Collaterals and extent of myocardial injury in patients with acute coronary syndromes – an analysis of the prospective SPUM-ACS cohort

Introduction

The impact of collateral circulation in the presence of severe coronary artery disease such as chronic total occlusion (CTO) has been extensively studied, with results despite few discrepancies, supporting an overall benefit on preservation of myocardial tissue and left ventricular ejection fraction (LVEF). However, less is known about the protective effects of collaterals in the context of acute coronary syndromes (ACS). In the current study we sought to analyze the incidence, grade and impact of collateral circulation in a large prospectively recruited cohort of patients presenting with ACS with independent events adjudication.

Methods and results

4'546 ACS patients presenting with ACS, enrolled in the prospective Special Program University Medicine ACS (SPUM-ACS) cohort were included. The current analysis showed the presence of a collateralized culprit lesion in 12.9% (n=586) of patients, 84% (n=492) originating from the contralateral side and 16% (n=94) from the ipsilateral side. Of those 64.6% (n=378) were being graded as Rentrop 2 or more. There were no differences in baseline characteristics between the two groups including incidence of diabetes, coronary artery disease, age and gender. However, despite the presence of collaterals graded Rentrop 2 or more, those patients had a significantly lower LVEF mean 48,44% vs 51.6%, p=0.025 and higher creatinine Kinase levels, mean (CK) 981 U/I vs 957 UI, p<0.001 as compared to patients with absent collateral-circulation on admission. Interestingly a sub analysis of the STEMI population showed no significant differences in both LVEF and CK at presentation, while troponin (TNT) plasma levels were significantly lower in patients with collaterals (mean TNT 0.0031 ug/l vs 0.035 ug/l p=0.001). Additionally no differences in cardiovascular mortality, stent thrombosis or MI was seen at one year follow-up.

Conclusion

The current analysis highlights a possible protective impact of a pre-existing collateral circulation against myocardial injury in the setting of ACS and ST elevation myocardial infarction. However this was not translated into improvement in hard outcomes acutely and up to one year of follow up, but may be important in the long run.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Swiss National Research Foundation - ZurichHeart House

Prevalence and outcomes of peripheral artery disease in a real-world cohort of patients with acute coronary syndrome: insights from the prospective SPUM registry

Background

Despite substantial improvement in secondary preventive therapy, the burden of recurrent cardiovascular (CV) events remains high. Peripheral artery disease (PAD), is a potential marker of increased residual ischemic risk in acute coronary syndrome (ACS) patients suggesting greater net clinical benefit from intensified individualized therapy.

Purpose

We aimed to assess the prevalence and cardiovascular (CV) outcomes of peripheral arterial disease (PAD) in 4'787 patients with acute coronary syndromes (ACS) in the Swiss prospective multicenter SPUM study.

Methods

PAD was defined according to international guidelines. The composite primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), i.e., stroke, myocardial infarction (MI) and death at 1 year. Adjusted Cox proportional hazards regression models were used to estimate the risk associated with PAD and outcomes.

Results

Out of 4'787 ACS patients, 285 patients (6.0%) had PAD. These patients were older (70.1±10.6 vs 63.3±12.4, p<0.001), presented all traditional CV risk factors (all p<0.001) and were more likely to have a complex history of CV disease, such as previous MI (24.3% vs 11.4%, p<0.001), prior percutaneous (32.3% vs 13.8%, p<0.001) or surgical (12.6% vs 3.5%, p<0.001) coronary revascularization. PAD-patients presented also higher levels of inflammatory biomarkers, such as hs-CRP, and GRACE 2.0 score (all p<0.001). At 1 year, patients with PAD had a higher rate of MACCE compared to those presenting without PAD. Rates of the individual components of the primary endpoint and CV-death were all significantly higher in patients with PAD (all p<0.001), except for a numerical increase in MI (5.3% vs 3.3%, p=0.060). This enhanced risk persisted after adjustment for differences in baseline characteristics, with a 53% (Adj. HR 1.53, CI95% 1.14–2.08, p=0.005) increase in MACCE. In spite of high-intensity anti-thrombotic therapy, PAD patients presented the same rate (Adj. HR 1.03, CI95% 0.68–1.54, p=0.901) of major bleeding events at 1 year.

Conclusions

Among a real-world cohort of ACS patients, the coexistence of PAD, a very-high CV risk phenotype, is associated with significantly increased rates of MACCE, but no difference in major bleeding events. These observations might help clinicians to further stratify this very-high risk population and to identify patients who may derive the greatest benefit from more intense secondary prevention therapies.

Funding Acknowledgement

Type of funding sources: None.

Systemic immune-inflammation index predicts major adverse cardiovascular events in patients with ST-elevation myocardial infarction

Background

ST-elevation myocardial infarction (STEMI) represents the life-threatening manifestation of atherosclerosis, a chronic inflammatory disease of arterial wall, and is associated with high rate of morbidity and mortality. Thus, inflammatory biomarkers may be useful in identifying high inflammatory burden patients who may benefit from tailored high-intensity secondary prevention therapy.

Purpose

We therefore assessed the relationship between the systemic immune-inflammation index (SII) and CV outcomesamong 1144 all-comers patients admitted to four Swiss University Hospital for STEMI and enrolled in the prospective multicenter SPUM registry cohort I (NCT 01000701).

Methods

SII was calculated as platelet counts x neutrophil counts / lymphocyte counts. Patients were subdivided into three groups according to SII tertiles. The composite primary endpoint was major adverse cardiac and cerebrovascular events (MACCE: stroke, myocardial infarction, CV death). Adjusted Cox proportional hazards regression models were implemented to determine the risk associated with SII and outcomes.

Results

Out of 1144 STEMI patients, 912 patients (79,7%) had available for SII. Patients within the highest tertile were slightly more frequently male (23.0 vs 22.0%, p=0.05), with higher plasma values of neutrophils (11.4±2.4 vs 6.5±3.7 G/l, p<0.001), platelets (275.3±97.5 vs 202.5±51.6 G/l, p<0.001) and lower levels of lymphocytes (1.0±0.6 vs 2.1±1.1 G/l, p<0.001) and LVEF (46.4±11.5% vs 50.4±10.3%, p<0.001) (Fig. 1A). At 1 year, these patients presented the highest rate of all-cause mortality (7.2% vs 2.6%, p=0.02) and MACCE (8.2% vs 3.3, p=0.03). This enhanced risk persisted for all-cause mortality and MACCE, after adjustment for age, sex, ace-inhibitors and statin therapy (Adj. HR 2.85, 95% CI 1.30–6.70, p=0.03 and Adj. HR 2.63, 95% CI 1.25–5.55, p=0.03, respectively, Fig. 1B).

Conclusions

Among a real-world cohort of STEMI-patients, SII highlights the highest inflammatory risk phenotype, being associated with significant increased rates of MACCE and all-cause of death. These observations might help clinicians to furtherly identify patients who may derive the greatest benefit from tailored more intense secondary prevention therapies including inflammatory modulation.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Location and impact of the infarct-related artery in acute coronary syndrome: insight from the Swiss SPUM- ACS cohort

Background

Identifying the infarct-related artery (IRA) in patients with acute coronary syndromes (ACS) has prognostic and therapeutic implications.

Purpose

We aimed to evaluate the distribution, clinical presentation and impact of the culprit lesion location on long-term outcomes in ACS patients treated with primary percutaneous coronary intervention, medication and secondary prevention according to Guidelines.

Methods

Patients referred for ACS to one of the participating centres of the observational SPUM-ACS study between 2009 and 2017 with one year outcomes and independent events adjudication were included. The distribution of IRA, clinical presentation (STEMI/NSTEMI) and impact of IRA location on major adverse cardiac events (cardiac death, myocardial infarction, stent thrombosis, target vessel revascularisation) at one year were investigated.

Results

4'546 patients were included with 55% presenting as STEMI (mean age 62-years; 20% women), 42% as NSTEMI and 3% as unstable angina. The left anterior descending (LAD) artery was involved in 44.3%, the right coronary artery (RCA) and left circumflex artery (LCX) in 32.9% and 20%, respectively. Proximal and middle segments of the 3 main vessels were more often the culprit location compared to distal segments and side branches (78% versus. 22%). Left main (LM) and bypass graft were rarely involved (1.6% and 1.2% respectively), but most often responsible to overall cardiac dysfunction (higher NT-proBNP and hs troponin levels). Patients with an occluded IRA at angiography usually presented as STEMI on ECG (100% for LM, 90.5% for LAD territory, 83.8% for RCA territory, 56.6% for LCX territory). However 43.1% of patients with occluded LCX presented as NSTEMI. These patients were prone to extensive cardiac damage and significantly higher hs troponin levels as compared to those with patent LCX or STEMI presentation (626 ng/l vs 310 ng/l and 626 ng/l vs 580 ng/l respectively, p<0.001). Overall, 1-year MACE occurred in 11.8%. In native coronaries, the location of IRA had no impact on outcomes (20% LM, 10.9% LAD, 11.8% RCA, 11.8% LCX, p=0.112). However, in NSTEMI-ACS there were twice as many events when the LM was the IRA (MACE 20%, p=0.023) and 3-times higher when a bypass-graft was the IRA (33.9%, p=0.0001).

Conclusions

ST elevations are highly suggestive of an occluded IRA. However more than 40% of patients presenting with ACS involving an occluded LCX did not demonstrate ST-elevation and were prone to extensive cardiac damage, urging the necessity for early invasive measures in these patients. In native coronaries the IRA location did not affect outcomes except in NSTEMI with LM involvement or ACS with bypass grafts as IRA that had much worse outcomes.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): - Swiss National Research Foundation - Zurich Heart House

Uncontrolled hypertension and elevated NT-proBNP predict acute kidney injury and cardiac death in all-comer patients 1 year after acute coronary syndromes

Background

Hypertension is a recognized cardiovascular (CV) risk factor and, although many highly effective antihypertensive drugs have been developed, most patients fail to achieve recommended blood pressure target levels. This may increase major adverse CV events after acute coronary syndromes (ACS) such as acute kidney injury (AKI) and cardiac death (CD).

Purpose

We assessed the prognostic value of uncontrolled hypertension (UH) and elevated NT-proBNP among 2,168 all-comer patients admitted to 4 Swiss University Hospitals for acute coronary syndromes (ACS) enrolled in the prospective multicenter SPUM registry.

Methods

Patients with UH defined as a systolic blood pressure≥140 mmHg, and a NT-proBNP>900 ng/l were considered for the analysis. The composite primary endpoint was AKI and CD. Adjusted Cox proportional hazards regression models were implemented to determine risk prediction for UH and elevated NT-proBNP levels.

Results

Out of 2,168 ACS patients, 235 patients (10.8%) showed UH and NT-proBNP>900 ng/l (Fig. 1A). Compared to the general ACS population, those with UH and elevated NT-proBNP were more likely to be older (41.7% vs 20.0%, p<0.001), of female sex (36.2% vs 19.7%, p<0.001) and with a more complex history of CV disease, such as hypertension (77.0% vs 56.2%, p<0.001), diabetes (24.7% vs 17.5%, p=0.006), peripheral artery disease (9.4% vs 5.2%, p=0.011), cerebrovascular disease (6.8% vs 3.4%, p=0.013), chronic heart failure (3.4% vs 1.3%, p=0.025), dialysis (2.1% vs 0.3%, p=0.004) as well as prior CABG (9.4% vs 5.2%, p=0.010) and more often admitted as NSTEMIs (59.6% vs 40.9%, p<0.001). Although these patients were on a more aggressive antihypertensive therapy at admission (all p<0.05 for ACEi, ARB, Beta-blockers, calcium antagonists, nitrates and diuretics), there was a higher rate of death (OR 1.83, 95% CI 1.07–3.14, p=0.027), CD (OR 2.13, 95% CI 1.19–3.81, p=0.009), AKI (OR 2.83, 95% CI 1.41–5.67, p=0.002) and composite endpoint AKI+CD (OR 2.46, 95% CI 1.56–3.90, p<0.001) at one year. This combined risk persisted after adjustment for baseline differences, with a 71% (Adj. HR 1.71, 95% CI 1.44–1.84, p=0.003) increase for the composite endpoint (Fig. 1B).

Conclusions

Among a real-world cohort of ACS patients, coexistence of UH with elevated levels of NT-proBNP confers increased risk for AKI and CD up to one year after ACS. These observations might help clinicians to identify ACS patients at risk using simple clinical parameters and biomarkers and to target them for more intense preventive therapies.

Figure 1. A: GRADE1 = 140–159 mmHg and/or 90–99 mmHg; GRADE2 = 160–179 mmHg and/or 100–109 mmHg; GRADE3 = ≥180 mmHg and/or ≥110 mmHg; ISH (isolate systolic hypertension) = ≥140 mmHg and <90 mmHg; NT-proBNP = N-terminal-pro B-type natriuretic peptide. B: UH = uncontrolled hypertension; AKI = acute kidney injury; CD = cardiac death.

Funding Acknowledgement

Type of funding source: None

P6440The perils of polyvascular disease with concomitant type 2 diabetes in a real-world cohort of patients with acute coronary syndrome

Background

Despite substantial improvement in type 2 diabetes (DM2) care, the burden of recurrent cardiovascular (CV) events remains high. Polyvascular disease (PVD), has recently emerged as a potential marker of heightened residual ischemic risk in DM2 patients, that are likely to derive a greater absolute risk reduction from more intense, individualized therapy.

Purpose

We sought to assess the relationship between DM2, PVD and CV outcomes among 2,168 all-comers patients admitted to four Swiss University Hospital for acute coronary syndrome (ACS) and enrolled in the prospective multicenter SPUM registry (NCT 01000701).

Methods

PVD was defined as concomitant peripheral artery disease, stroke or transient ischemic attack, or both. The composite primary endpoint was major adverse cardiac and cerebrovascular events (MACCE: Stroke, myocardial infarction, CV death). Adjusted Cox proportional hazards regression models were implemented to determine the risk associated with PVD disease in DM2 and outcomes, and intention-to-treat analysis was performed.

Results

Out of 2,168 ACS patients, 396 patients (18.3%) had DM2; of these 62 (15%) had PVD. Despite compared with the general ACS population, those with PVD + DM2 were more likely to have a complex history of CV disease, such as previous MI (27.4% vs 14.7%, p=0.021), prior percutaneous (37.1% vs 17%, p<0.001) or surgical (24.2% vs 5.1%, p<0.001) coronary revascularization, one third was not on statin therapy. At 1 year, patients with PVD + DM2 had a higher rate of MACCE compared to those presenting with PVD or DM2 alone. Rates of the single components of the primary endpoint and all-cause of death were all significantly higher in patients with PVD + DM2 vs. PVD or DM2 alone (Fig. 1A, all p<0.001). This enhanced risk persisted after adjustment for significant baseline differences, with a 34% (Adj. HR 1.34, 95% CI 1.15–1.49, p=0.02) increase in MACCE and a 44% increment of all cause of death (Adj. HR 1.44, 95% CI 1.06–1.54, p=0.02, Fig. 1B).

Outcomes by PVD and DM2 status.

Conclusions

Among a real-world cohort of ACS-patients, the coexistence of PVD and DM2 highlights the highest CV risk phenotype, being associated with significant increased rates of MACCE and all-cause of death. These observations might help clinicians to furtherly stratify the very high risk population and to identify patients who may derive the greatest benefit from more intense secondary prevention therapies.

[Multimodal imaging in the differential diagnosis of soft tissue calcinosis]

Soft tissue calcinosis is a common radiographic finding, which may be related to different types of pathological processes. Multimodality imaging, combined with analysis of clinical and laboratory data, plays an important role for the differential diagnosis of these conditions. Conventional radiography is considered the first line approach to soft tissue calcinosis; CT and MRI may provide further information to better characterize calcified deposits. Imaging may help to distinguish metabolic calcification, such as primary tumoral calcinosis and the secondary one (associated with acquired disorders of calcium or phosphate regulation), from dystrophic calcification, which is associated to normal blood values of phosphate. The sedimentation sign typical of tumoral calcinosis has been demonstrated by plain film radiography, CT, MRI, and, more recently, by ultrasonography. Other types of soft tissue calcinosis may have a degenerative, metaplastic or neoplastic origin, and their characterization strongly relies on multimodality imaging.

High prevalence of vitamin D deficiency and its association with left ventricular dilation: an echocardiography study in elderly patients with chronic heart failure

BACKGROUND AND AIMS

Vitamin D deficiency has been associated with chronic heart failure (CHF). We evaluated vitamin D levels in relationship with New York Heart Association (NYHA) classes, N-terminal pro-brain natriuretic peptide (NT-proBNP) values and left ventricular (LV) measures in ≥60 year old patients with stable CHF. Differently from previous investigations, LV function was assessed by transthoracic echocardiography, to provide easily reproducible results.

METHODS AND RESULTS

The study was performed at geographic latitude 44° N, from March to May and from September to November 2008. Acute HF and diseases or drugs altering vitamin D status were exclusion criteria. NYHA scores and 25-hydroxyvitamin D [25(OH)D], 1,25-dihydroxyvitamin D and NT-proBNP concentrations were assessed in 90 (45 F, 45 M) Caucasian patients with CHF secondary to hypertension and/or coronary artery disease. Vitamin D levels were also measured in 31 subjects without heart disease (controls). LV echocardiography was performed in 52 (26 F, 26 M) representative patients. Vitamin D concentrations were significantly lower in CHF cases than in controls. Among subject with CHF, 97.8% presented vitamin D deficiency (25(OH)D<75 nmol/L), being severe (<25 nmol/L) in 66.7%. LV end-diastolic and end-systolic diameters were significantly longer, LV end-diastolic and end-systolic volumes bigger and fractional shortening lower in CHF patients with 25(OH)D<25 nmol/L than with 25(OH)D≥25 nmol/L (p<0.05). Log-values of 25(OH)D were negatively correlated with LV end-systolic diameter and volume (r=-0.28; p<0.05). On subgroup analysis, these results persisted only in male patients.

CONCLUSIONS

In elderly CHF patients, vitamin D deficiency was highly prevalent and often severe. This first addressed echocardiography study showed a sex-specific association between vitamin D deficiency and LV dilation. Since further echocardiography data are easily obtainable, larger investigations are demanded.

[Esophagectomy without thoracotomy: indications and our experience]

In this paper the Authors report their experience of Orringer operation in 12 patients with oesophageal cancer observed from 1978 to 1992, and stress the possibility to extend the indications to Akijama oesophagectomy without thoracotomy for the treatment of malignant tumors of the entire oesophagus.