Trimethylamine-N-Oxide and Related Metabolites: Assessing Cardiovascular Risk in the Dallas Heart Study

OBJECTIVE

To evaluate the association between trimethylamine N-oxide (TMAO) and related metabolites with adverse cardiovascular events in a multiethnic urban primary prevention population.

METHODS

We performed a case-control study of 361 participants of the Dallas Heart Study, including 88 participants with an incident atherosclerotic cardiovascular disease (ASCVD) event and 273 controls matched for age, sex, and body mass index without an ASCVD event during 12 years of follow-up (January 1, 2000, through December 31, 2015). Plasma levels of TMAO, choline, carnitine, betaine, and butyrobetaine were measured by mass spectrometry. The differential odds for incident ASCVD by metabolite levels between cases and controls were compared by a conditional logistic regression model adjusted for cardiovascular risk factors.

RESULTS

Participants with incident ASCVD had higher levels of TMAO and related metabolites compared with those without ASCVD (P<.05 for all). Those with plasma TMAO concentrations in quartile 4 had a more than 2-fold higher odds of ASCVD compared with those in quartile 1 (odds ratio, 2.77 [95% CI, 1.05 to 7.7; P=.04] for hard ASCVD and 2.41 [95% CI, 1.049 to 5.709; P=.04]). Similar trends were seen with the related metabolites choline, betaine, carnitine, and butyrobetaine.

CONCLUSION

Our results suggest that TMAO and related metabolites are independently associated with ASCVD events. Although further studies are needed, measurement of TMAO and related metabolites may have a role in ASCVD risk stratification for primary prevention.

Novel plasma biomarkers of coronary artery calcium incidence or progression: Insights from the prospective multi-ethnic Dallas Heart Study cohort

BACKGROUND AND AIMS

Identifying the association of novel plasma biomarkers with coronary artery calcium (CAC) incidence or progression may provide insights into the pathophysiology of atherogenesis and plaque formation.

METHODS

Participants of the Dallas Heart Study (DHS), a multi-ethnic cohort of ambulatory individuals at low-intermediate risk for future atherosclerotic cardiovascular disease (ASCVD), who had their blood tested for 31 biomarkers reflecting multiple pathophysiological pathways, underwent 2 serial non-contrast computed tomography assessments for CAC a median ∼7 years apart. The collected biomarkers were explored for association with CAC incidence or progression using univariate and multivariate analysis.

RESULTS

A total of 1424 participants were included; mean age 43 years, 39 % male, and nearly half African-American. Over a 7-year interval between the two CAC measurements, 340 participants (23.9 %) had CAC incidence or progression, 105 (7.4 %) with incident CAC, and 309 (21.7 %) with CAC progression. Although several plasma biomarkers were associated with CAC incidence or progression in a univariate model, only soluble intercellular adhesion molecule-1 (sICAM-1), related to atherosclerosis by the inflammatory pathway, remained independently associated in a multivariate model adjusted for traditional risk factors.

CONCLUSIONS

Further studies are needed to characterize the role of sICAM-1 in CAC evolvement to establish whether it has a pivotal mechanistic contribution or is rather an innocent bystander. Alternate measures of coronary atherosclerosis may be needed to elucidate contributors to atherosclerosis incidence or progression.

The obesity paradox in patients with acute coronary syndromes over 2 decades - the ACSIS registry 2000-2018

BACKGROUND

Obesity is a worldwide epidemic which is associated with major cardiovascular (CV) risk factors. Nevertheless, substantial distant data, mostly published more than a decade ago, have demonstrated an obesity paradox, where obese patients generally have a better short- and long-term prognosis than do their leaner counterparts with the same CV profile. Nonetheless, it is not fully elucidated whether the obesity paradox is still relevant in the contemporary cardiology era among patients with acute coronary syndrome (ACS). We aimed to examine temporal trends in the clinical outcomes of ACS patients by their BMI status.

METHODS

Data from the ACSIS registry including all patients with calculated BMI data between the years 2002-2018. Patients were stratified by BMI groups to underweight, normal, overweight and obese. Clinical endpoints included 30d major cardiovascular events (MACE), and 1-year mortality. Temporal trends were examined in the late (2010-2018) vs. the early period (2002-2008). Multivariable models examined factors associated with clinical outcomes by BMI status.

RESULTS

Among the 13,816 patients from the ACSIS registry with available BMI data, 104 were underweight, 3921 were normal weight, 6224 were overweight and 3567 were obese. 1-year mortality was highest among underweight patients (24.8%), as compared to normal weight patients (10.7%) and lowest among overweight and obese patients (7.1% and 7.5% respectively; p for trend <0.001). 30-day MACE rates followed a similar pattern (24.3% for underweight, 13.6% for normal weight, 11.6% for overweight, and 11.7% for obese; p for trend<0.001). Comparing the 2 time-periods, 30-day MACE was significantly lower in the late period in all BMI groups, but unchanged in patients who were underweight. Similarly, 1-year mortality has decreased in normal weight and obese patients but remained similarly high in underweight patients.

CONCLUSIONS

In ACS patients, during 2-decades, 30-day MACE and 1-year mortality were lower among overweight and obese patients compared to underweight and even normal weight patients. Temporal trends revealed that 30-day MACE and 1-year mortality have decreased among all BMI groups other than the underweight ACS patients, among whom the adverse CV rates were consistently high. Our findings suggest that the obesity paradox is still relevant in ACS patients in the current cardiology era.

Implantable Cardioverter Defibrillator for the Primary Prevention of Sudden Cardiac Death among Patients With Cancer

Data are limited regarding the characteristics and outcomes of patients with cancer who are found eligible for primary defibrillator therapy. We performed a single-center retrospective analysis of patients with preexisting cancer diagnoses who become eligible for a primary prevention implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy (CRT) defibrillator. Multicenter Automatic Defibrillator Implantation Trial-ICD (MADIT-ICD) benefit scores were calculated. The study included 75 cancer patients at a median age of 73 (interquartile range 64, 81) years at heart failure diagnosis. Active cancer was present in 51%. Overall, 55% of the cohort had coronary artery disease and 37% were CRT eligible. We found that 48%, 49%, and 3% of cohorts had low, intermediate, and high MADIT-ICD Benefit scores, respectively. Only 27% of patients underwent primary defibrillator implantation. Using multivariate analysis, indication for CRT and intermediate/high MADIT-ICD Benefit categories were found as independent predictors for implantation (odds ratio 8.42 p <0.001 and odds ratio 3.74 p = 0.040, respectively). During a median follow-up of 5.3 (interquartile range 4.5, 7.2) years, one patient (5%) with a defibrillator had appropriate shock therapy and 2 patients (10%) had bacteremia. Of 13 patients with CRT defibrillator-implants, one patient was admitted for heart failure exacerbation (8%). Using a time-varying covariate model, we did not observe statistically significant differences in the survival of patients with cancer implanted versus those not implanted with primary defibrillators (hazard ratio 0.521, p = 0.127). In conclusion, although primary defibrillator therapy is underutilized in patients with cancer, its relative benefit is limited because of competing risk of nonarrhythmic mortality. These findings highlight the need for personalized cardiologic and oncologic coevaluation.

Current challenges in the diagnosis and management of acute coronary syndromes in women

Cardiovascular disease remains the leading cause of death among women nowadays. However, there is a persistent lack of awareness of the impact of different risk factors on women's cardiovascular health, in specific pregnancy-related complications, hormonal changes, and psychological aspects. Moreover, there is still not enough awareness of the importance of coronary artery disease (CAD) in women, which leads to a delay in the diagnosis and prompt treatment, particularly during emergent coronary scenarios. Although guidelines suggest the same treatment for women and men who present with acute coronary syndrome (ACS), women are still undertreated. Contemporary data show an improvement over time in the management of ACS in women, however, women are still less likely than men to receive revascularization and pharmacological treatments. Women have higher rates of complications and mortality, in particular the young population, in which all outcomes are still worse in women compared to men. In this review, we aim to emphasize the importance of women's risk factors, women-specific pathophysiology, and clinical presentation in the setting of ACS. This is a review of current challenges in the diagnosis and treatment of women with ACS.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Assessment of Adult Patients with Long COVID Manifestations Suspected as Cardiovascular: A Single-Center Experience

Background: Persistent symptoms affect a subset of coronavirus disease 2019 (COVID-19) survivors. Some of these may be cardiovascular (CV)-related. Objective: To assess the burden of objective CV morbidity among, and to explore the short-term course experienced by, COVID-19 patients with post-infectious symptomatology suspected as CV. Methods: This was a single-center, retrospective analysis of consecutive adult patients with new-onset symptoms believed to be CV following recovery from COVID-19, who had been assessed at a dedicated ‘Cardio’-COVID clinic between June 2020 and June 2021. All participants were followed for 1 year for symptomatic course and the occurrence of new CV diagnoses and major adverse cardiovascular events (MACE). Results: A total of 96 patients (median age 54 (IQR, 44–64) years, 52 (54%) females) were included in the final analysis. Initial visits occurred within a median of 142 days after the diagnosis of acute COVID. Nearly all (99%) patients experienced a symptomatic acute illness, which was graded as severe in 26 (27%) cases according to the National Institutes of Health (NIH) criteria. Long-COVID symptoms included mainly dyspnea and fatigue. While the initial work-up was mostly normal, 45% of the 11 cardiac magnetic resonance studies performed revealed pathologies. New CV diagnoses were made in nine (9%) patients and mainly included myocarditis that later resolved. An abnormal spirometry was the only variable associated with these. No MACE were recorded. Fifty-two (54%) participants felt that their symptoms improved. No association was found between CV morbidity and symptomatic course. Conclusions: In our experience, long-COVID symptoms of presumed CV origin signified actual CV disease in a minority of patients who, irrespective of the final diagnosis, faced a fair 1-year prognosis.

Temporal trends in the management and outcome of obese patients with an acute coronary syndrome – the ACSIS registry 2000–2018

Introduction

Obesity has been increasing in epidemic proportions over many decades, and is clearly associated with major cardiovascular (CV) risk factors [1–2]. We aimed to examine temporal trends in the management and clinical outcomes of obese patients with an acute coronary syndrome (ACS).

Methods

Data from the ACSIS registry including all obese patients (calculated BMI of 30 or above) between the years 2000–2018. Patients were stratified by BMI to obesity classes: Class 1 – BMI 30–34; class 2 – BMI 35–39 and class 3 – BMI 40 and above. Clinical endpoints included 30d MACE and 1-year mortality. Temporal trends were examined in the late (2010–2018) vs. the early period (2000–2008).

Results

Among the 13,816 patients from the ACSIS registry with available BMI data, of whom 3567 were defined as obese, 2670 were in obesity class 1, 679 were in class 2, and 218 were defined as class 3. Patients in higher obesity classes had more CV risk-factors including dyslipidemia, hypertension, and diabetes mellitus (p&lt;0.01 for all interactions). Overall, invasive and pharmacological treatment has improved during time in all obesity classes. The rates of 30-day MACE were numerically higher among patients in class 3 (11.6% in class 1, 11.3% in class 2, and 15.6% in class 3, p-trend= 0.3), and so was the rate of 1-year mortality (7.3%, 7.3%, and 10.9%, respectively, p-trend = 0.1) Comparing the 2 time-periods, 30-day MACE was significantly lower in the late period in class 1 and 2, but has remained unchanged in class 3. Similarly, 1-year mortality has not changed during the years among patients in class 3, but has decreased among patients in classes 1 and 2 (8.6% to 5.8%, p=0.007, and 9.3% to 5.5%, p=0.08, respectively) [Figure 1].

Conclusions

In obese patients admitted with an ACS, the rates of 30-day MACE and 1-year mortality are numerically higher among patients who are extremely obese. During 2 decades, 30-day MACE and 1-year mortality have decreased among obesity classes 1 and 2, but remained unchanged among patients in class 3. Extremely obese patients admitted with an ACS are a particularly high-risk group and future efforts should examine treatment modalities in order to curtail this increased risk.

Funding Acknowledgement

Type of funding sources: None.

The obesity paradox in patients with acute coronary syndromes – is it still applicable to the current era? The ACSIS registry 2000–2018

Background

Obesity is a major epidemic which is associated with major cardiovascular (CV) risk factors. Nevertheless, substantial data, mostly published more than a decade ago, have demonstrated an obesity paradox, where obese patients generally have a better short- and long-term prognosis than do their leaner counterparts with the same CV profile. As for the obesity paradox in acute coronary syndrome (ACS), prior studies demonstrated that the body-mass index (BMI)-mortality association followed a “U” shape curve: it is the highest in underweight (BMI&lt;19) or severely obese (BMI &gt;44), and is the lowest in overweight or mildly obese patients (BMI 30–34 and BMI 35–39) [1–2]. It is not fully elucidated whether the obesity paradox is still relevant in the current era in patients with ACS. We aimed to examine temporal trends in the clinical outcomes of ACS patients by their BMI status.

Methods

Data from the ACSIS registry including all patients with calculated BMI data between the years 2000–2018. Patients were stratified by BMI groups to underweight, normal, overweight and obese. Clinical endpoints included 30d MACE, and 1-year mortality. Temporal trends were examined in the late (2010–2018) vs. the early period (2000–2008). Multivariable models examined factors associated with clinical outcomes by BMI status.

Results

Among the 13,816 patients from the ACSIS registry with available BMI data, 104 were underweight, 3921 were normal, 6224 were overweight and 3567 were obese. 1-year mortality was highest among underweight patients (24.8%), as compared to normal weight patients (10.7%) and lowest among overweight and obese patients (7.1% and 7.5% respectively; p for trend &lt;0.001) [Figure 1]. 30-day MACE rates were qualitatively similar (24.3% for underweight, 13.6% for normal weight, 11.6% for overweight, and 11.7% for obese; p for trend&lt;0.001). Comparing the 2 time-periods, 30-day MACE was significantly lower in the late period in all BMI groups, excluding patients who were underweight. Similarly, 1-year mortality has not changed during the years in underweight patients, and has decreased in normal weight and obese patients.

Conclusions

In ACS patients, during 2-decades, 30-day MACE and 1-year mortality were lower among overweight and obese patients compared with underweight and normal weight patients. During time, 30-day MACE and 1-year mortality have decreased among the majority of BMI groups, excluding the underweight patients, in which the rates were consistently high. Our findings suggest that the obesity paradox is still relevant in ACS patients in the current era.

Funding Acknowledgement

Type of funding sources: None.

Overall survival in the OlympiA phase III trial of adjuvant olaparib in patients with germline pathogenic variants in BRCA1/2 and high risk, early breast cancer

BACKGROUND

The randomized, double-blind OlympiA trial compared 1 year of the oral poly(adenosine diphosphate-ribose) polymerase inhibitor, olaparib, to matching placebo as adjuvant therapy for patients with pathogenic or likely pathogenic variants in germline BRCA1 or BRCA2 (gBRCA1/2pv) and high-risk, human epidermal growth factor receptor 2-negative, early breast cancer (EBC). The first pre-specified interim analysis (IA) previously demonstrated statistically significant improvement in invasive disease-free survival (IDFS) and distant disease-free survival (DDFS). The olaparib group had fewer deaths than the placebo group, but the difference did not reach statistical significance for overall survival (OS). We now report the pre-specified second IA of OS with updates of IDFS, DDFS, and safety.

PATIENTS AND METHODS

One thousand eight hundred and thirty-six patients were randomly assigned to olaparib or placebo following (neo)adjuvant chemotherapy, surgery, and radiation therapy if indicated. Endocrine therapy was given concurrently with study medication for hormone receptor-positive cancers. Statistical significance for OS at this IA required P < 0.015.

RESULTS

With a median follow-up of 3.5 years, the second IA of OS demonstrated significant improvement in the olaparib group relative to the placebo group [hazard ratio 0.68; 98.5% confidence interval (CI) 0.47-0.97; P = 0.009]. Four-year OS was 89.8% in the olaparib group and 86.4% in the placebo group (Δ 3.4%, 95% CI -0.1% to 6.8%). Four-year IDFS for the olaparib group versus placebo group was 82.7% versus 75.4% (Δ 7.3%, 95% CI 3.0% to 11.5%) and 4-year DDFS was 86.5% versus 79.1% (Δ 7.4%, 95% CI 3.6% to 11.3%), respectively. Subset analyses for OS, IDFS, and DDFS demonstrated benefit across major subgroups. No new safety signals were identified including no new cases of acute myeloid leukemia or myelodysplastic syndrome.

CONCLUSION

With 3.5 years of median follow-up, OlympiA demonstrates statistically significant improvement in OS with adjuvant olaparib compared with placebo for gBRCA1/2pv-associated EBC and maintained improvements in the previously reported, statistically significant endpoints of IDFS and DDFS with no new safety signals.

Peripheral artery disease, abnormal ankle-brachial index, and prognosis in patients with acute coronary syndrome

Objectives

Ankle-brachial index (ABI) is an independent prognostic marker of cardiovascular events among patients with coronary artery disease (CAD). We aimed to investigate the outcome of patients hospitalized with acute coronary syndrome (ACS) and abnormal ABI.

Approach and results

ABI was prospectively measured in 1,047 patients hospitalized due to ACS, who were stratified into three groups, namely, those with clinical peripheral artery disease (PAD) (N = 132), those without clinical PAD but with abnormal (< 0.9) ABI (subclinical PAD; N = 148), and those without clinical PAD with normal ABI (no PAD; N = 767). Patients were prospectively followed for 30-day major adverse cardiovascular event (MACE) and 1-year all-cause mortality. The mean age was 64 years. There was a significant gradual increase throughout the three groups in age, i.e., the incidence of prior stroke, diabetes mellitus, and hypertension (p for trend = 0.001 for all). The in-hospital course showed a gradual rise in the incidence of complications with an increase in heart failure [2.5, 6.1, and 9.2%, (p for trend = 0.001)] and acute kidney injury [2, 4.1, and 11.5%, (p for trend = 0.001)]. At day 30, there was a stepwise increase in MACE, such that patients without PAD had the lowest rate, followed by subclinical and clinical PADs (3.5, 6.8, and 8.1%, respectively, p for trend = 0.009). Similarly, there was a significant increase in 1-year mortality from 3.4% in patients without PAD, through 6.8% in those with subclinical PAD, to 15.2% in those with clinical PAD (p for trend = 0.001).

Conclusion

Subclinical PAD is associated with poor outcomes in patients with ACS, suggesting that routine ABI screening could carry important prognostic significance in these patients regardless of PAD symptoms.

Detecting Coronary Artery Disease using Exhaled Breath Analysis

INTRODUCTION

Coronary artery disease (CAD) is the leading cause of morbidity and mortality worldwide, and there is an unmet need for a simple, inexpensive, non-invasive tool aimed at CAD detection. The aim of this pilot study was to evaluate the possible use of breath analysis in detecting the presence of CAD.

MATERIALS AND METHODS

In a prospective study, breath from patients with no history of CAD who presented with acute chest pain to the emergency room was sampled using a designated portable electronic nose (eNose) system. First, breath samples from 60 patients were analyzed and categorized as obstructive, non-obstructive and no-CAD according to the actual presence and extent of CAD as was demonstrated on cardiac imaging (either computerized tomography angiography or coronary angiography). Classification models were built according to the results, and their diagnostic performance was then examined in a blinded manner on a new set of 25 patients. The data were compared with the actual results of coronary arteries evaluation. Sensitivity, specificity and accuracy were calculated for each model.

RESULTS

Obstructive CAD was correctly distinguished from non-obstructive and no-CAD with 89% sensitivity, 31% specificity, 83% negative predictive value (NPV), 42% positive predictive value (PPV) and 52% accuracy. In another model, any extent of CAD was successfully distinguished from no-CAD with 69% sensitivity, 67% specificity, 54% NPV, 79% PPV and 68% accuracy.

CONCLUSION

This proof-of-concept study shows that breath analysis has the potential to be used as a novel rapid, non-invasive diagnostic tool to help identify presence of CAD in patients with acute chest pain.

Association of socioeconomic status measures with physical activity and subsequent frailty in older adults

Background

Despite increased recognition, frailty remains a significant public health challenge.

Objective

we aimed to assess the role of education and income, as well as neighborhood socioeconomic status, on physical activity and subsequent frailty in older adults.

Methods

Using a population-based cohort of older adults, this study examined the relationship between socioeconomic status (SES) factors, physical activity and frailty. The study included 1,799 participants (mean [SD], 74.6 (6.2), 53.3% female) from the "National Health and Nutrition Survey of Older Adults Aged 65 and Over in Israel", conducted in 2005–2006. A follow-up interview was performed 12–14 years later in a subgroup of 601 subjects (mean [SD], age 84[4]; 56% women). Self-reported leisure-time physical activity (LTPA) was measured at both baseline and follow-up. SES measures were assessed at baseline. Frailty was measured at follow-up, using the Fried's Phenotype Model.

Results

All SES measures were strongly and positively associated with LTPA (all p < 0.001). Eighty-two participants (14%) were classified as frail at follow-up. After age and sex adjustment and accounting for attrition bias using inverse probability weighting, baseline LTPA (OR = 2.77, 95% CI: 1.57–4.90, for inactivity; OR = 1.41, 95% CI: 0.75–2.68, for insufficient activity, compared with sufficient activity, P_trend < 0.001) was inversely associated with incident frailty. The association persisted after further adjustment for SES and comorbidity.

Conclusion

Among older individuals, multiple SES measures were positively associated with LTPA, which was a strong predictor of lower subsequent frailty risk.

Association of socioeconomic status measures with physical activity and subsequent frailty in older adults

Funding Acknowledgements

Type of funding sources: None.

Background

Despite increased recognition, frailty remains a significant public health challenge.

Methods

Using a population-based cohort of older adults, this study examined the relationship between socioeconomic status (SES) factors, physical activity and frailty. The study included 1,799 participants (mean [SD], age 75[6]; 53% women) from the "National Health and Nutrition Survey of Older Adults Aged 65 and Over in Israel", conducted in 2005-2006. A follow-up interview was performed 12-14 years later in a subgroup of 601 subjects (mean [SD], age 84[4]; 56% women). Extensive data including self-reported leisure time physical activity (LTPA) and SES measures were assessed at baseline. Frailty was measured at follow-up.

Results

All SES measures were strongly and positively associated with LTPA (all p&lt;0.001). Eighty-two participants (14%) were classified as frail at follow-up. After age and sex adjustment and accounting for attrition bias using inverse probability weighting, baseline LTPA (OR=2.77, 95% CI: 1.57-4.90, for inactivity; OR=1.41, 95% CI: 0.75-2.68, for insufficient activity, compared with sufficient activity, Ptrend&lt;0.001) was inversely associated with incident frailty. The association persisted after further adjustment for SES and comorbidity.

Conclusion

Among older individuals, multiple SES measures were positively associated with LTPA, which was a strong predictor of lower subsequent frailty risk.

Edoxaban versus Warfarin in high-risk patients with atrial fibrillation: A comprehensive analysis of high-risk subgroups

BACKGROUND

To compare the efficacy and safety of edoxaban vs warfarin in high-risk subgroups.

METHODS

ENGAGE AF-TIMI 48 was a multicenter randomized, double-blind, controlled trial in 21,105 patients with atrial fibrillation (AF) within 12 months and CHADS₂ score >2 randomized to higher-dose edoxaban regimen (HDER) 60 mg/reduced 30 mg, lower-dose edoxaban regimen (LDER) 30 mg/reduced 15 mg, or warfarin, and followed for 2.8 years (median). The primary outcome for this analysis was the net clinical outcome (NCO), a composite of stroke/systemic embolism events, major bleeding, or death. Multivariable risk-stratification analysis was used to categorize patients by the number of high-risk features.

RESULTS

The annualized NCO rates in the warfarin arm were highest in patients with malignancy (19.2%), increased fall risk (14.0%), and very-low body weight (13.5%). The NCO rates increased with the numbers of high-risk factors in the warfarin arm: 4.5%, 7.2%, 9.9% and 14.6% in patients with 0 to 1, 2, 3, and >4 risk factors, respectively (P_trend <0.001). Versus warfarin, HDER was associated with significant reductions of NCO in most of the subgroups: elderly, patients with moderate renal dysfunction, prior stroke/TIA, of Asian race, very-low body weight, concomitant single antiplatelet therapy, and VKA-naïve. With more high-risk features (0->4+), the absolute risk reductions favoring edoxaban over warfarin increased: 0.3%->2.0% for HDER; 0.4%->3.4% for LDER vs warfarin (P = .065 and P < .001, respectively).

CONCLUSIONS

While underuse of anticoagulation in high-risk patients with AF remains common, substitution of effective and safer alternatives to warfarin, such as edoxaban, represents an opportunity to improve clinical outcomes.

Management and outcomes over time of acute coronary syndrome patients at particularly high cardiovascular risk : the ACSIS registry-based retrospective study

OBJECTIVE

Some patients following acute coronary syndrome (ACS) are at particularly increased risk for recurrent cardiovascular events. We aimed to examine temporal trends in the management and outcomes across the spectrum of these particularly high-risk patients.

DESIGN AND SETTING

A retrospective study based on the ACS Israeli survey (ACSIS) registry, a multicentre prospective national registry, taking place biennially in 25 cardiology departments in Israel. Temporal trends were examined in the early (2002-2008) and late (2010-2018) time periods.

PARTICIPANTS

Consecutive patients with ACS enrolled in the ACSIS registry were stratified according to the Thrombolysis in Myocardial Infarction Risk Score for secondary prevention (TRS2^°P) to high (TRS2^°p=3), very high (TRS2^°p=4) or extremely high risk (TRS2^°p=5-9). Patients with TRS2^°p<3 were excluded. From the initial 15 196 patients enrolled, 5359 patients were eventually included.Clinical outcome measures included 30-day major adverse cardiovascular events (MACE) and 1-year mortality.

RESULTS

Among 5359 patients (50% high risk, 30% very high risk and 20% extremely high risk), those with a higher risk were older, had more comorbidities, presented more with non-ST elevation myocardial infarction, and were treated less often with guideline-recommended pharmacotherapy and percutaneous coronary intervention. Over time, treatment has improved in all risk strata, and the rate of 30-day MACE has significantly decreased in all risk groups (from 21% to 10%, from 22% to 15%, and from 26% to 16%, in high, very high and extremely high-risk groups, respectively, p<0.001 for each). However, 1-year mortality decreased only among high and very high-risk patients, and not among extremely high-risk patients in whom 1-year mortality rates remained very high (28.7% vs 28.9%, p=1).

CONCLUSION

Within a particularly high-risk cohort of patients with ACS, treatment has significantly progressed over almost 2 decades. While short-term outcomes have improved in all risk groups, 1-year mortality has remained unchanged in extremely high-risk patients with ACS.

Temporal Trends and Outcome of Patients with Acute Coronary Syndrome and Prior Myocardial Infarction

Patients who have previously had a myocardial infarction (MI) are considered a high-risk group with increased risk for cardiovascular (CV) events. During the last decade, the outcome of acute coronary syndrome (ACS) patients has improved due to advances in medical therapy and interventional techniques. We aimed to examine temporal trends and outcomes of patients with prior MI admitted due to ACS from the Acute Coronary Syndrome Israeli Survey (ACSIS). Included were 16,934 ACS patients, of whom 31.4% had prior MI. For temporal trend analysis, the cohort was divided into an early period (2000-2008) and late period (2010-2018). For patients with prior MI, patients in the late period had a higher rate of CV risk factors and were treated more frequently with revascularization and guidelines-directed medical therapy. Recurrent MI (6.7% vs. 12%, p < 0.001), MACE (10.6% vs. 21%, p < 0.001) and 1-year mortality (10.7% vs. 14.6%, p < 0.001) were significantly lower in the late period. However, the mortality rate for patients with prior MI remained higher compared with patients without prior MI (10.7% vs. 6.8% p < 0.001) with an overall higher mortality rate in the STEMI group. Thus, despite significant improvement in outcome measures in the contemporary era, ACS patients with prior MI are still at increased risk for recurrent ischemic CV events and mortality.

Diffused coronary involvement in Takayasu arteritis with concomitant malignancy

Large vessel vasculitis (LVV) is composed of conditions in which inflammation of blood vessel walls affects mainly large arteries, such as the aorta and its main branches, and in some cases the coronary arteries. Coronary artery involvement in systemic vasculitis is associated with significant morbidity and mortality. We present a case of a young patient diagnosed with extensive coronary disease diagnosed as Takayasu arteritis, when whom a concomitant diagnosis of Hodgkin's lymphoma was made. The literature review revealed ten cases of malignancies associated with Takayasu arteritis. We discuss the complexity of the management of concurrent hematological malignancy with TAK and extensive coronary arteritis. This complicated and cross-disciplinary case also represents the pivotal importance of multi-disciplinary team decision in order to achieve the best clinical outcome of both disorders.

Worse outcomes of ACS patients without versus with traditional cardiovascular risk factors

INTRODUCTION

Up to 20% of patients presenting with acute coronary syndrome (ACS) have no traditional cardiovascular risk-factors (RFs). Data regarding the determinants, management, and outcomes of these patients are scarce.

OBJECTIVES

To evaluate the management, outcomes, and time-dependent changes of ACS patients without RFs.

METHODS

Evaluation of clinical characteristics, management strategies, and outcomes as well as time-dependent changes [by 3 time periods: early (2000-2006), mid (2008-2013), and late (2016-2018)] of ACS patients without RFs (diabetes mellitus, hypertension, dyslipidemia, family history of ischemic heart disease, and smoking) or known coronary artery disease, enrolled in the biennial ACS Israeli Surveys (ACSIS) between 2000 and 2018. We compared ACS patients without RFs (no-RF group) to those with ≥1 RFs (RF group).

RESULTS

Overall, 554/9,683 (5.7%) eligible ACS patients did not have any RFs [median age 63 (IQR 52-76) years, 25% females]. The no-RF group were older, with lower body mass index and prevalence of other cardiovascular comorbidity and chronic kidney disease compared with the RF group. The in-hospital percutaneous coronary intervention rates were lower among the no-RF vs. the RF group (55% vs. 66%, respectively p<0.001). Furthermore, lower rate of guideline-recommended medical therapy upon discharge was prescribed in the no-RF group. The rate of in-hospital complications was greater in the no-RF vs. RF group (31.6% vs. 26.1%, respectively p=0.005). The rates of 30-day major adverse cardiovascular events (MACE; 17.6% vs.12.8%, respectively, p=0.002) and of 30-day and 1-year all-cause mortality (8.4% vs. 4.2%, p<0.001 and 11.4% vs. 7.7%, p=0.003 respectively) were higher among patients with no-RF vs. RF. Following propensity score matching 30-day MACE, 30-day and 1-year mortality risk remained higher in the no-RF group. The rate of 30-day MACE decreased between the early and the late study period in the no-RF group (21.5% vs. 10.5%, p=0.003, respectively).

CONCLUSIONS

ACS patients without traditional cardiovascular risk-factors comprise a unique group with reduced prevalence of comorbidities yet significantly worse outcomes. Additional research to identify unique risk-factors and targets for interventions to improve outcomes of this group of patients is warranted.

Temporal Trends in the Characteristics, Treatment, and Outcomes of Conservatively Managed Patients With Non-ST Elevation Acute Coronary Syndrome (from the ACSIS Registry 2000 to 2016)

Despite advances in percutaneous coronary interventions (PCI), a subgroup of acute coronary syndrome (ACS) patients are still managed medically by a conservative approach. We sought to characterize a contemporary, large-scale, real-world cohort of ACS patients treated conservatively via pharmacological management, without PCI. Data was gathered from the ACS Israeli Survey (ACSIS) between 2000 and 2016, encompassing all consecutive patients admitted to cardiology wards with an ACS diagnosis. Included were 3,543 conservatively managed patients with non-ST elevation ACS (NSTE-ACS). Patients with ST elevation MI or those who underwent any coronary revascularization (PCI or bypass surgery) were excluded. Primary endpoints were 30-day major adverse cardiovascular events (MACE) and 1-year mortality. The study cohort was divided to 4 time-periods. Over 2 decades, medically managed NSTE-ACS patients remained of similar age (67 ± 13 years, p = 0.78), but had more atherosclerotic risk-factors and comorbidities. During time, patients were more often referred to diagnostic angiography and treated with statins, ACE-I/ARBs, and P2Y12 inhibitors (p < 0.001 for each). Over time, there were less in-hospital complications such as kidney injury and heart failure. The rate of 30-day MACE decreased (from 20.7% to 10.3%, earliest to latest period, p < 0.001). Compared with the earliest period, the latest period was associated with a reduction in 1-year mortality (14.7% to 11.6%; adjusted HR 0.65, 95% CI 0.47 to 0.90). In conclusion, Over 2 decades, in medically managed NSTE-ACS patients, short term prognosis has significantly improved while 1-year mortality demonstrated improvement only recently, likely due to incremental benefits of medical management.

Myocarditis following COVID-19 vaccination: magnetic resonance imaging study

AIMS

To describe the cardiac magnetic resonance (CMR) imaging findings of patients who developed myocarditis following messenger RNA (mRNA) coronavirus disease 2019 (COVID-19) vaccination.

METHODS AND RESULTS

The present study retrospectively evaluated patients with clinically adjudicated myocarditis within 42 days of the first Pfizer-BNT162b2 mRNA COVID-19 vaccination, between 20 December 2020 and 24 May 2021 who underwent CMR. A total of 15 out 54 patients (28%) with myocarditis underwent a CMR and were included, 100% males, median age of 32 years (interquartile range = 22.5-40). Most patients presented with chest pain (87%) and had an abnormal electrocardiogram (79%). The severity of the disease was mild in 67% and intermediate in 33%. All patients survived and one patient was readmitted during the study period. CMR was performed at a median of 65 days (range 3-130 days) following diagnosis. Median ejection fraction was 58% (range 51-74%) global- and regional wall motion abnormalities were present in one and three patients, respectively. Native T1 was available in 13/15 patients (2/3 in 3 T and 11/12 in the 1.5 T), with increased values among 6/13. Late gadolinium enhancement (LGE) was found among 13/15 patients with a median of 2% (range 0-15%) with inferolateral wall being the most common location (8/13). The patterns of the LGE were: mid-wall in six patients; epicardial in five patients; and mid-wall and epicardial in two patients.

CONCLUSIONS

Among patients who were diagnosed with post-vaccination clinical myocarditis, CMR imaging findings are mild and consistent with 'classical myocarditis'. The short-term clinical course and outcomes were favourable.

Coronary Artery Disease in Women: A Comprehensive Appraisal

Coronary artery disease (CAD) is a significant cause of illness and death amongst women. The pathophysiology, manifestations, and outcomes of CVD and CAD differ between sexes. These sex differences remain under-recognized. The aim of this review is to highlight and raise awareness of the burden and unique aspects of CAD in women. It details the unique pathophysiology of CAD in women, cardiovascular risk factors in women (both traditional and sex-specific), the clinical presentation of CAD in women, and the range of disease in obstructive and non-obstructive CAD in women.

Worse outcomes of ACS patients without versus with traditional cardiovascular risk factors

Introduction

Approximately 5–15% patients presenting with acute coronary syndrome were found to have no traditional cardiovascular risk factors (RFs). Data regarding the determinants, management and outcomes of these patients are scarce.

Purpose

To evaluate the management, outcomes and time dependent changes of ACS patients without RFs.

Methods

Evaluation of clinical characteristics, management strategies, and outcomes as well as time dependent changes (by 3 time periods: early [2000–2006], mid [2008–2013], and late [2016–2018]) of ACS patients without RFs (diabetes mellitus, hypertension, dyslipidemia, family history of IHD and current or past smoking) or known coronary artery disease, enrolled in the biennial ACS Israeli Surveys (ACSIS) between 2000 and 2018. We compared ACS patients without RFs (RF−) to those ≥1 RFs (RF+).

Results

Overall 583 out of 10,324 (5.6%) eligible ACS patients did not have any RFs (median age 64 [IQR 52–77], 25% females]. The RF− group were older, more educated, with lower BMI and prevalence of another cardiovascular comorbidity and chronic kidney disease compared with the RF+ group. The in-hospital PCI rates were lower among the RF− vs. the RF+ group (55% vs. 66%, respectively p&lt;0.001). Furthermore, lower rate of guideline-recommended medical therapy upon discharge were prescribed in the RF− vs. the RF+ group. The rate of in-hospital complications was greater in the RF− vs. RF+ group (31.4% vs. 26.1%, respectively p=0.006). The rates of 30-day major adverse cardiac events (MACE) were significantly higher among patients with RF− vs. RF+ (18.1% vs.12.8%, respectively p&lt;0.001). Similarly, the rates of 30-day and 1-year all-cause mortality (figure 1) were higher among patients with RF− vs. RF+ (8.7% vs. 4.2%, p&lt;0.001 and 11.9% vs. 7.7% p&lt;0.001 respectively). A trend of decline in the rate of MACE was observed between the early and the late study period in the RF− group (22% vs. 10.7% p=0.002 respectively). One-year mortality did not decrease significantly in the RF− group during the study periods (13.6% vs. 10% early vs. late period respectively p=0.16).

Conclusions

ACS patients without traditional cardiovascular risk factors comprise a unique group with reduced prevalence of comorbidities yet significantly worse short-and long-term outcomes. Additional research to identify unique risk factors and targets for interventions to improve outcomes of this group of patients is warranted.

Funding Acknowledgement

Type of funding sources: None.

Cardio-COVID clinic – a one-center experience

Background

Persistent symptoms affect a relatively large portion of coronavirus disease (COVID) survivors. Hence, specific clinics had been established in order to better characterize and manage this emerging entity of Post-COVID, among them our Cardio-COVID Clinic, which is dedicated to the cardiovascular (CV) aspects of the phenomenon.

Aim

To present the experience of our Cardio-COVID Clinic.

Methods

Included in this report are 76 adult patients seen at the clinic between June 2020 and March 2021, who have recovered from a polymerase chain reaction (PCR)-confirmed COVID, and who were suspected by their referring physicians to experience ongoing cardiac sequelae. All participants underwent a structured assessment by a single cardiologist, which consisted of history taking, physical examination (PE), electrocardiogram (ECG), trans-thoracic echocardiogram (TTE), and further tests as deemed appropriate, including any combination of Holter, ischemic provocation test, cardiopulmonary exercise test (CPET), cardiac magnetic resonance (CMR), and cardiac computed tomography (CCT).

Results

Initial visits occurred within a median of 131 days after diagnosis. Most participants (83%) were referred from our general Long-COVID Clinic. About half were males, and the mean age was 53 years. 18% of participants had prior CV conditions, and the majority (72%) had at least one CV risk factor, mostly dyslipidemia. Nearly all participants experienced a symptomatic acute illness, which was graded according to the National Institutes of Health (NIH) criteria as severe in 23% of the study cohort. As for Post-COVID, late symptoms were present in 97% of patients, the most common being dyspnea (57%). While PE was unremarkable in all but 3 patients who exhibited murmurs, ECG findings were revealed in 45% – mostly non-specific ST-T changes (31%) and conduction abnormalities (14%) – and TTE aberrations were discovered in 28% – including pericardial effusion (24%), reduced left ventricular ejection fraction (LVEF) (5%), grade 2 diastolic dysfunction (3%), moderate and up valvular dysfunction (1%), and systolic pulmonary hypertension (1%); right ventricular function was universally normal. Upon conclusion of the work-up, CV diagnoses were made in 8 (11%) patients – including myocarditis (4), myopericarditis (1), inappropriate sinus tachycardia (1), chronotropic incompetence (1), and an aberrant coronary (1). Of note, CPET and CMR had the highest diagnostic yield, in light of 57% positive results on each – followed by CCT, Holter, and provocation test. Interesting as well, among those with abnormal CMR findings, 40% had normal ECG's and TTE's. Also, none of the CV restraints on CPET translated to provocation test anomalies.

Conclusion

CV symptoms of Post-COVID are highly prevalent, but signify actual CV disease only in a minority of patients. Further research is needed that will help identify predictors for CV morbidity and define optimal clinical pathways.

Funding Acknowledgement

Type of funding sources: None.

Incidence, determinants and impact of acute kidney injury in ACS patients with versus without diabetes mellitus

Introduction

Acute kidney injury (AKI) is a common complication in patients presenting with acute coronary syndrome (ACS), particularly following percutaneous coronary intervention (PCI). Patients with diabetes mellitus (DM) are considered to be at increased risk for AKI in this setting. However, data regarding the incidence, risk factors and outcomes of AKI in diabetic patients compared to non-diabetics presenting with ACS is scarce.

Purpose

To evaluate the incidence, risk factors and outcomes of AKI in patients with vs. without DM who are admitted with ACS.

Methods

ACS patients enrolled in the biannual ACS Israeli Surveys (ACSIS) between 2000 and 2018 were analyzed. AKI was defined as an absolute increase in serum creatinine (≥0.5 mg/dL) or above 1.5 mg/dL or new renal replacement therapy upon admission with ACS. Outcomes included 30-day major adverse cardiovascular events (MACE) and 1-year all-cause mortality.

Results

The current study included a total of 16,879 patients, median age 64 (IQR 54–74), 77% males, 36% with DM. The incidence of AKI was significantly higher among patients with vs. without DM (8.4% vs. 4.7%, p&lt;0.001). The rates of 30-day MACE (40.8% vs. 13.4%, p&lt;0.001) and 1-year mortality (43.7% vs. 10%, p&lt;0.001) were significantly greater among patients who developed vs. those that did not develop AKI respectively yet very similar in diabetics and non-diabetics.

Multivariate analyses (figure 1) adjusted to potential confounders showed similar independent predictors of AKI among patients with and without DM comprising; older age, chronic kidney disease, congestive heart failure, and peripheral arterial disease

Conclusions

Although patients with DM are at greater risk for AKI when admitted with ACS, the independent predictors of AKI and the worse patient outcomes when AKI occurs, are similar and irrespective to DM.

Funding Acknowledgement

Type of funding sources: None.

Temporal trends in the characteristics, treatment and clinical outcomes of conservatively managed patients with non-ST elevation acute coronary syndrome: ACSIS registry 2000–2016

Background

Despite advances in percutaneous coronary interventions (PCI), a sub group of acute coronary syndrome (ACS) patients are still managed medically by a conservative approach. We sought to characterize a contemporary, large-scale, real-world cohort of ACS patients treated conservatively via pharmacological management, without PCI.

Methods

Data from the ACS Israeli Survey (ACSIS) accrued between 2000–2016, encompassing all consecutive patients admitted to cardiology wards with an ACS diagnosis. Examined were 3543 conservatively managed patients with non-ST elevation ACS (NSTE-ACS). Patients with ST elevation MI or those referred to bypass surgery were excluded. Primary endpoints were 30-day major adverse cardiovascular events (MACE) and 1-year mortality. The study cohort was divided to 4 time-periods.

Results

Over 2 decades, medically managed NSTE-ACS patients remained of similar age (67±13y, p=0.78), but had more atherosclerotic risk-factors and comorbidities. During time, patients were more often referred to diagnostic angiography and treated with statins, ACE-I/ARBs, and P2Y12 inhibitors (p&lt;0.001 for each). Over time, there were less in-hospital complications such as kidney injury and heart failure. The rate of 30-day MACE decreased (from 20.7% to 10.3%, earliest to latest period, p&lt;0.001). Compared with the earliest period, the latest period was associated with a reduction in 1-year mortality (14.7% to 11.6%; adjusted HR 0.65, 95% CI 0.47–0.90).

Conclusions

Over two decades, in medically managed NSTE-ACS patients, short term prognosis has significantly improved while 1-year mortality demonstrated improvement only recently, likely due to incremental benefits of medical management. Further studies are needed to examine treatment modalities in these unique ACS patients.

Funding Acknowledgement

Type of funding sources: None. Kaplan Meier survival curvesTrends in management and Angiographies

The Effect of Tafamidis on Circulating Endothelial Progenitor Cells in Patients with Transthyretin Cardiac Amyloidosis

AIMS

Endothelial microvascular dysfunction is a known mechanism of vascular pathology in cardiac amyloidosis (CA). Scientific evidence regarding the possible protective role of the amyloid transthyretin (ATTR) stabilizer, tafamidis, is lacking. Circulating endothelial progenitor cells (cEPCs) have an important role in the process of vascular repair. We aimed to examine the effect of tafamidis on cEPCs.

METHODS AND RESULTS

Study population included patients with ATTR-CA. cEPCs were assessed using flow cytometry by the expression of CD34⁽⁺⁾/CD133⁽⁺⁾ and vascular endothelial growth factor receptor (VEGFR)-2⁽⁺⁾ and by the formation of colony-forming units (CFUs) and production of VEGF. Tests were repeated at pre-specified time-points up to 12 months following the initiation of tafamidis. Included were 18 ATTR-CA patients at a median age of 77 (IQR 71, 85) years and male predominance (n = 15, 83%). Following the initiation of tafamidis and during 12 months of drug treatment, there was a gradual increase in the levels of CD34⁽⁺⁾/VEGFR-2⁽⁺⁾ (0.43 to 2.42% (IQR 1.53, 2.91)%, p = 0.002) and CD133⁽⁺⁾/VEGFR-2⁽⁺⁾ (0.49 to 1.64% (IQR 0.97, 2.90)%, p = 0.004). Functionally, increase in EPCs-CFUs was microscopically evident following treatment with tafamidis (from 0.5 CFUs (IQR 0.0, 1.0) to 3.0 (IQR 1.3, 3.8) p < 0.001) with a concomitant increase in EPC's viability as demonstrated by an MTT assay (from 0.12 (IQR 0.03, 0.16) to 0.30 (IQR 0.18, 0.33), p < 0.001). VEGF levels increased following treatment (from 54 (IQR 52, 72) to 107 (IQR 62, 129) pg/ml, p = 0.039).

CONCLUSIONS

Tafamidis induced the activation of the cEPCs pathway, possibly promoting endothelial repair in ATTR-CA.

Temporal trends in the pre-procedural TIMI flow grade among patients with ST- segment elevation myocardial infarction - From the ACSIS registry

•

Preprocedural TIMI flow grade remains of prognostic significance.

•

Patients with TIMI 0 have a poorer prognosis than their counterparts with TIMI 1-3.

•

In-hospital complications have decreased among patients with TIMI 0 over time.

•

30-d MACE and 1-year mortality remained unchanged in those with TIMI 0 or 1-3.

Background

Pre-procedural TIMI coronary flow grade in patients with ST segment elevation myocardial infarction (STEMI) is associated with adverse clinical outcomes. There have been great advances in pharmacologic and invasive treatment of STEMI patients in the current era. We aimed to assess the temporal trends in clinical outcomes according to the TIMI flow grade amongst these patients.

Methods

Data of patients with STEMI from the acute coronary syndrome Israeli Survey (ACSIS) registry. A time-dependent analysis stratifying patient by TIMI flow grade 0 and TIMI flow grade 1–3 was performed. Survey years were divided to early (2008–2010) and late period (2013–2018). Clinical outcomes included in-hospital complications, 30d MACE (death, myocardial infarction, stroke, unstable angina, stent thrombosis, urgent revascularization) and 1-year mortality.

Results and Conclusions: Included were 2453 patients. The majority of patients had pre-procedural TIMI flow 0 (58.9% in the early period and 58.7% in the late period, P = 0.97). In-hospital complications of patients with TIMI flow 0 has significantly decreased over time (36.1% vs 26.8%, P < 0.001) but not amongst patients with TIMI flow 1–3. Compared with TIMI flow 1–3, patients with TIMI flow 0 had worse 30d MACE and 1-year mortality. There was no temporal change of these outcomes in either TIMI flow grade group. TIMI flow grade 0 is still more common among patients with STEMI and is associated with poorer prognosis. Nevertheless, over time, in-hospital complications have decreased among patients with TIMI 0, while 30d MACE and 1-year mortality has remained unchanged.

Management and outcome across the spectrum of high-risk patients with myocardial infarction according to the thrmobolysis in myocardial infarction (TIMI) risk-score for secondary prevention

Background

Patients with myocardial infarction (MI) are at increased risk for recurrent cardiovascular events, yet some patients, such as the elderly and those with prior comorbidities, are particularly at the highest risk. Whether these patients benefit from contemporary management is not fully elucidated.

Methods

Included were consecutive patients with MI who underwent percutaneous coronary intervention (PCI) in a large tertiary medical center. Patients were stratified according to the thrombolysis in myocardial infarction (TIMI) risk score for secondary prevention (TRS2°P) to high (TRS2°P = 3), very high (TRS2°P = 4), or extremely high‐risk (TRS2°P = 5–9). Excluded were low and intermediate‐risk patients (TRS2°P < 3). Outcomes included 30‐day/1‐year major adverse cardiac events (MACE) and 1‐year mortality. Temporal trends were examined in the early (2004–2010) and late (2011–2016) time‐periods.

Results

Among 2053 patients, 50% were high‐risk, 30% very high‐risk and 20% extremely high‐risk. Extremely high‐risk patients were older (age 74 ± 10 year) and had significant comorbidities (chronic kidney disease 68%, prior CABG 40%, heart failure 78%, peripheral artery disease 29%). Drug‐eluting stents and potent antiplatelets were more commonly used over time in all risk‐strata. Over time, 30‐day MACE rates have decreased, mainly attributed to the very high (11.3% to 5.1%, p = .006) and extremely high‐risk groups (15.9% to 8.0%, p = .016), but not the high‐risk group, with similar quantitative results for 1‐year MACE. The rates of 1‐year mortality remained unchanged in either group.

Conclusion

Within a particularly high‐risk cohort of MI patients who underwent PCI, the implementation of guideline‐recommended therapies has improved over time, with the highest‐risk groups demonstrating the greatest benefit in outcomes.

Report from a large and comprehensive single-center Women's Health Cardiology Clinic

Objective:

This article describes the women population and work at a unique Women’s Health Cardiology Clinic in order to raise cardiovascular disease awareness with an emphasis on women-specific risk factors, and thus to improve women’s clinical outcomes. This expectantly will aid in opening similar centers allowing more women to get superior care.

Methods:

Electronic medical records of women referred to the Women’s Health Cardiology Clinic were analyzed. The statistical analysis is descriptive in nature. Women’s Health Cardiology Clinic personnel work as a multidisciplinary team, and patients receive specialized diagnostic tests and treatments. Referrals are by physicians according to traditional and women’s specific risk factors for cardiovascular disease.

Results:

985 women visited the Women’s Health Cardiology Clinic, accumulating 2062 visits. Median age was 57.5 years. The majority of the women were menopausal (575 women, 58%), 62 pregnant with complications and 25 oncology patients. At least, 30% of women had diabetes/hypertension/or dyslipidemia. 72 women had a history of either cerebrovascular event or acute coronary syndrome, and 139 women had evidence of atherosclerosis. Overall, 388 women underwent endothelial function test, 40% of these women had a score indicating endothelial dysfunction. 277 women underwent a psychological intervention.

Conclusion:

Described here are the experiences from a multidisciplinary Women’s Health Cardiology Clinic using a gender-specific cardiovascular care approach for women geared toward improved health and wellbeing. It is of utmost importance that this report will raise women-specific cardiovascular disease risk factors awareness in order to promote women’s cardiovascular and overall health.

Natural history and disease progression of early cardiac amyloidosis evaluated by echocardiography

Funding Acknowledgements

Type of funding sources: None.

Background

Since the diagnosis of cardiac amyloidosis (CA) is often delayed, echocardiographic findings are frequently indicative of already advanced cardiomyopathy.

Aims

to describe early echocardiographic features in patients subsequently diagnosed with CA and to delineate disease progression.

Methods

Pre-amyloid diagnosis echocardiographic studies were screened for structural and functional parameters and stratified according to the pathogenetic amyloid subtype (immunoglobulin light-chain (AL) or amyloid transthyretin (ATTR)). Abnormalities were defined based on published guidelines.

Results

Our cohort included 75 CA patients of whom 42 (56%) were diagnosed with AL and 33 (44%) with ATTR. Forty-two patients had an earlier echocardiography exam available for review. Patients presented with increased wall thickness (1.3 (IQR 1.0, 1.5)cm) ≥3 years before the diagnosis of CA and relative wall thickness (RWT) was increased (0.47 (IQR 0.41, 0.50)) ≥7 years pre-diagnosis. Between 1 to 3 years before CA diagnosis restrictive left ventricular (LV) filling pattern was present in 19% of patients and LV ejection fraction (LVEF)≤50% was present in 21% of patients. Right ventricular dysfunction was detected concomitantly with disease diagnosis. The echocardiographic phenotype of ATTR versus AL-CA showed increased RWT (0.74 (IQR 0.62, 0.92) vs. 0.62 (IQR 0.54, 0.76), p = 0.004) and LV mass index (144 (IQR 129, 191) vs. 115 (IQR 105, 146)g/m2,p = 0.020) and reduced LVEF (50 (IQR 44, 58) vs. (60 (IQR 53, 60)%, p = 0.009) throughout the time course of CA progression, albeit survival time was similar.

Conclusions

Increased wall thickness and diastolic dysfunction in CA develop over a time course of several years and can be diagnosed in their earlier stages by standard echocardiography

Abstract Figure. Schematic proposed timeline of CA

Thrombin Generation in Patients with Atrial Fibrillation Undergoing Percutaneous Coronary Intervention

BACKGROUND

The optimal antithrombotic treatment for patients with atrial fibrillation (AF) that undergo percutaneous coronary intervention (PCI) is controversial. Dual therapy (clopidogrel and a direct oral anticoagulant [DOAC]) is safer than triple therapy (warfarin, aspirin, and clopidogrel), while efficacy is unclear. We aimed to evaluate thrombin generation (TG) under dual and triple therapy.

METHODS

A noninterventional prospective trial in patients with AF undergoing PCI. Patients received 4 weeks of triple therapy with aspirin, clopidogrel, and a DOAC followed by aspirin withdrawal. TG was measured in platelet-rich plasma (PRP) and platelet-poor plasma (PPP) at 3 five to 21 points, day 1 after PCI (TIME 0), 4 weeks after PCI (TIME 1), and 2 weeks after aspirin withdrawal (TIME 2).

RESULTS

Twenty-three patients (18 men, median age 78 years, 83% with acute coronary syndrome) were included. Endogenous thrombin potential (ETP) in PPP was high at TIME 0 compared with TIME 1 (ETP 3,178 ± 248 nM vs. 2,378 ± 222 nM, p = 0.005). These results remained consistent when measured in PRP. No significant difference in ETP was found before (TIME 1) and after aspirin withdrawal (TIME 2) although few patients had high ETP levels after stopping aspirin.

CONCLUSIONS

TG potential is high immediately after PCI and decreases 4 weeks after PCI in patients receiving triple therapy. TG remains constant after aspirin withdrawal in most patients, suggesting that after 1 month the antithrombotic effect of dual therapy may be similar to triple therapy.

Outcome of patients with prior coronary bypass surgery admitted with an acute coronary syndrome

BACKGROUND

Patients with prior coronary artery bypass graft surgery (CABG) are at increased risk for recurrent cardiovascular ischaemic events. Advances in management have improved prognosis of patients with acute coronary syndrome (ACS), yet it is not known whether similar trends exist in patients with prior CABG.

AIM

Examine temporal trends in the prevalence, treatment and clinical outcomes of patients with prior CABG admitted with ACS.

METHODS

Time-dependent analysis of patients with or without prior CABG admitted with an ACS who enrolled in the ACS Israeli Surveys between 2000 and 2016. Surveys were divided into early (2000-2008) and late (2010-2016) time periods. Outcomes included 30 days major adverse cardiac events (30d MACE) (death, myocardial infarction, stroke, unstable angina, stent thrombosis, urgent revascularisation) and 1-year mortality.

RESULTS

Among 15 152 patients with ACS, 1506 (9.9%) had a prior CABG. Patients with prior CABG were older (69 vs 63 years), had more comorbidities and presented more with non-ST elevation-ACS (82% vs 51%). Between time periods, utilisation of antiplatelets, statins and percutaneous interventions significantly increased in both groups (p<0.001 for each). The rate of 30d MACE decreased in patients with (19.1%-12.4%, p=0.001) and without (17.4%-9.5%, p<0.001) prior CABG. However, 1-year mortality decreased only in patients without prior CABG (10.5% vs 7.4%, p<0.001) and remained unchanged in patients with prior CABG. Results were consistent after propensity matching.

CONCLUSIONS

Despite an improvement in the management and prognosis of patients with ACS in the last decade, the rate of 1-year mortality of patients with prior CABG admitted with an ACS remained unchanged.

The Effect of Proprotein Convertase Subtilisin Kexin Type 9 Inhibitors on Circulating Endothelial Progenitor Cells in Patients with Cardiovascular Disease

PURPOSE

Circulating endothelial progenitor cells (cEPCs) are vital to vascular repair by re-endothelialization. We aimed to explore the effect of proprotein convertase subtilisin kexin type 9 inhibitors (PCSK9i) on cEPCs hypothesizing a possible pleiotropic effect.

METHODS

Patients with cardiovascular disease (CVD) were sampled for cEPCs at baseline and following the initiation of PCSK9i. cEPCs were assessed using flow cytometry by the expression of CD34⁽⁺⁾/CD133⁽⁺⁾ and vascular endothelial growth factor receptor (VEGFR)-2⁽⁺⁾, and by the formation of colony-forming units (CFUs) and production of VEGF.

RESULTS

Our cohort included 26 patients (median age 68 (IQR 63, 73) years; 69% male). Following 3 months of treatment with PCSK9i and a decline in low-density lipoprotein cholesterol levels (153 (IQR 116, 176) to 56 (IQR 28, 72) mg/dl), p < 0.001), there was an increase in CD34⁽⁺⁾/CD133⁽⁺⁾ and VEGFR-2⁽⁺⁾ cell levels (0.98% (IQR 0.37, 1.55) to 1.43% (IQR 0.90, 4.51), p = 0.002 and 0.66% (IQR 0.22, 0.99) to 1.53% (IQR 0.73, 2.70), p = 0.05, respectively). Functionally, increase in EPCs-CFUs was microscopically evident following treatment with PCSK9i (1 CFUs (IQR 0.0, 1.0) to 2.5 (IQR 1.5, 3), p < 0.001) with a concomitant increase in EPC's viability as demonstrated by an MTT assay (0.15 (IQR 0.11, 0.19) to 0.21 (IQR 0.18, 0.23), p < 0.001). VEGF levels increased following PCSK9i treatment (57 (IQR 18, 24) to 105 (IQR 43, 245), p = 0.006).

CONCLUSIONS

Patients with CVD treated with PCSK9i demonstrate higher levels of active cEPCs, reflecting the promotion of endothelial repair. These findings may represent a novel mechanism of action of PCSK9i.

Acute Presentation of Normal Pressure Hydrocephalus After Transcatheter Aortic Valve Implantation: A Novel Interaction Between the First and Third Circulations

BACKGROUND

Idiopathic normal pressure hydrocephalus (iNPH) negatively affects gait and cognition abilities and urine continence in the elderly. It is associated with systemic hypertension, although the exact pathophysiology is still unknown. A correlation to increased intracranial pulsatility and decreased compliance was suggested. Transcatheter aortic valve implantation (TAVI) is increasingly used in the treatment of severe AS. New-onset systemic hypertension affects some patients after TAVI.

OBJECTIVE

To identify any association between aortic valve replacement and the development of NPH.

METHODS

A cohort was created retrospectively of all patients who were evaluated for NPH with cerebrospinal fluid (CSF) tap test at a single institute during 2014-2019. Patients were reviewed for a past medical history of aortic valvular disease or aortic valve replacement.

RESULTS

A total of 242 patients underwent evaluations for NPH. Of these patients, 133 were considered to have iNPH. Six patients underwent aortic valve replacement before the initial symptoms of NPH: 1 surgical and 5 TAVI. The time from aortic valve replacement to the initial NPH symptoms was <6 months in 3 patients (as low as 1 month in 2 of them). Two patients had functional improvement after CSF tap test and proceeded to receive a shunt, 4 and 6 months after TAVI, respectively. Two patients developed hypertension after TAVI. Pulse pressure increased by >10 mm Hg in 3 patients after TAVI.

CONCLUSIONS

This is the first case series of symptomatic NPH after TAVI. In this unique subgroup, NPH symptoms can develop rapidly. Post-TAVI iNPH represents a novel interaction between the blood and CSF circulations.

Quantitative and functional evaluation of endothelial progenitor cells in patients with cardiac amyloidosis

Background

Endothelial microvascular dysfunction is a known mechanism of injury in cardiac amyloidosis (CA), but evidence regarding the level and function of endothelial progenitor cells (EPCs) in patients with CA is lacking.

Methods

Study population included patients with light-chain or transthyretin (ATTR) CA. Patients with diagnosed heart failure and preserved ejection fraction (HFpEF) without monoclonal gammopathy and a 99mTc-DPD scan incompatible with TTR were used as controls. Blood circulating EPCs were assessed quantitatively by the expression of VEGFR-2(+), CD34(+) and CD133(+) using flow cytometry, and functionally by the formation of colony forming units (CFUs). MTT assay was used to demonstrate cell viability. Tests were repeated 3 months following the initiation of amyloid-suppressive therapies (either ATTR-stabilizer or targeted chemotherapy) in CA patients.

Results

Our preliminary cohort included 14 CA patients (median age 74 years, 62% ATTR CA).

Patients with CA vs. patients with HFpEF (n=8) demonstrated lower expression of CD34(+)/VEGFR-2(+) cells [0.51% (IQR 0.4, 0.7) vs. 1.03% (IQR 0.6, 1.4), P=0.043] and CD133(+)/VEGFR-2(+) cells [0.35% (IQR 0.23, 0.52) to 1.07% (IQR 0.6, 1.5), P=0.003]. Functionally, no differences were noted between groups. Following the initiation of amyloid-suppressive therapies in CA patients, we observed the up-regulation of CD34(+)/VEGFR-2(+) cells [2.47% (IQR 2.1, 2.7), P&lt;0.001] and CD133(+)/VEGFR-2(+) cells [1.38% (IQR 1.1, 1.7), P=0.003]. Moreover, functionally, active EPCs were evident microscopically by their ability to form colonies (from 0.5 CFUs [IQR 0, 1.5) to 2 CFUs (IQR 1, 3.5), P=0.023]. EPCs' viability was demonstrated by an MTT assay [0.12 (IQR 0.04, 0.12) to 0.24 (IQR 0.16, 0.3), p=0.014].

Conclusions

These preliminary results demonstrate reduced EPCs levels in CA patients indicating significant microvascular impairment. Amyloid-targeted therapies induce the activation of EPCs, thus possibly promoting endothelial regeneration. These findings may represent a novel mechanism of action of amyloid-suppressive therapies

EPCs in CA patients and during therapy

Funding Acknowledgement

Type of funding source: None

Temporal trends of acute kidney injury in patients undergoing percutaneous coronary intervention over a span of 12 years

Background

Acute kidney injury (AKI) is a known complication following percutaneous coronary intervention (PCI), and is associated with higher rates of complications. We sought to determine the potential impact of temporal changes on the rates of AKI over time, as well as possible determinants of risk.

Methods

From a large prospective registry of patients undergoing PCI, 20,032 consecutive patients were assessed at two time periods: 2006–2012 and 2012–2018. Of these, included were cases for which data existed regarding change in creatinine levels from baseline to 48 hours after PCI. AKI was defined according to two methods- a relative elevation of ≥25% in serum creatinine or an absolute elevation of ≥0.5 mg/dL in serum creatinine at 48 hours.

Results

15,153 patients were available for final analysis, 7,913 in the first period and 7,240 in the second. Mean age was 65.0y and 66.0y (p&lt;0.01) and baseline creatinine was 1.08 mg/dL and 1.15 mg/dL respectively (p&lt;0.01, table 1).

AKI according to 25% relative rise in serum creatinine was documented in 11.1% in the early period and in 7.3% of the patients in the late period, p&lt;0.01. According to the definition of 0.5 mg/dL absolute rise in serum creatinine, respective rates were 3% and 2.9%, p=0.82 (figure 1). Multivariate analysis demonstrated a lower risk of AKI in the late period (OR- 0.72; CI 0.61–0.85, P&lt;0.01). Factors associated with risk of AKI included reduced ejection fraction (OR-0.98; CI 0.976–0.99, p&lt;0.01), older age (OR-1.01; CI 1.005–1.02, p=0.01) and female gender (OR- 1.73; CI 1.46–2.06, p&lt;0.01).

Conclusions

We have witnessed an improvement in the rates of post-PCI AKI over time. Further research is warranted, to further reduce peri-procedural AKI.

Figure 1. Change in the rates of AKI

Funding Acknowledgement

Type of funding source: None

Natural History and Disease Progression of Early Cardiac Amyloidosis Evaluated by Echocardiography

Since the diagnosis of cardiac amyloidosis (CA) is often delayed, echocardiographic findings are frequently indicative of advanced cardiomyopathy. We aimed to describe early echocardiographic features in patients subsequently diagnosed with CA. Preamyloid diagnosis echocardiographic studies were screened for structural and functional parameters and stratified according to the pathogenetic subtype (immunoglobulin light-chain [AL] or amyloid transthyretin [ATTR]). Abnormalities were defined based on published guidelines. Our cohort included 75 CA patients of whom 42 (56%) were diagnosed with AL and 33 (44%) with ATTR. Forty-two patients had an earlier echocardiography exam available for review. Patients presented with increased wall thickness (1.3 [interquartile range {IQR} 1.0, 1.5] cm) ≥3 years before the diagnosis of CA and relative wall thickness was increased (0.47 [IQR 0.41, 0.50]) ≥7 years prediagnosis. One to 3 years before CA diagnosis restrictive left ventricular (LV) filling pattern was present in 19% of patients and LV ejection fraction ≤50% was present in 21% of patients. Right ventricular dysfunction was detected concomitantly with disease diagnosis. The echocardiographic phenotype of ATTR versus AL-CA showed increased relative wall thickness (0.74 [IQR 0.62, 0.92] versus 0.62 [IQR 0.54, 0.76], p = 0.004) and LV mass index (144 [IQR 129, 191] versus 115 [IQR 105, 146] g/m², p = 0.020) and reduced LV ejection fraction (50 [IQR 44, 58] versus (60 [IQR 53, 60]%, p = 0.009) throughout the time course of CA progression, albeit survival time was similar. In conclusion, increased wall thickness and diastolic dysfunction in CA develop over a time course of several years and can be diagnosed in their earlier stages by standard echocardiography.

Aspirin and low-dose rivaroxaban - the dual pathway concept in patients with stable atherosclerotic disease: a comprehensive review

INTRODUCTION

Cardiovascular disease is the leading cause of morbidity and mortality in adults in western nations. In the last decades, tremendous research has been conducted in the field of secondary prevention in order to reduce recurrent cardiovascular events. This review summarizes the novel dual pathway concept of aspirin and very low-dose rivaroxaban, from mechanisms to clinical practice.

AREAS COVERED

The COMPASS trial demonstrated that in patients with stable atherosclerotic disease, very low-dose rivaroxaban, a direct factor Xa inhibitor, when combined with aspirin, reduced the rate of recurrent ischemic events, at the cost of increased bleeding. This effect was present in patients with ischemic heart disease, as well as in patients with atherosclerosis in other beds, such as in peripheral arterial disease. Sub-studies from the COMPASS trial examined other high-risk populations who might benefit the most from this regimen.

EXPERT OPINION

There are currently multiple antiplatelet and anticoagulation treatment regimens for patients with stable atherosclerotic disease. The dual pathway concept is a novel approach that combines both mechanisms. Identifying patients who might benefit the most in terms of ischemic events at the least bleeding events still remains a challenge, yet prescribing this combination to high-risk patients might be the most effective.

Breast cancer diagnosis and treatment wait times in specialized diagnostic units compared with usual care: a population-based study

Background

Breast assessment sites (bass) were developed to provide expedited and coordinated care for patients being evaluated for breast cancer (bca) in Ontario. We compared the diagnostic and treatment intervals for patients diagnosed at a bas and for those diagnosed through a usual care (uc) route.

Methods

This population-based, cross-sectional study of patients diagnosed with bca in Ontario during 2007-2015 used linked administrative data. "Diagnostic interval" was the time from the earliest cancer-related health care encounter before diagnosis to diagnosis; "treatment interval" was the time from diagnosis to treatment. Diagnosis at a bas was determined from the patient's biopsy and mammography institutions. Interval lengths for the bas and uc groups were compared using multivariable quantile regression, stratified by detection method.

Results

The diagnostic interval was shorter for patients who were bas-diagnosed than for those who were uc-diagnosed, with adjusted median differences of -4.0 days [95% confidence interval (ci): -3.2 days to -4.9 days] for symptomatic patients and -5.4 days (95% ci: -4.7 days to -6.1 days) for screen-detected patients. That association was modified by stage at diagnosis, with larger differences in patients with early-stage cancers. In contrast, the treatment interval was longer in patients who were bas-diagnosed than in those who were uc-diagnosed, with adjusted median differences of 4.2 days (95% ci: 3.8 days to 4.7 days) for symptomatic patients and 4.2 days (95% ci: 3.7 days to 4.8 days) for screen-detected patients.

Conclusions

Diagnosis of bca through a bas was associated with a shorter diagnostic interval, but a longer treatment interval. Although efficiencies in the diagnostic interval might help to reduce distress experienced by patients, the longer treatment intervals for patients who are bas-diagnosed remain a cause for concern.

Baseline staging imaging for distant metastasis in women with stages I, II, and III breast cancer

Background

In Ontario, there is no clearly defined standard of care for staging for distant metastasis in women with newly diagnosed and biopsy-confirmed breast cancer whose clinical presentation is suggestive of early-stage disease. This guideline addresses baseline imaging investigations for women with newly diagnosed primary breast cancer who are otherwise asymptomatic for distant metastasis.

Methods

The medline and embase databases were systematically searched for evidence from January 2000 to April 2019, and the best available evidence was used to draft recommendations relevant to the use of baseline imaging investigation in women with newly diagnosed primary breast cancer who are otherwise asymptomatic. Final approval of this practice guideline was obtained from both the Staging in Early Stage Breast Cancer Advisory Committee and the Report Approval Panel of the Program in Evidence-Based Care.

Recommendations

These recommendations apply to all women with newly diagnosed primary breast cancer (originating in the breast) who have no symptoms of distant metastasis Staging tests using conventional anatomic imaging [chest radiography, liver ultrasonography, chest-abdomen-pelvis computed tomography (ct)] or metabolic imaging modalities [integrated positron-emission tomography (pet)/ct, integrated pet/magnetic resonance imaging (mri), bone scintigraphy] should not be routinely ordered for women newly diagnosed with clinical stage i or stage ii breast cancer who have no symptoms of distant metastasis, regardless of biomarker status. In women newly diagnosed with stage iii breast cancer, baseline staging tests using either anatomic imaging (chest radiography, liver ultrasonography, chest-abdomen-pelvis ct) or metabolic imaging modalities (pet/ct, pet/mri, bone scintigraphy) should be considered regardless of whether the patient is symptomatic for distant metastasis and regardless of biomarker profile.

Temporal Trends Analysis of the Characteristics, Management, and Outcomes of Women With Acute Coronary Syndrome (ACS): ACS Israeli Survey Registry 2000-2016

Background Cardiovascular disease remains a leading cause of death among women. Despite improvements in the management of patients with acute coronary syndrome (ACS), women with an ACS remain at higher risk. Methods and Results We performed a time-dependent analysis of the management and outcomes of women admitted with ACS who enrolled in the prospective biennial ACS Israeli Surveys between 2000 and 2016. Surveys were divided into 3 time periods (2000-2004, 2006-2010, and 2013-2016). Outcomes included 30-day major adverse cardiac events (death, myocardial infarction, stroke, unstable angina, stent thrombosis, urgent revascularization) and 1-year mortality. Overall, 3518 women were admitted with an ACS. Their mean age (70±12 years) was similar among the time periods. Over the time course of the study, more women were admitted with non-ST-elevation ACS (51.9%, 59.6%, and 66.1%, respectively; P<0.001), and statins and percutaneous coronary intervention were increasingly utilized (66%, 91%, 93%, and 42%, 60%, and 68%, respectively; P<0.001 for each). Among women with ST-segment-elevation myocardial infarction, more primary percutaneous coronary interventions were performed (48.5%, 84.7%, and 95.3%, respectively; P<0.001). The rate of 30-day major adverse cardiac events has significantly decreased over the years (24.6%, 18.6%, and 13.5%, respectively; P<0.001). However, 1-year mortality rates declined only from 2000 to 2004 (16.9%, 12.8%, and 12.3%; P=0.007 for the overall difference), and this change was not significant after propensity matching or multivariate analysis. Conclusions Over more than a decade, 30-day major adverse cardiac events have decreased among women with ACS. Advances in pharmacological treatments and an early invasive approach may have accounted for this improvement. However, the lack of further reduction in 1-year mortality rates among women suggests that more measures should be provided in this high-risk population.

Comparison of Outcomes in Patients With Acute Coronary Syndrome Presenting With Typical Versus Atypical Symptoms

Although typical chest pain is an important clinical feature required for diagnosis of acute coronary syndrome (ACS), many patients present with atypical complaints. The full extent and implication of this presentation is largely unknown. The study aim was to evaluate possible relations and temporal trends between presenting symptoms and outcomes in patients with ACS. Data was obtained from the Acute Coronary Syndrome Israeli Survey on patients presenting with typical chest pain versus atypical complaints, including dyspnea, nonspecific chest pain, palpitations or other. Temporal trends analysis examined the early (2000 to 2006) versus the late (2008 to 2016) period. During 2000 to 2016, 14,722 patients with ACS were enrolled; 11,508 (79%) presented with typical chest pain and 3,214 (21%) with atypical complaints. Patients with atypical complaints were older, majority female, and had more co-morbidities (p <0.001 for each). The 30-day major adverse cardiac events, 30-day mortality, and 1-year mortality rate were significantly higher in patients presenting with atypical complaints, (18% vs 13.5%, 7.7% vs 3.6%, and 15.6% vs 7.5%, respectively, p <0.001 for each). Although 1-year mortality decreased significantly over the years in patients with typical chest pain, there were no significant changes in patients who presented with atypical complaints. These results were consistent in STEMI and non-STE-ACS patients. In conclusion, ACS patients who present with atypical complaints have a less favorable outcome compared with patients who present with typical chest pain, and failed to show an improvement in mortality over the past 2 decades. Identification and utilization of guideline-recommended therapies in these high-risk patients may improve their future outcome.

Temporal Trends in the Characteristics, Management and Outcomes of Patients With Acute Coronary Syndrome According to Their Killip Class

Based on the historical Killip Classification, higher Killip class is associated with increased mortality in patients with acute coronary syndrome (ACS), yet data on current prognosis are lacking. We sought to examine temporal trends in the management and outcomes of patients admitted with an ACS by Killip class and to assess its contemporary prognostic value. Time-dependent analysis (early-period 2000 to 2008 vs late-period 2010 to 2016) in patients with lower (=1) and higher (≥2) Killip classes in a national ACS survey. Clinical outcomes included 30d MACE (death, myocardial infarction, stroke, unstable angina, stent thrombosis, urgent revascularization) and 1-year mortality. Included were 9,736 and 5,288 patients in the early and late time-periods of which 18.5% and 11.5% were categorized as higher Killip class, respectively (p <0.001). Baseline co-morbidities (diabetes, hypertension, dyslipidemia) were more prevalent in the late versus early time periods in both study groups (p <0.001). Rates of 30d MACE decreased in both Killip classes (p <0.001), yet 1-year mortality decreased only in patients with lower Killip class (p = 0.02), and remained extremely high (30%) in patients with higher Killip class (p = 0.75). Killip class was a significant independent predictor for 1-year mortality, both in the early (adjusted hazard ratio 3.23, confidence interval 2.8, 3.7) and late (adjusted hazard ratio 4.13, confidence interval 3.21, 5.32) time periods. In conclusion, even in the current era, patients presenting with ACS and higher Killip class have poor 1-year survival. Efforts should focus on improving the adherence to guideline-recommended therapies. The Killip classification system is still a reliable prognostic tool.

Cost-utility analysis of 21-gene assay for node-positive early breast cancer

Background

For women with lymph node (ln)-positive, estrogen receptor-positive, and her2 (human epidermal growth factor receptor 2)-negative breast cancer (bca), current guidelines recommend treatment with both hormonal therapy and chemotherapy. The 21-gene Recurrence Score (rs) assay might be helpful in selecting patients with bca who can be spared chemotherapy when they have 1-3 positive lns and a lower risk of recurrence. In the present study, we performed a cost-utility analysis comparing use of the 21-gene rs assay with current practice from the perspective of a Canadian health care payer.

Methods

A Markov model was developed to determine costs and quality-adjusted life-years (qalys) over a patient's lifetime. Patient outcomes in both study groups were examined based on published clinical trials. Costs were derived primarily from published Canadian sources. Costs and outcomes were discounted at 1.5% annually, and costs are reported in 2016 Canadian dollars. A probabilistic analysis was used, and the model parameters were varied in a sensitivity analysis.

Results

The results indicate that use of the 21-gene rs assay was less costly ($432 less) and more effective (0.22 qalys) than current practice. The probabilistic analysis revealed that 70% of the 10,000 simulated incremental cost-effectiveness ratios were in the southeast quadrant. The results were sensitive to the probability of a low rs and to the probability of receiving chemotherapy in the low-risk rs category and in current practice.

Conclusions

Use of the 21-gene rs assay could be a cost-effective strategy for Ontario patients with estrogen receptor-positive, her2-negative early bca and 1-3 positive lns.