the multilevel logistic regression, older age (OR: 0.944, 95% CI: 0.932, 0.957, P < 0.001), cardiogenic shock (OR: 0.233, 95% CI: 0.079, 0.629, P = 0.009), pulmonary moist rales (OR: 0.368, 95% CI: 0.197, 0.686, P = 0.002), and prior chronic kidney disease (OR: 0.070, 95% CI: 0.018, 0.273, P < 0.001) was negatively associated with CAG.

Conclusion

This real-world cohort study of NSTEMI patients confirmed that the early invasive strategy did not reduce the incidence of MACEs and mortality within 30 days compared with the delayed invasive strategy in NSTEMI patients.

Risk of death associated with incident heart failure in patients with known or suspected chronic coronary syndrome

AIMS

Traditional adverse events in chronic coronary syndrome (CCS) include atherothrombotic events but usually exclude heart failure (HF). Data are scarce about how new-onset HF modifies mortality risk. We aimed to determine the incidence of HF and compare its long-term mortality risk with myocardial infarction (MI) and stroke in patients with known or suspected CCS.

METHODS

We prospectively evaluated 5811 consecutive HF-free patients submitted to vasodilator stress cardiac magnetic resonance (CMR) for known or suspected CCS. Ischaemic burden and left ventricular ejection fraction were assessed by CMR. HF included outpatient diagnosis or acute HF hospitalization. The mortality risk for the incident events and their cross-comparisons were evaluated using a Markov illness-death model with transition-specific survival models.

RESULTS

The mean age was 55 ± 11 years, and 38.9% were female. At a median follow-up of 5.44 (IQR = 2.53-8.55) years, 591 deaths were registered (1.79 per 100 P-Y). The rates of new-onset HF were higher compared with MI and stroke [1.02, 0.62, and 0.51, respectively (P < 0.05)]. The adjusted association between new-onset HF, MI, and stroke, and subsequent mortality was time dependent. The risk increased almost linearly for HF and became significant by the third year. By Year 10, the mortality risk attributable to new-onset HF was more than 2.5-fold (HR: 2.68, 95% CI = 1.74-4.12). For MI, there was a significant increase in mortality risk up to the second year, followed by a monotonic decrease. For stroke, the mortality risk increased for the entire follow-up but became significant by the third year. A cross-comparison among incident endpoints HF outnumbers risk for those with MI by the sixth year (HR_year6.3 : 1.88, 95% CI = 1.03-3.43). There was no difference in mortality risk between incident HF and stroke.

CONCLUSIONS

In patients with CCS, long-term rates of incident HF were higher than MI and stroke. Patients with new-onset HF showed a higher risk of long-term mortality.

Comparison of Clinical Outcomes after Non-ST-Segment and ST-Segment Elevation Myocardial Infarction in Diabetic and Nondiabetic Populations

Using a new-generation drug-eluting stent, we compared the 2-year clinical outcomes of patients with diabetes mellitus (DM) and non-DM concomitant with a non-ST-segment elevation myocardial infarction (NSTEMI) and an ST-segment elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention. A total of 11,798 patients with acute myocardial infarction were classified into two groups: DM (NSTEMI, n = 2399; STEMI, n = 2693) and non-DM (NSTEMI, n = 2694; STEMI, n = 4012). The primary clinical outcome was the occurrence of major adverse cardiac events (MACE), defined as all-cause death, recurrent myocardial infarction, or any coronary repeat revascularization. The secondary outcome was the occurrence of definite or probable stent thrombosis. In all the patients, both multivariable and propensity score-adjusted analyses revealed that the incidence rates of MACE (adjusted hazard ratio (aHR), 1.214; p = 0.006 and aHR, 1.298; p = 0.002, respectively), all-cause death, cardiac death (CD), and non-CD rate were significantly higher in the NSTEMI group than in the STEMI group. Additionally, among patients with NSTEMI, there was a higher non-CD rate (aHR, 2.200; p = 0.007 and aHR, 2.484; p = 0.004, respectively) in the DM group and a higher CD rate (aHR, 2.688; p < 0.001 and 2.882; p < 0.001, respectively) in the non-DM group. In this retrospective study, patients with NSTEMI had a significantly higher 2-year mortality rate than those with STEMI did. Furthermore, strategies to reduce the non-CD rate in patients with DM and the CD rate in patients without DM could be beneficial for those with NSTEMI.

Comparison of the T-MACS score with the TIMI score in patients presenting to the emergency department with chest pain

OBJECTIVES

Guidelines recommend the use of risk scoring in patients with chest pain. In this study, we aimed to compare the thrombolysis in myocardial infarction risk index (TIMI) score with the Troponin Only Manchester Acute Coronary Syndrome Score (T-MACS) score and to investigate the usability of the T-MACS score in the emergency department.

METHODS

In our study; The TIMI and T-MACS scores of 310 patients with suspected NSTEMI who applied to the emergency department with chest pain and met the inclusion and exclusion criteria were prospectively evaluated. The primary outcome was MACE at 30 days including acute coronary syndromes, need for revascularization and deaths. Descriptive data and TIMI and T-MACS scores for predicting MACE and ACS was evaluated by calculating sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). ROC (Receiver Operating Characteristic) analysis was also performed to determine TIMI and T-MACS risk class.

RESULTS

In our study, the mean age of the patients was 49.7 ± 19.4 years, the 1-month mortality rate was 1.3%, majör adverse cardiac event (MACE) rate was 6.5%, and acute coronary syndrome (ACS) rate was 5.5%. T-MACS risk class for predicting MACE sensitivity 100%, selectivity 51.72, PPV 12.5% (for very low risk), NPV was calculated as 100%; sensitivity for TIMI risk class low risk 35%, selectivity 88.97%, PPV was calculated as 17.9%, NPV was calculated as 95.2%. T-MACS high risk class for predicting MACE; sensitivity was 60%, selectivity 99.66%, PPV 92.3% and NPV was 97.3%; TIMI high risk class for predicting MACE; sensitivity was 10%, selectivity was 97.93%, PPV was 25% and NPV was 94%.

CONCLUSIONS

The findings obtained in this study suggest that the T-MACS score is more successful than the TIMI score in determining the low risk (very low risk for T-MACS score), high risk, and estimated 1-month MACE risk in cases who presented to the emergency department with chest pain.

Association Between the Expression of MicroRNA-125b and Survival in Patients With Acute Coronary Syndrome and Coronary Multivessel Disease

Background

MicroRNAs (miRNA, miR) have an undeniable physiological and pathophysiological significance and act as promising novel biomarkers. The aim of the study was to investigate blood-derived miRNAs and their association with long-term all-cause mortality in patients with multivessel disease (MVD) suffering from acute coronary syndrome (ACS).

Materials and Methods

This study was an observational prospective study, which included 90 patients with MVD and ACS. Expression of miR-125a, miR-125b, and miR-223 was analysed by polymerase chain reaction (PCR). Patients were followed-up for a median of 7.5 years. All-cause mortality was considered as the primary endpoint. Adjusted Cox-regression analysis was performed for prediction of events.

Results

Elevated expression of miR-125b (&gt;4.6) at the time-point of ACS was associated with increased long-term all-cause mortality (adjusted [adj.] hazard ratio [HR] = 11.26, 95% confidence interval [95% CI]: 1.15–110.38; p = 0.038). The receiver operating characteristic (ROC) analysis showed a satisfactory c-statistics for miR-125b for the prediction of long-term all-cause mortality (area under the curve [AUC] = 0.76, 95% CI: 0.61–0.91; p = 0.034; the negative predictive value of 98%). Kaplan–Meier time to event analysis confirmed an early separation of the survival curves between patients with high vs low expression of miR-125b (p = 0.003). An increased expression of miR-125a and miR-223 was found in patients with non-ST-segment elevation ACS (NSTE-ACS) as compared to those with ST-segment elevation myocardial infarction (STEMI) (p = 0.043 and p = 0.049, respectively) with no difference in the expression of miR-125b between the type of ACS.

Conclusion

In this hypothesis generating study, lower values of miR-125b were related to improved long-term survival in patients with ACS and MVD. Larger studies are needed to investigate whether miR-125b can be used as a suitable predictor for long-term all-cause mortality.

Efficacy and Safety of Shenqisuxin Granule for Non-ST-segment Elevation Acute Coronary Syndrome: Study Protocol for a Randomized, Double-Blinded, Placebo-Controlled Trial

Introduction

The Chinese herbal compound formula, Shenqisuxin granule (SQSX), promotes neovascularization and prevents in-stent restenosis in modern pharmaceutical studies and is expected to provide an effective strategy for non-ST-segment elevation acute coronary syndrome (NSTEACS). Thus, this study aims to examine the efficacy and safety of SQSX for NSTEACS and initially reveal its mechanism.

Methods/Design

The study is a randomized, double-blinded and placebo-controlled trial. A total of 66 participants will be randomly allocated to one of the following two groups. Participants in the SQSX group will receive conventional treatment plus SQSX, while the placebo group will receive conventional treatment plus placebo, both for 14 days. The primary outcome, hs-CRP, and secondary outcome the Seattle Angina Questionnaire (SAQ) will be assessed at baseline, 7 ± 3 days and 14 ± 3 days. At all visit windows, other indicators including creatine kinase (CK), creatine kinase-myocardial band (CK-MB), cardiac troponins I (cTnI), 12-lead electrocardiograph and the syndrome scores of Qi deficiency and blood stasis will be tested and metagenomic sequencing for intestinal flora will be performed. Echocardiography and safety assessment will be performed at baseline and 14 ± 3 days. Adverse events will be monitored during the trial.

Discussion

The purpose of the study is to examine the efficacy and safety of SQSX to improve NSTEACS and initially reveal its mechanism.

Trial Registration

China Clinical Trial Registry, ChiCTR2000029226. Registered on January 19, 2020.

Association between admission ECG changes and long-term mortality in patients with an incidental myocardial infarction: Results from the KORA myocardial infarction registry

BACKGROUND

The aim of this study was to examine the predictive value of specific changes in admission ECG on long-term outcome in acute myocardial infarction (AMI).

METHODS

From 2000 until 2017 all AMI cases (n = 9,689) in the study area of Augsburg, Germany, were prospectively recorded. For this study, all patients with a first-time AMI, who survived the first 28 days, were considered. Median observational time was 6.7 years (IQR: 3.6-10.9). Each case was assigned to one of the following groups according to the admission ECG: 'ST-segment elevation', 'ST-segment depression', 'T-wave inversion', 'unspecific changes', 'normal ECG' and 'bundle branch block' (BBB). Multivariable adjusted COX regression models were calculated to compare long-term all-cause mortality.

RESULTS

The final regression model revealed a significantly higher mortality among patients with BBB (HR: 1.52 [1.34-1.73], p-value: < 0.001) and 'ST-segment depression' (HR: 1.16 [1.03-1.29], p-value: 0.01252) compared to the STEMI group (reference group). The 'normal ECG' group (HR: 0.76 [0.66-0.87], p-value: < 0.001) on the other hand was associated with significantly lower long-term mortality. The 'T-wave inversion' group (HR: 1.08 [0.96-1.21]) and the 'unspecific changes' group (HR: 1.05 [0.94-1.17]) did not differ significantly from the STEMI group.

CONCLUSION

ST-segment depressions and BBB admission ECGs go along with higher long-term mortality in AMI patients compared to STEMI cases. This should be taken into account by physicians when treating patients with NSTEMIs. Only the complete absence of AMI-related ECG changes predicts a more favorable outcome.

Impact of Ticagrelor Versus Clopidogrel on Coronary Microvascular Function After Non-ST-Segment-Elevation Acute Coronary Syndrome

BACKGROUND

Coronary microvascular dysfunction after acute coronary syndrome is an important predictor of long-term prognosis. Data is lacking on the effects of oral P2Y₁₂-inhibitors on coronary microvascular function in non-ST-segment-elevation acute coronary syndrome. The aim of this study was to compare the acute effects of ticagrelor versus clopidogrel pretreatment on coronary microvascular function in non-ST-segment-elevation acute coronary syndrome patients.

METHODS

Hospitalized non-ST-segment-elevation acute coronary syndrome patients were randomized (1:1) to ticagrelor or clopidogrel. The index of microcirculatory resistance, coronary flow reserve, and resistive reserve ratio were obtained using an intracoronary pressure-temperature sensor-tipped wire.

RESULTS

In total, 128 patients were randomized between March 2018 and July 2020. Mean age 59.2±11.8 years, 84% were male, mean Global Registry of Acute Coronary Events score was 93.7±24.5. Intracoronary physiological measurements were obtained in 118 patients (60 ticagrelor, 58 clopidogrel). In the infarct-related artery, the ticagrelor group had lower baseline index of microcirculatory resistance (22.0 [13.0-34.9] versus 27.7 [19.3-29.8]; P=0.02) and higher baseline resistive reserve ratio (3.0 [2.3-4.4] versus 2.4 [1.7-3.4]; P=0.01) compared with the clopidogrel group. A total of 88 patients underwent percutaneous coronary intervention (PCI; 45 ticagrelor, 43 clopidogrel). The ticagrelor group had lower post-PCI index of microcirculatory resistance (22.0 [15.0-29.0] versus 27.0 [18.5-47.5]; P=0.02) and higher post-PCI resistive reserve ratio (3.0 [1.8-3.8] versus 1.8 [1.5-3.4]; P=0.006) compared with the clopidogrel group. The coronary flow reserve was not significantly different between the 2 groups at baseline or post-PCI. No between-group differences were seen in any of the indices in the non-infarct-related artery.

CONCLUSIONS

In non-ST-segment-elevation acute coronary syndrome patients, ticagrelor significantly improved coronary microvascular function before and after PCI compared with clopidogrel.

REGISTRATION

URL: https://www.anzctr.org.au; Unique identifier: ACTRN12618001610224.

Coronary Computed Tomography Angiographic Predictors of Non-culprit Territory Unrecognized Myocardial Infarction Assessed by Cardiac Magnetic Resonance in Non-ST-elevation Acute Coronary Syndrome

Objectives

This study sought to assess the predictors of coronary computed tomography angiographic findings for non-infarct-related (non-IR) territory unrecognized myocardial infarction (UMI) in patients with a first episode of non-ST-elevation acute coronary syndrome (NSTE-ACS).

Background

UMI detected by cardiac magnetic resonance imaging (CMR) is associated with adverse outcomes in patients with both acute coronary syndrome and chronic coronary syndrome. However, the association between the presence of UMI and coronary computed tomography angiographic (CCTA) findings remains unknown.

Methods

We investigated 158 patients with a first clinical episode of NSTE-ACS, who underwent pre-PCI 320-slice CCTA and uncomplicated urgent percutaneous coronary intervention (PCI) within 48 h of admission. In these patients, post-PCI CMR was performed within 30 days from urgent PCI and before non-IR lesion staged PCI. UMI was assessed using late gadolinium enhancement (LGE)-CMR by identifying regions of hyperenhancement with an ischemic distribution pattern in non-IR territories (non-IR UMI). CCTA analysis included qualitative and quantitative assessments of the culprit segment, Agatston score, mean peri-coronary fat attenuation index (FAI), epicardial fat volume (EFV) and epicardial fat attenuation (EFA).

Results

Non-IR UMI was detected in 30 vessel territories (9.7%, 30/308 vessels) of 28 patients (17.7%, 28/158 patients). The presence of low-attenuation plaque, spotty calcification, napkin ring sign, and positive remodeling was not significantly different between vessels with and without subtended non-IR UMI. Agatston score >30.0 (OR: 8.39, 95% confidence interval (CI): 2.17 to 32.45, p = 0.002), mean FAI >-64.3 (OR: 3.23, 95% CI: 1.34 to 7.81, p = 0.009), and stenosis severity (OR: 1.04, 95% CI: 1.02 to 1.06, p < 0.001) were independently associated with non-IR UMI. Neither EFV (p = 0.340) nor EFA (p = 0.700) was associated with non-IR UMI.

Conclusion

The prevalence of non-IR UMI was 17.7 % in patients with first NSTE-ACS presentation. Agatston score, mean FAI, and coronary stenosis severity were independent CCTA predictors of the presence of non-IR UMI. The integrated CCTA assessment may help identify the presence of non-IR UMI before urgent PCI.

Prognosis Between ST-Elevation and Non-ST-elevation Myocardial Infarction in Older Adult Patients

Background: Whether there is a difference in prognosis between elderly patients with ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) remains mysterious. Methods: We conducted a retrospective cohort study by analyzing the data in the Longitudinal Health Insurance Database (LHID) in Taiwan to explore differences between STEMI and NSTEMI with respect to in-hospital and long-term (3-year) outcomes among older adult patients (aged ≥65 years). Patients were further stratified based on whether they received coronary revascularization. Results: In total, 5,902 patients aged ≥65 years with acute myocardial infarction (AMI) who underwent revascularization (2,254) or medical therapy alone (3,648) were included. In the revascularized group, no difference was observed in cardiovascular (CV) and all-cause mortality during hospitalization or at 3-year follow-up between the two AMIs. Conversely, in the non-revascularized group, patients with NSTEMI had higher crude odds ratio (cOR) for all-cause death during hospitalization [cOR: 1.33, 95% confidence interval (CI) = 1.07-1.65] and at 3-year follow-up (cOR: 1.47, 95% CI = 1.21-1.91) relative to patients with STEMI. However, after multivariable adjustments, only NSTEMI indicated fewer in-hospital CV death [adjusted odds ratio (aOR): 0.75, 95% CI = 0.58-0.98] than STEMI in non-revascularized group. Moreover, major bleeding was not different between patients with STEMI or NSTEMI aged ≥65 years old. Conclusion: Classification of AMI is not associated with the difference of in-hospital or 3-year CV and all-cause death in older adult patients received revascularization. In a 3-year follow-up period, STEMI was an independent predictor of a higher incidence of revascularization after the index event. Non-ST-elevation myocardial infarction had more incidence of MACE than patients with STEMI did in both treatment groups.

Development and Validation of a Risk Nomogram Model for Predicting Contrast-Induced Acute Kidney Injury in Patients with Non-ST-Elevation Acute Coronary Syndrome Undergoing Primary Percutaneous Coronary Intervention

Objective

To establish a nomogram model to predict the risk of contrast-induced acute kidney injury (CI-AKI) by analyzing the risk factors of CI-AKI and to evaluate its effectiveness.

Methods

Retrospectively analyze the clinical data of non-ST-elevation acute coronary syndrome (NSTE-ACS) patients who underwent percutaneous coronary intervention (PCI) in our cardiology department from September 2018 to June 2021. Of these, patients who underwent PCI in an earlier period formed the training cohort (70%; n = 809) for nomogram development, and those who underwent PCI thereafter formed the validation cohort (30%; n = 347) to confirm the model’s performance. The independent risk factors of CI-AKI were determined by LASSO regression and multivariable logistic regression analysis. By using R software from which nomogram models were subsequently generated. The nomogram was developed and evaluated based on discrimination, calibration, and clinical efficacy using the concordance statistic (C-statistic), calibration plot, and decision curve analysis (DCA), respectively.

Results

The nomogram consisted of six variables: age >75, left ventricular ejection fraction, diabetes mellitus, fibrinogen-to-albumin ratio, high-sensitive C-reactive protein, and lymphocyte count. The C-index of the nomogram is 0.835 (95% CI: 0.800–0.871) in the training cohort and 0.767 (95% CI: 0.711–0.824) in the validation cohort, respectively. The calibration plots exhibited that the nomogram was in good agreement between prediction and observation in the training and validation cohorts. Decision curve analysis and clinical impact curve suggested that the predictive nomogram had clinical utility.

Conclusion

The nomogram model established has a good degree of differentiation and accuracy, which is intuitively and individually to screen high-risk groups and has a certain predictive value for the occurrence of CI-AKI in NSTE-ACS patients after PCI.

Two-year outcomes between ST-elevation and non-ST-elevation myocardial infarction in patients with chronic kidney disease undergoing newer-generation drug-eluting stent implantation

BACKGROUND

We evaluated the 2-year clinical outcomes of ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) in patients with chronic kidney disease (CKD) who received newer-generation drug-eluting stents (DES).

METHODS

Overall, 18,875 acute myocardial infarction patients were divided into two groups: CKD (STEMI, n = 1707; NSTEMI, n = 1648) and non-CKD (STEMI, n = 8660; NSTEMI, n = 6860). The occurrence of major adverse cardiac events (MACE), defined as all-cause death, recurrent myocardial infarction (re-MI), any repeat coronary revascularization, and definite or probable stent thrombosis (ST), was evaluated.

RESULTS

After multivariable-adjusted analysis, in the CKD group, the MACE (adjusted hazard ratio [aHR]: 1.365, p = 0.004), all-cause death (aHR: 1.503, p = 0.004), noncardiac death (non-CD; aHR: 1.960, p = 0.004), and all-cause death or MI rates (aHR: 1.458, p = 0.002) were significantly higher in the NSTEMI group than in the STEMI group. In the non-CKD group, the non-CD rate (aHR: 1.78, p = 0.006) was also higher in the NSTEMI group. The CD, re-MI, any repeat revascularization, and ST rates were similar between groups. In the CKD group, from 6 months to 2 years after the index procedure, all-cause death, non-CD, and all-cause death or MI rates were significantly higher in the NSTEMI group than in the STEMI group. These results may be related to the higher non-CD rate in the NSTEMI group.

CONCLUSIONS

In the era of contemporary newer-generation DES, NSTEMI showed a relatively higher non-CD rate than STEMI in both CKD and non-CKD groups.

ST-segment elevation versus non-ST-segment elevation myocardial infarction in current smokers after newer-generation drug-eluting stent implantation

We compared the 2-year major clinical outcomes between ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) in patients who are current smokers who underwent successful percutaneous coronary intervention (PCI) with newer-generation drug-eluting stents (DESs). The availability of data in this regard is limited.A total of 8357 AMI patients were included and divided into 2 groups: the STEMI group (n = 5124) and NSTEMI group (n = 3233). The primary endpoint was the occurrence of major adverse cardiac events (MACE), defined as all-cause death, recurrent myocardial infarction (re-MI), or coronary repeat revascularization. The secondary endpoints were the cumulative incidences of the individual components of MACE and stent thrombosis (definite or probable).After propensity score-matched (PSM) analysis, 2 PSM groups (2250 pairs, C-statistics = 0.795) were generated. In the PSM patients, both for 1 month and at 2 years, the cumulative incidence of MACE (P = .183 and P = .655, respectively), all-cause death, cardiac death, re-MI, all-cause death or MI, any repeat revascularization, and stent thrombosis (P = .998 and P = .341, respectively) was not significantly different between the STEMI and NSTEMI groups. In addition, these results were confirmed using multivariate analysis.In the era of contemporary newer-generation DESs, both during 1 month and at 2 years after index PCI, the major clinical outcomes were not significantly different between the STEMI and NSTEMI groups confined to the patients who are current smokers. However, further research is needed to confirm these results.