Cardiac Magnetic Resonance to Predict Cardiac Mass Malignancy: The CMR Mass Score

BACKGROUND

Multimodality imaging is currently suggested for the noninvasive diagnosis of cardiac masses. The identification of cardiac masses' malignant nature is essential to guide proper treatment. We aimed to develop a cardiac magnetic resonance (CMR)-derived model including mass localization, morphology, and tissue characterization to predict malignancy (with histology as gold standard), to compare its accuracy versus the diagnostic echocardiographic mass score, and to evaluate its prognostic ability.

METHODS

Observational cohort study of 167 consecutive patients undergoing comprehensive echocardiogram and CMR within 1-month time interval for suspected cardiac mass. A definitive diagnosis was achieved by histological examination or, in the case of cardiac thrombi, by histology or radiological resolution after adequate anticoagulation treatment. Logistic regression was performed to assess CMR-derived independent predictors of malignancy, which were included in a predictive model to derive the CMR mass score. Kaplan-Meier curves and Cox regression were used to investigate the prognostic ability of predictors.

RESULTS

In CMR, mass morphological features (non-left localization, sessile, polylobate, inhomogeneity, infiltration, and pericardial effusion) and mass tissue characterization features (first-pass perfusion and heterogeneity enhancement) were independent predictors of malignancy. The CMR mass score (range, 0-8 and cutoff, ≥5), including sessile appearance, polylobate shape, infiltration, pericardial effusion, first-pass contrast perfusion, and heterogeneity enhancement, showed excellent accuracy in predicting malignancy (areas under the curve, 0.976 [95% CI, 0.96-0.99]), significantly higher than diagnostic echocardiographic mass score (areas under the curve, 0.932; P=0.040). The agreement between the diagnostic echocardiographic mass and CMR mass scores was good (κ=0.66). A CMR mass score of ≥5 predicted a higher risk of all-cause death (P<0.001; hazard ratio, 5.70) at follow-up.

CONCLUSIONS

A CMR-derived model, including mass morphology and tissue characterization, showed excellent accuracy, superior to echocardiography, in predicting cardiac masses malignancy, with prognostic implications.

Prognostic Role of Early Cardiac Magnetic Resonance in Myocardial Infarction With Nonobstructive Coronary Arteries

BACKGROUND

Cardiac magnetic resonance (CMR) plays a pivotal diagnostic role in myocardial infarction with nonobstructive coronary arteries (MINOCA). To date, a prognostic stratification of these patients is still lacking.

OBJECTIVES

This study aims to assess the prognostic role of CMR in MINOCA.

METHODS

The authors assessed 437 MINOCA from January 2017 to October 2021. They excluded acute myocarditis, takotsubo syndromes, cardiomyopathies, and other nonischemic etiologies. Patients were classified into 3 subgroups according to the CMR phenotype: 1) presence of late gadolinium enhancement (LGE) and abnormal mapping (M) values (LGE+/M+); 2) regional ischemic injury with abnormal mapping and no LGE (LGE-/M+); and 3) nonpathological CMRs (LGE-/M-). The primary outcome was the presence of major adverse cardiovascular events (MACE). The mean follow-up was 33.7 ± 12.0 months and CMR was performed on average at 4.8 ± 1.5 days from the acute presentation.

RESULTS

The final cohort included 198 MINOCA; 116 (58.6%) comprised the LGE+/M+ group. During follow-up, MACE occurred significantly more frequently in MINOCA LGE+/M+ than in the LGE+/M- and normal-CMR (LGE-/M-) subgroups (20.7% vs 6.7% and 2.7%; P = 0.006). The extension of myocardial damage at CMR was significantly greater in patients who developed MACE. In multivariable Cox regression, %LGE was an independent predictor of MACE (HR: 1.123 [95% CI: 1.064-1.185]; P < 0.001) together with T2 mapping values (HR: 1.190 [95% CI: 1.145-1.237]; P = 0.001).

CONCLUSIONS

In MINOCA with early CMR execution, the %LGE and abnormal T2 mapping values were identified as independent predictors of adverse cardiac events at ∼3.0 years of follow-up. These parameters can be considered as high-risk markers in MINOCA.

Predictive value of Killip classification in MINOCA patients

BACKGROUND

Killip classification is a practical clinical tool for risk stratification in patients with acute myocardial infarction (AMI). However, its prognostic role in myocardial infarction with non-obstructive coronary artery (MINOCA) is still poorly explored. Our purpose was to evaluate the prognostic role of high Killip class in the specific setting of MINOCA and compare the results with a cohort of patients with obstructive coronary arteries myocardial infarction (MIOCA).

METHODS

This study included 2455 AMI patients of whom 255 were MINOCA. We compared the Killip classes of MINOCA with those of MIOCA and evaluated the prognostic impact of a high Killip class, defined if greater than I, on both populations' outcome. Short-term outcomes included in-hospital death, re-AMI and arrhythmias. Long-term outcomes were all-cause mortality, re-AMI, stroke, heart failure (HF) hospitalization and the composite endpoint of MACE.

RESULTS

Killip class >1 occurred in 25 (9.8%) MINOCA patients compared to 327 (14.9%) MIOCA cases. In MINOCA subjects, a high Killip class was associated with a greater in-hospital mortality (p = 0.002) and, at long term follow-up, with a three-fold increased mortality (p = 0.001) and a four-fold risk of HF hospitalization (p = 0.003). Among MINOCA, a high Killip class was identified as a strong independent predictor of MACE occurrence [HR 2.66, 95% CI (1.25-5.64), p = 0.01] together with older age and worse kidney function while in MIOCA population also left ventricular ejection fraction and troponin value predicted MACE.

CONCLUSIONS

Killip classification confirmed its prognostic impact on short- and long-term outcomes also in a selected MINOCA population, which still craves for a baseline risk stratification.

[Periprocedural myocardial injury and infarction after myocardial revascularization: incidence, clinical features and prognosis]

Myocardial revascularization, either percutaneous or surgical, is the cornerstone of chronic and acute ischemic coronary artery disease therapy. Periprocedural myocardial injury and infarction are possible complications of these procedures. Several pathogenetic mechanisms have been proposed in the setting of percutaneous (distal embolism, vasospasm, obstruction of a minor vessel) or surgical revascularization (prolonged ischemic time, early graft failure, arrhythmia or severe hypotension during the procedure). High-sensitivity cardiac troponins have emerged as the recommended biomarkers due to their important prognostic implications. However, data regarding diagnostic criteria, management and prognostic implications of these complications are lacking. The present review aims to provide an overview regarding the possible diagnostic criteria, management and prognostic role of periprocedural myocardial injury and infarction.

Characteristics of patients with recurrent acute myocardial infarction after MINOCA

BACKGROUND

Myocardial infarction (MI) with non-obstructed coronary arteries (MINOCA) is an increasingly recognized condition with challenging management. Some MINOCA patients ultimately experience recurrent acute MI (re-AMI) during follow-up; however, clinical and angiographic factors predisposing to re-AMI are still poorly defined.

METHODS

In this retrospective multicenter cohort study we enrolled consecutive patients fulfilling diagnostic criteria of MINOCA according to the IV universal definition of myocardial infarction; characteristics of patients experiencing re-AMI during the follow-up were compared to a group of MINOCA patients without re-AMI.

RESULTS

54 patients (mean age 66 ± 13) experienced a subsequent re-AMI after MINOCA and follow-up was available in 44 (81%). Compared to MINOCA patients without re-AMI (n = 695), on first invasive coronary angiography (ICA) MINOCA patients with re-AMI showed less frequent angiographically normal coronaries (37 versus 53%, p = 0.032) and had a higher prevalence of atherosclerosis involving 3 vessels or left main stem (17% versus 8%, p = 0.049). Twenty-four patients (44%) with re-AMI underwent a new ICA: 25% had normal coronary arteries, 12.5% had mild luminal irregularities (<30%), 20.8% had moderate coronary atherosclerosis (30-49%), and 41.7% showed obstructive coronary atherosclerosis (≥50% stenosis). Among patients undergoing new ICA, atherosclerosis progression was observed in 11 (45.8%), 37.5% received revascularization, only 4.5% had low-density lipoprotein cholesterol (LDL_C) under 55 mg/dL and 33% experienced a new cardiovascular disease (CVD) event (death, AMI, heart failure, stroke) at subsequent follow-up.

CONCLUSIONS

In the present study, only a minority of MINOCA patients with re-AMI underwent a repeated ICA, nearly one out of two showed atherosclerosis progression, often requiring revascularization. Recommended LDL-C levels were achieved only in a minority of the cases, indicating a possible underestimation of CVD risk in this population.

Sex- and age-related differences in outcomes of patients with acute myocardial infarction: MINOCA vs. MIOCA

AIMS

The aim of the study is to evaluate the impact of sex on acute myocardial infarction (AMI) patients' clinical presentation and outcomes, comparing those with non-obstructive and obstructive coronary arteries (MINOCA vs. MIOCA).

METHODS AND RESULTS

We enrolled 2455 patients with AMI undergoing coronary angiography from January 2017 to September 2021. Patients were divided according to the type of AMI and sex: male (n = 1593) and female (n = 607) in MIOCA and male (n = 87) and female (n = 168) in MINOCA. Each cohort was further stratified based on age (≤/> 70 years). The primary endpoint (MAE) was a composite of all-cause death, recurrent AMI, and hospitalization for heart failure (HF) at follow-up. Secondary outcomes included all-cause and cardiovascular death, recurrent AMI, HF re-hospitalization, and stroke. MINOCA patients were more likely to be females compared with MIOCA ones (P < 0.001). The median follow-up was 28 (15-41) months. The unadjusted incidence of MAE was significantly higher in females compared with males, both in MINOCA [45 (26.8%) vs. 12 (13.8%); P = 0.018] and MIOCA cohorts [203 (33.4%) vs. 428 (26.9%); P = 0.002]. Age was an independent predictor of MAE in both cohorts. Among MINOCA patients, females ≤70 years old had a higher incidence of MAE [18 (23.7%) vs. 4 (5.9%); P = 0.003] compared with male peers, mainly driven by a higher rate of re-hospitalization for HF (P = 0.045) and recurrence of AMI (P = 0.006). Only in this sub-group of MINOCA patients, female sex was an independent predictor of MAE (hazard ratio = 3.09; 95% confidence interval: 1.02-9.59; P = 0.040). MINOCA females ≤70 years old had worse outcomes than MIOCA female peers.

CONCLUSION

MINOCA females ≤70 years old had a significantly higher incidence of MAE, compared with males and MIOCA female peers, likely due to the different pathophysiology of the ischaemic event.

TRIAL REGISTRATION

Data were part of the ongoing observational study 'AMIPE: Acute Myocardial Infarction, Prognostic and Therapeutic Evaluation' (ClinicalTrials.gov Identifier: NCT03883711).

Performance of Prognostic Scoring Systems in MINOCA: A Comparison among GRACE, TIMI, HEART, and ACEF Scores

Background: the prognosis of patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) is not benign; thus, prompting the need to validate prognostic scoring systems for this population. Aim: to evaluate and compare the prognostic performance of GRACE, TIMI, HEART, and ACEF scores in MINOCA patients. Methods: A total of 250 MINOCA patients from January 2017 to September 2021 were included. For each patient, the four scores at admission were retrospectively calculated. The primary outcome was a composite of all-cause death and acute myocardial infarction (AMI) at 1-year follow-up. The ability to predict 1-year all-cause death was also tested. Results: Overall, the tested scores presented a sub-optimal performance in predicting the composite major adverse event in MINOCA patients, showing an AUC ranging between 0.7 and 0.8. Among them, the GRACE score appeared to be the best in predicting all-cause death, reaching high specificity with low sensitivity. The best cut-off identified for the GRACE score was 171, higher compared to the cut-off of 140 generally applied to identify high-risk patients with obstructive AMI. When the scores were tested for prediction of 1-year all-cause death, the GRACE and the ACEF score showed very good accuracy (AUC = 0.932 and 0.828, respectively). Conclusion: the prognostic scoring tools, validated in AMI cohorts, could be useful even in MINOCA patients, although their performance appeared sub-optimal, prompting the need for risk assessment tools specific to MINOCA patients.

The Role of Non-Invasive Multimodality Imaging in Chronic Coronary Syndrome: Anatomical and Functional Pathways

Coronary artery disease (CAD) is one of the major causes of mortality and morbidity worldwide, with a high socioeconomic impact. Currently, various guidelines and recommendations have been published about chronic coronary syndromes (CCS). According to the recent European Society of Cardiology guidelines on chronic coronary syndrome, a multimodal imaging approach is strongly recommended in the evaluation of patients with suspected CAD. Today, in the current practice, non-invasive imaging methods can assess coronary anatomy through coronary computed tomography angiography (CCTA) and/or inducible myocardial ischemia through functional stress testing (stress echocardiography, cardiac magnetic resonance imaging, single photon emission computed tomography-SPECT, or positron emission tomography-PET). However, recent trials (ISCHEMIA and REVIVED) have cast doubt on the previous conception of the management of patients with CCS, and nowadays it is essential to understand the limitations and strengths of each imaging method and, specifically, when to choose a functional approach focused on the ischemia versus a coronary anatomy-based one. Finally, the concept of a pathophysiology-driven treatment of these patients emerged as an important goal of multimodal imaging, integrating 'anatomical' and 'functional' information. The present review aims to provide an overview of non-invasive imaging modalities for the comprehensive management of CCS patients.

Impact of SGLT2-inhibitors on contrast-induced acute kidney injury in Diabetic patients with Acute Myocardial Infarction with and without chronic kidney disease: Insight from SGLT2-I AMI PROTECT Registry

AIMS

To analyze the association between chronic SGLT2-I treatment and development of contrast-induced acute kidney injury (CI-AKI) in diabetic patients with acute myocardial infarction (AMI) undergoing PCI.

METHODS

Multicenter international registry of consecutive patients with type 2 diabetes mellitus (T2DM) and AMI undergoing PCI between 2018-2021. The study population was stratified by the presence of chronic kidney disease (CKD) and anti-diabetic therapy at admission (SGLT2-I versus non-SGLT2-I users).

RESULTS

The study population consisted of 646 patients: 111 SGLT2-I users [28 (25.2%) with CKD] and 535 non-SGLT2-I users [221 (41.3%) with CKD]. The median age was 70 [61-79] years. SGLT2-I users exhibited significantly lower creatinine values at 72h after PCI, both in the non-CKD and CKD stratum. The rate of CI-AKI was 76 (11.8%), significantly lower in SGLT2-I users compared to non-SGLT2-I patients (5.4% vs 13.1%, p=0.022). This finding was also confirmed in patients without CKD (p=0.040). In the CKD cohort, SGLT2-I users maintained significantly lower creatinine values at discharge. The use of SGLT2-I was an independent predictor of reduced rate of CI-AKI (OR 0.356; 95%CI 0.134-0.943, p=0.038).

CONCLUSION

In T2DM patients with AMI, the use of SGLT2-I was associated with a lower risk of CI-AKI, mostly in patients without CKD.

Sex-Related Disparities in Cardiac Masses: Clinical Features and Outcomes

BACKGROUND

Cardiac masses (CM) represent a heterogeneous clinical scenario, and sex-related differences of these patients remain to be established.

PURPOSE

To evaluate sex-related disparities in CMs regarding clinical presentation and outcomes.

MATERIAL AND METHODS

The study cohort included 321 consecutive patients with CM enrolled in our Centre between 2004 and 2022. A definitive diagnosis was achieved by histological examination or, in the case of cardiac thrombi, with radiological evidence of thrombus resolution after anticoagulant treatment. All-cause mortality at follow-up was evaluated. Multivariable regression analysis assessed the potential prognostic disparities between men and women.

RESULTS

Out of 321 patients with CM, 172 (54%) were female. Women were more frequently younger (p = 0.02) than men. Regarding CM histotypes, females were affected by benign masses more frequently (with cardiac myxoma above all), while metastatic tumours were more common in men (p < 0.001). At presentation, peripheral embolism occurred predominantly in women (p = 0.03). Echocardiographic features such as greater dimension, irregular margin, infiltration, sessile mass and immobility were far more common in men. Despite a better overall survival in women, no sex-related differences were observed in the prognosis of benign or malignant masses. In fact, in multivariate analyses, sex was not independently associated with all-cause death. Conversely, age, smoking habit, malignant tumours and peripheral embolism were independent predictors of mortality.

CONCLUSIONS

In a large cohort of cardiac masses, a significant sex-related difference in histotype prevalence was found: Benign CMs affected female patients more frequently, while malignant tumours affected predominantly men. Despite better overall survival in women, sex did not influence prognosis in benign and malignant masses.

Echocardiographic Markers in the Diagnosis of Cardiac Masses

BACKGROUND

The echocardiographic parameters required for a comprehensive assessment of cardiac masses (CMs) are still largely unknown. The aim of this study was to identify and integrate the echocardiographic features of CMs that can accurately predict malignancy.

METHODS

An observational cohort study was conducted among 286 consecutive patients who underwent standard echocardiographic assessment for suspected CM at Bologna University Hospital between 2004 and 2022. A definitive diagnosis was achieved by histologic examination or, in the case of cardiac thrombi, with radiologic evidence of thrombus resolution after appropriate anticoagulant treatment. Logistic and multivariable regression analysis was performed to confirm the ability of six echocardiographic parameters to discriminate malignant from benign masses. The unweighted count of these parameters was used as a numeric score, ranging from 0 to 6, with a cutoff of ≥3 balancing sensitivity and specificity with respect to the histologic diagnosis of malignancy. Classification tree analysis was used to determine the ability of echocardiographic parameters to discriminate subgroups of patients with differential risk for malignancy.

RESULTS

Benign masses were more frequently pedunculated, mobile, and adherent to the interatrial septum (P < .001). Malignant masses showed a greater diameter and exhibited a higher frequency of irregular margins, an inhomogeneous appearance, sessile implantation, polylobate shape, and pericardial effusion (P < .001). Infiltration, moderate to severe pericardial effusion, nonleft localization, sessile implantation, polylobate shape, and inhomogeneity were confirmed to be independent predictors of malignancy in both univariate and multivariable models. The predictive ability of the unweighted score of ≥3 was very high (>0.90) and similar to that of the previously published weighted score. Classification tree analysis generated an algorithm in which infiltration was the best discriminator of malignancy, followed by nonleft localization and sessile implantation. The percentage correctly classified by classification tree analysis as malignant was 87.5%. Agreement between observer readings and CM histology ranged between 85.1% and 91.5%. The presence of at least three echocardiographic parameters was associated with lower survival.

CONCLUSIONS

In the approach to CMs, some echocardiographic parameters can serve as markers to accurately predict malignancy, thereby informing the need for second-level investigations and minimizing the diagnostic delay in such a complex clinical scenario.

Outcomes in diabetic patients treated with SGLT2-Inhibitors with acute myocardial infarction undergoing PCI: The SGLT2-I AMI PROTECT Registry

AIMS

To investigate in-hospital and long-term prognosis in T2DM patients presenting with acute myocardial infarction (AMI) treated with SGLT2-I versus other oral anti-diabetic agents (non-SGLT2-I users).

METHODS

In this multicenter international registry all consecutive diabetic AMI patients undergoing percutaneous coronary intervention between 2018 and 2021 were enrolled and, based on the admission anti-diabetic therapy, divided into SGLT-I users versus non-SGLT2-I users. The primary endpoint was defined as a composite of cardiovascular death, recurrent AMI, and hospitalization for HF (MACE). Secondary outcomes included i) in-hospital cardiovascular death, recurrent AMI, occurrence of arrhythmias, and contrast-induced acute kidney injury (CI-AKI); ii) long-term cardiovascular mortality, recurrent AMI, heart failure (HF) hospitalization.

RESULTS

The study population consisted of 646 AMI patients (with or without ST-segment elevation): 111 SGLT2-I users and 535 non-SGLT-I users. The use of SGLT2-I was associated with a significantly lower in-hospital cardiovascular death, arrhythmic burden, and occurrence of CI-AKI (all p < 0.05). During a median follow-up of 24 ± 13 months, the primary composite endpoint, as well as cardiovascular mortality and HF hospitalization were lower for SGLT2-I users compared to non-SGLT2-I patients (p < 0.04 for all). After adjusting for confounding factors, the use of SGLT2-I was identified as independent predictor of reduced MACE occurrence (HR=0.57; 95%CI:0.33-0.99; p = 0.039) and HF hospitalization (HR=0.46; 95%CI:0.21-0.98; p = 0.041).

CONCLUSIONS

In T2DM AMI patients, the use of SGLT2-I was associated with a lower risk of adverse cardiovascular outcomes during index hospitalization and long-term follow-up. Our findings provide new insights into the cardioprotective effects of SGLT2-I in the setting of AMI.

REGISTRATION

Data are part of the observational international registry: SGLT2-I AMI PROTECT.

CLINICALTRIALS

gov Identifier: NCT05261867.

866 INFARCT SIZE, INFLAMMATORY BURDEN AND ADMISSION HYPERGLYCEMIA IN DIABETIC PATIENTS WITH ACUTE MYOCARDIAL INFARCTION TREATED WITH SGLT2-INHIBITORS: A MULTICENTER INTERNATIONAL REGISTRY

Background

Sodium-glucose co-transporter 2 inhibitors (SGLT2-I) currently receive intense clinical interest in patients with and without diabetes mellitus (DM) with pleiotropic beneficial effects. Nowadays, the inflammation response in the setting of acute myocardial infarction (AMI) has been proposed as a potential pharmacological intervention target. In this setting, we tested the hypothesis that the SGLT2-I displays anti-inflammatory effect along with glucose-lowering properties. We investigated the relationship between stress hyperglycemia, inflammation burden and infarct size in a cohort of type 2 diabetic AMI patients treated with SGLT2-I versus other oral anti-diabetic (OAD) agents alone.

Methods

In this multicenter international registry, all diabetic patients with AMI treated with percutaneous coronary intervention (PCI) between 2018 and 2021 were enrolled. Based on the admission anti-diabetic therapy, patients were divided into those receiving SGLT2-I versus other OAD agents alone. Patients on insulin therapy alone or combined with OAD agents or with unavailable admission medical therapy were excluded from the study. Further exclusion criteria encompassed AMI (mostly NSTEMI) treated with coronary artery bypass grafting (CABG) after the CAG, severe valvular heart disease, prosthetic heart valves, severe anemia, major acute bleeding, pulmonary embolism, fever (38° C), chronic renal failure (glomerular filtration rate &lt; 30 mL/min/1.73 m2), autoimmune diseases, malignancies and congenital heart disease. The following inflammatory markers were evaluated at different time points: total white blood cell, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and neutrophil-to-platelet ratio (NPR), C-reactive protein. Infarct size was assessed by peak troponin levels and echocardiographic parameters.

Results

The final study population consisted of 583 patients hospitalized for AMI (both STEMI and NSTEMI) classified as SGLT2-I users (n = 98) versus other OAD agents alone (n = 485). Admission hyperglycemia was more prevalent among the other OAD agents group. Reduced infarct size was detected in patients treated with SGLT2-I compared to those treated with other OAD agents alone. Both at admission, and after 24 hours, inflammatory indices were significantly higher in patients treated with other OAD agents alone, with a significant increase in neutrophils levels at 24 hours, compared to the SGLT2-I group. In multivariate analysis, SGLT2-I emerged as a significant predictor of reduced inflammatory response (OR 0.45, 95%CI 0.27–0.75, p = 0.002), together with peak troponin values, independently of age, admission creatinine values and admission glycemia.

Conclusions

Type 2 Diabetic patients hospitalized for AMI and receiving SGLT2-I exhibited modest inflammatory response and myocardial damage/infarct size compared to other OAD agents alone, independently of glucose-metabolic control. Our findings pave the way for new pathophysiological and therapeutic insights regarding the cardioprotective effect of SGLT2-I in the setting of coronary artery disease.

948 MULTIMODALITY IMAGING IN CARDIAC MASSES

Background

Cardiac masses (CM) are an extremely heterogeneous clinical scenario, including benign and malignant neoformations. After a first echocardiographic assessment, Cardiac Computed Tomography (CCT) together with Cardiac Magnetic Resonance (CMR) and 18-Fluorodeoxyglucose Positron Emission Tomography (18-FDG-PET) represent second-line and third-line imaging techniques to determine the nature of the mass. However, data regarding their diagnostic performance and a standardized imaging algorithm are lacking.

Purpose

To evaluate the different roles of CCT, CMR, and PET in defining the nature of CMs and to propose an evidence-based, stepwise, diagnostic approach.

Materials and methods

Out of 312 patients with suspected mass from January 2000 and August 2022, we enrolled 87 patients who underwent CCT, CMR and 18-FDG-PET within a month from the initial evaluation. A definitive diagnosis was achieved by histological examination or, in case of cardiac thrombi, with radiological evidence of thrombus resolution after an appropriate anticoagulant treatment. For each imaging technique, we identified a model with the strongest predictors of malignancy at multivariate analysis and evaluated their ability to discriminate between benign and malignant neoformations. A multiple model with forwarding selection was performed to identify the strongest predictors of malignancy at CCT, CMR and 18-FDG-PET.

Results

CCT model included 4 variables (irregular margins, mass dimension, invasiveness and not-hypodense lesion) with an Area Under the Curve (AUC) of 0.972, 95% Confidence Interval (CI) 0.94-1.0; CMR model included 3 parameters (invasiveness, pericardial effusion and irregular margins, AUC 0.976 with 95% CI 0.95-1.0); PET model included only cardiac maximum Standardized Uptake Value (SUVmax), with an AUC 0.87 (95% IC 0.74-0.971). When implemented with SUVmax, CCT and CMR models showed only a slight improvement in their discrimination ability (AUC 0.975 and 0.986, respectively). No statistical difference was observed between CCT and CMR models regarding their discrimination ability (AUC 0.972 vs 0.976, p=0.26). However, on a multiple model with forwarding selection evaluating CCT, CMR and PET variables, only the 3 MR parameters remained significant predictors of malignancy.

Conclusion

After a first echocardiographic assessment, the application of the CMR model may be the most accurate second-level investigation to discriminate between benign and malignant lesions. When CMR is not available, or the patient has contraindications to CMR, the CCT model performs similarly, and 18-FDG-PET provides a negligible advantage.

855 PREDICTORS OF LATE GADOLINIUM ENHANCEMENT DEVELOPMENT AND EXTENSION IN MYOCARDIAL INFARCTION WITH NON-OBSTRUCTIVE CORONARY ARTERIES

Background

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous clinical entity and in its complex diagnostic approach cardiovascular magnetic resonance (CMR) plays a pivotal role.

Purpose

To characterize the differences of MINOCA patients with and without late gadolinium enhancement (LGE) at CMR and to identify the predictors for ischemic LGE development and extension.

Methods

We assessed 461 MINOCA cases from January 2016 to June 2021. MINOCA were defined according to the current European guidelines criteria. We excluded acute myocarditis, Tako-tsubo syndromes, cardiomyopathies, or non-pathological CMR. According to CMR imaging findings, our cohort was divided into two CMR phenotypes based on regional myocardial necrosis detected throughout LGE (“LGE-positive MINOCA”) or regional ischemic injury without LGE (“LGE-negative MINOCA”). Extended LGE was considered as the presence of &gt;2 segments with transmural LGE. Multivariate logistic regression analysis was used to determine the predictors of LGE and extended LGE.

Results

The final cohort included 175 MINOCA: 121 (69.1%) constituted the LGE-positive group. The mean time delay between acute clinical presentation and CMR was 6 ± 2.9 days. At admission, MINOCA LGE-patients more frequently presented angina and ST segment elevation (24% vs 7.4%, p = 0.01), compared to the LGE negative ones. Furthermore, the LGE positive group had a significantly greater infarct size, measured by peak hs-Troponin I values and left ventricular function. The only predictor of LGE was the peak troponin value (OR 1.64, 95% CI 1.18–2.28, p = 0.003), while predictors of extended LGE were ST-segment elevation at admission (OR 7.44, 95% CI 1.57–35.22, p = 0.01), peak troponin values (OR 1.07, 95% CI 1.02–1.13, p = 0.01) and the presence of non-obstructive coronary artery disease at coronary angiography (OR 5.49, 95% CI 1.20–25.09, p = 0.028).

Conclusion

The presence and extension of LGE at early CMR evaluation is an important feature in the setting of MINOCA. In addition, simple baseline characteristics (such as ST elevation, peak troponin value and LVEF) may aid the identification of a greater ischemic necrosis burden at CMR and therefore these high-risk MINOCA subjects could be benefit from a stricter management effort.

996 INCIDENCE AND PREDICTORS OF HEART FAILURE DEVELOPMENT IN A COHORT OF PATIENTS WITH MYOCARDIAL INFARCTION WITH NON-OBSTRUCTIVE CORONARY ARTERIES

Background

A higher risk of death and major cardiovascular events, including Heart Failure (HF), after a Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) has been described. In particular, HF has a negative impact not only on survival but also on quality of life. In this context, strategies to identify subjects with a greater risk of developing HF are needed.

Aims

To assess the incidence and predictors of HF developing subsequently a MINOCA.

Methods

461 subjects with suspected MINOCA from 2016 to 2021 were assessed. Acute myocarditis, Takotsubo syndromes, cardiomyopathies and patients with incomplete data were excluded. The final cohort consisted of 188 patients with a confirmed MINOCA diagnosis. After a mean follow-up of 36±14.8 months, 20 patients (10.6%) had hospital readmission for HF. Demographic, clinical, laboratory, and instrumental data were collected and analyzed.

Results

None among demographic characteristics, cardiovascular risk factors or comorbidities showed correlation with HF occurrences. Paroxysmal or permanent atrial fibrillation was more frequent among patients who developed HF (p .005), such as ST-elevation at onset (p .001). Higher glycemia at admission correlated with HF (p .012). In this regard, hyperglycemia could act as a direct toxic agent or as an indirect marker of a greater stress response. Cardiac troponin I (cTnI) at peak, but not first cTnI measurement, was significantly higher in patients who developed HF (p&lt;.001), confirming the prognostic value of troponin, even in this context. Concerning echocardiography, HF incidence was higher in patients with any wall motion abnormalities (p .037), lower ejection fraction (EF; p .046), especially if EF≤40% (p&lt;.001), higher atrial maximum diameter (p .005), end-diastolic diameter (p. 001) or normalized end-diastolic volume (p&lt;.001). Among cardiac magnetic resonance findings, HF occurred more often (p&lt;.001) in patients with a transmural pattern of late gadolinium enhancement (LGE), which resulted as an independent risk factor for HF developing at the multivariate analysis (HR 15.32, 95% CI 5.13-45.75, p&lt;.001). Finally, 32 patients (17%) were affected by non-obstructive coronary arteries stenosis (i.e., &lt;50%). This finding, but not re-infarction, was also associated with HF development (p .004). Notably, only 2 out of the 68 patients dismissed with DAPT developed HF (p .010). In our study beta-blockers, RAS inhibitors and statins at dismission had not reduced the risk of HF. Nevertheless, the low sample size forbids inferring conclusions about the therapy.

Conclusion

In our cohort of patients with MINOCA, several clinical, laboratory and echocardiographic characteristics correlated with a higher frequency of HF occurrences. Moreover, a broader extent of cardiac damage, as testified by cTnI, wall motion abnormalities, reduced EF and transmural LGE, could predict HF development. Further studies to establish adequate follow-up programs and therapy to prevent HF progression in these patients are needed.

509 RECURRENCE OF ACUTE MYOCARDIAL INFARCTION AFTER MINOCA: INSIGHTS FROM A MULTICENTRE NATIONAL REGISTRY

Background

Myocardial infarction with non-obstructed coronary arteries (MINOCA) is an increasingly recognized condition with challenging management. Prognosis of this patients could be of concern, in particular for those who experienced recurrent acute myocardial infarction (re-AMI). Moreover, there are limited data on characteristics of re-AMI among MINOCA patients.

Methods

In this retrospective multicentre cohort study involving seven Hub Hospitals across Italy we enrolled consecutive patients 18 years and older discharged with diagnosis of MINOCA according to the IV universal definition of myocardial infarction who experienced hospitalization for re-AMI during follow-up.

Results

A total of 54 patients were included (mean age 66±13). Compared to MINOCA patients without re-AMI (n=695), on first angiography MINOCA patients with re-AMI showed less frequently angiographically normal coronaries (37 versus 53%, p=0,032) and had higher prevalence of atherosclerosis involving 3 vessels or left main stem (17% versus 8%, p=0,049).

Twenty four patients (44%) with re-AMI underwent a new coronary angiography and 25% had normal coronary arteries, 12% had mild luminal irregularities (&lt;30%), 21% had moderate coronary atherosclerosis (30-49%), and 42% showed obstructive coronary atherosclerosis (≥50%).

Among patients undergoing new angiography, only 4% had LDL cholesterol under 55 mg/dL, atherosclerosis progression was observed in 11 (46%), 38% received revascularization and 33% experienced a new cardiovascular event (death, AMI, heart failure, stroke) at subsequent follow-up.

Conclusions

In the present study near one out of two patients with re-AMI after MINOCA showed angiographic atherosclerosis progression requiring revascularization in the majority of cases. These patients rarely presented with recommended LDL cholesterol levels and are at risk for further cardiovascular events, indicating a possible underestimation of cardiovascular risk in this population.

1016 CARDIAC MAGNETIC RESONANCE IMAGING IN DIFFERENTIAL DIAGNOSIS OF CARDIAC MASSES

Background

Differential diagnosis of cardiac masses represents a challenging issue with important implications for therapeutic management and patient's prognosis. Cardiac Magnetic Resonance (CMR) is a non-invasive imaging technique used to characterize morphologic and functional features of masses. Integration of these information can lead to an accurate diagnosis.

Purpose

To evaluate the diagnostic role of CMR in defining the nature of cardiac masses.

Methods

One hundred-fourteen patients with cardiac masses evaluated with CMR were enrolled. All masses had histological certainty. CMR sequences allowed a qualitative morphologic description as well as tissue characterization. Evaluation of masses morphology included localization, size and borders assessment, detection of potential multiple lesions and pericardial effusion. Tissue characterization resulted from an estimation of contrast enhancement - early gadolinium enhancement (EGE) and late gadolinium enhancement (LGE) sequences - and tissue homogeneity in T1 and T2 weighted acquisitions. The descriptive analysis was carried out by comparing benign vs malignant lesions as well as dividing patients into 4 subgroups: primitive benign tumours, primitive malignant tumours, metastatic tumours and pseudotumours.

Results

The descriptive analysis of morphologic features showed that diameter &gt; 50 mm, invasion of surrounding planes, irregular margins and presence of pericardial effusion were able to predict malignancy (p &lt; 0.001). As for tissue characteristics, heterogeneous signal intensity - independently from T1 and T2 weighted acquisitions - and EGE were more common in malignant lesions (p &lt;0.001). When analysing the four subgroups, CMR features did not discriminate between primitive malignant masses and metastasis. Conversely, hyperintensity signal in T2 w-TSE, EGE and heterogeneity after gadolinium enhancement were more common in benign primitive lesions compared to pseudotumours.

Furthermore, using classification and regression tree (CART) analysis, we developed an algorithm to differentiate masses: invasion of surrounding planes was a common characteristic of malignancy and identifies itself malignant tumours. In the absence of invasive features, gadolinium enhancement was evaluated: the lack of contrast uptake was able to increase the probability of a pseudotumour. Last step of decision algorithm included ejection fraction assessment to discriminate between benign tumours: a reduced ejection fraction increased the probability of pseudotumour diagnosis and reduced the probability of primary benign tumour diagnosis.

Conclusions

Cardiac magnetic resonance is a very powerful diagnostic tool for differential diagnosis of cardiac masses as it correctly addresses malignancy. Furthermore, an accurate evaluation of the several CMR features may discriminate primary benign masses and pseudotumours.

528 OUTCOMES IN DIABETIC PATIENTS WITH ACUTE MYOCARDIAL INFARCTION TREATED WITH SGLT2-I: THE SGLT2-I AMI PROTECT REGISTRY

Background

Sodium-glucose co-transporter 2 inhibitors (SGLT2-I) receive intense clinical interest in patients with and without type 2 diabetes mellitus (T2DM) for their pleiotropic beneficial effects.

Objectives

To investigate in-hospital and long-term prognosis in a cohort of T2DM patients presenting with acute myocardial infarction (AMI) treated with SGLT2-I versus other oral anti-diabetic (OAD) agents (non-SGLT2-I users).

Methods

In this multicenter international registry all consecutive diabetic AMI patients undergoing percutaneous coronary intervention (PCI) between 2018 and 2021 were enrolled and, based on the admission anti-diabetic therapy, divided into SGLT-I users versus non-SGLT2-I users. In-hospital outcomes included cardiovascular death, recurrent AMI, occurrence of arrhythmias, and contrast-induced acute kidney injury (CI-AKI). Long-term outcomes were cardiovascular mortality, recurrent AMI, heart failure (HF) hospitalization, and their composite (MACE).

Results

The study population consisted of 646 AMI patients (with or without ST-segment elevation): 111 SGLT2-I users and 535 non-SGLT-I users. The use of SGLT2-I was associated with a significantly lower in-hospital cardiovascular death, arrhythmic burden, and occurrence of CI-AKI (all p&lt;0.05). During a median follow-up of 24±13 months, cardiovascular mortality, HF hospitalization and the composite endpoint were lower for SGLT2-I users compared to non-SGLT2-I patients (p&lt;0.04 for all). After adjusting for confounding factors, the use of SGLT2-I was identified as independent predictor of HF hospitalization (HR=0.46; 95%CI:0.21-0.98; p=0.041) and MACE occurrence (HR=0.57; 95%CI:0.33-0.99; p=0.039).

Conclusions

In T2DM AMI patients, the use of SGLT2-I was associated with a lower risk of adverse cardiovascular outcomes during index hospitalization and long-term follow-up. Our findings provide new insights into the cardioprotective effects of SGLT2-I in the setting of AMI.

1031 IMPACT OF PRE-TREATMENT WITH A P2Y12 RECEPTOR INHIBITOR ON PERIPROCEDURAL MYOCARDIAL INFARCTION AND MYOCARDIAL INJURY IN NSTEMI

Background

Dual antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor is the standard of care in patients with acute coronary syndromes. The optimal timing of the administration of oral P2Y12 inhibitors has been largely debated, particularly among patients with non-ST-segment elevation myocardial infarction (NSTEMI). The latest European Society of Cardiology guidelines, based on recent scientific evidence, do not recommend routine pre-treatment with a P2Y12 inhibitor before coronary angiography. However, the impact of pre-treatment on the incidence of peri-procedural myocardial infarction (MI) and myocardial injury has never been explored.

Purpose

To evaluate the impact of pre-treatment with a P2Y12 receptor inhibitor on periprocedural myocardial infarction and injury in NSTEMI patients undergoing invasive treatment.

Methods

We evaluated all consecutive patients admitted to our coronary care unit from 2016 to 2021 affected by NSTEMI undergoing invasive management with percutaneous coronary intervention (PCI). We enrolled only patients with stable (≤ 20% variation) or falling pre-procedure baseline cardiac troponin (cTn) values. The entire population was divided into two groups: patients pre-treated with dual antiplatelet therapy (an oral P2Y12 inhibitor in adjunct to aspirin) before performing coronary angiography (upstream group) and patients who started an oral P2Y12 inhibitor only after PCI (downstream group). All patients received aspirin and anticoagulant therapy before coronary angiography. The primary endpoint was the incidence rate of periprocedural MI and myocardial injury according to the fourth universal definition of myocardial infarction. Finally, a safety endpoint of major and minor bleeding according to Thrombolysis in Myocardial Infarction (TIMI) criteria was evaluated for all bleeding episodes during hospitalization.

Results

A total of 878 patients with NSTEMI undergoing PCI and with pre-procedure stable cTn levels were analyzed: 615 (70%) constituted the upstream group. The mean age of the study population was 70.1±12.5 years and 71.3% were males. There were no significant differences regarding traditional cardiovascular risk factors, comorbidities, cTn and hemoglobin levels between the two groups.

After PCI, the rate of periprocedural myocardial injury and MI did not significantly differ between the upstream and downstream groups (19.5% vs 24.7%, p=0.08 and 17.6% vs 19.4%, p=0.5, respectively). A trend of lower periprocedural myocardial injury and MI cumulative incidence was observed in the upstream group (37.1% vs 44.1%, p=0.051). Notably, major and minor bleedings during hospitalization occurred more frequently in the upstream group compared to the downstream one (5.2% vs 1.9%, p=0.02).

Conclusions

Among NSTEMI patients undergoing invasive management and with stable pre-procedure cTn levels, pretreatment with an oral P2Y12 inhibitor did not reduce the rate of periprocedural MI and myocardial injury but was associated with an increase in major and minor bleeding complications during hospitalization.

1018 DIAGNOSTIC AGREEMENT BETWEEN ECHOCARDIOGRAPHY AND SECOND-LEVEL IMAGING TECHNIQUES IN PATIENTS WITH CARDIAC MASSES

Background

Cardiac masses (CMs) are a diagnostic dilemma in clinical practice and require multimodality imaging to assess malignancy, which is essential to guide the proper treatment.

Aim

To define diagnostic accuracy and agreement between echocardiographic features and second-level imaging techniques (cardiac computed tomography – CCT or cardiac magnetic resonance – CMR) in patients with CMs.

Methods

All consecutive patients with histologically confirmed cardiac masses from January 2004 to December 2020, undergoing CCT and/or CMR after echocardiographic assessment were enrolled. Six echocardiographic variables, namely infiltration, polylobate mass, moderate-severe pericardial effusion, inhomogeneity, sessile and non-left localization, were used to predict malignancy. Patients with more than 3 of these features were considered at higher risk of malignancy. For the patients before 2017, the choice of which second-level imaging to perform was up to the clinical cardiologist. Since 2017, the indication has been the result of a multidisciplinary discussion by the Heart Team. A definitive diagnosis was achieved by histological examination or, in the case of cardiac thrombi, with radiological evidence of thrombus resolution after an appropriate anticoagulant treatment. The echo-vs-CCT agreement and echo-vs-CMR agreement were evaluated. Accuracy indicators (sensitivity, specificity, PPV, NPV, Cohen's Kappa coefficient) were calculated by standard formulas.

Results

Out of 249 patients with histologically confirmed CM, 138 underwent a CCT and 112 a CMR, after the standard echocardiographic assessment. A complete agreement between the echocardiographic assignment (using the cut-off of 3 parameters as a marker for malignancy) and CCT was reached in 104 out of 138 cases (75.4%), ranging from 85.1 to 70.3% for benign and malignant cardiac masses, respectively. On the other side, the agreement between the echocardiographic assignment and CMR report was in 93 out of 112 cases (83%), ranging from 88.7 to 82% for benign and malignant cardiac masses. The agreement between these imaging techniques expressed as Cohen's κ was higher for echocardiography versus CMR (k=0.73), compared to echocardiography versus CCT (k=0.61). These results were also confirmed by the higher diagnostic accuracy of echocardiography versus CMR compared to echocardiography versus CCT (87% vs 80%), with best values of sensitivity, and specificity, denoting good reliability between the first 2 techniques.

Conclusions

A multimodal imaging approach is mandatory in the diagnostic work-up of CMs. The CMR, after a standard echocardiographic assessment, turned out to be the most accurate second-level investigation to discriminate between benign and malignant masses. However, when CMR is not available or the patient has a contraindication, the CCT could still be reliable.

1024 PROGNOSTIC VALUE OF CI-AKI AND HIS RELATIONSHIP WITH PERIPROCEDURAL MYOCARDIAL DAMAGE IN NSTEMI

Background

Periprocedural myocardial damage and contrast-induced acute kidney injury (CI-AKI) are frequent complications of percutaneous coronary intervention (PCI) and impact prognosis. The possible associations and the prognostic role of these peri-procedural complications are still not well understood.

Purpose

To evaluate predictors and prognostic role of CI-AKI in patients with NSTEMI and the relationship between CI-AKI and periprocedural myocardial damage.

Methods

Patients with NSTEMI undergoing coronary angiography within 72 hours were enrolled from January 2016 to September 2021. To detect post-PCI acute myocardial damage in this setting of NSTEMI patients, we included only those with stable (≤ 20% variation) or falling pre-procedure baseline cardiac troponin (cTn) values. Serum cTnI were measured at baseline and at 3-6-12 hours after PCI in all patients. Periprocedural myocardial damage was evaluated according to postprocedural hsTnI criteria provided by most recent consensus documents. Renal injury was documented when absolute serume creatinine increased of ≥ 0.3 mg/dL or ≥ 50% within 72 hours or urine output reduced to ≤ 0.5 mL/Kg/hour for at least 6 hours.

Results

We enrolled 878 patients with NSTEMI undergoing PCI and with pre procedure stable cTn levels. 53 patients suffered from AKI post contrast and among these 8 patients exhibited myocardial periprocedural injury and 20 patients had periprocedural myocardial infarction according to European Society of Cardiology guidelines. Myocardial periprocedural damage occurred more frequently in the CI- AKI group compared to non-CI-AKI group (52% vs 38%, p = 0.01). Patients who experienced CI-AKI were significantly older (mean age 86 ± 4) and had more frequently cardiovascular risk factors such as diabetes (p &lt; 0.001) and hypertension (p = 0.006), compared to non-CI-AKI group. Moreover NSTEMI patients with CI-AKI were more often on beta-blockers (p= 0.001) and statins (p &lt; 0.001) and exhibited more frequently at admission ST-T segment (p &lt; 0.000) and wall motion alterations at echocardiography evaluation (p = 0.004).Regarding intra-hospital outcomes, CI-AKI population experienced more frequently reinfarction (p = 0.02) and arrhythmias (p &lt; 0.000) compared to others . Surprisingly, the multivariate logistic regression showed that the stronger predictor of CI-AKI was periprocedural myocardial infarction (p &lt; 0.001). Finally, at 3 years of follow-up, in patients with CI-AKI there was more incidence of all-cause mortality (p = 0.001) and the composite of all-cause death, re-acute myocardial infarction and hospitalization for heart failure (p = 0.05) compared to non-CI-AKI group.

Conclusion

In NSTEMI patients, contrast-induced acute kidney injury was associated with majors adverse events, both intra-hospital and at long-term follow-up. Subjects who experienced acute kidney injury were older, had more comorbidities and had a worse clinical and instrumental profile at admission. CI-AKI was also associated with peri-procedural acute myocardial injury and infarction. More studies are needed to understand the patophysiological relations between these to post-PCI complications to improve their management.

1134 IN-HOSPITAL ARRHYTHMIC BURDEN REDUCTION IN DIABETIC PATIENTS WITH ACUTE MYOCARDIAL INFARCTION TREATED WITH SGLT2-INHIBITORS: INSIGHTS FROM THE SGLT2-I AMI PROTECT STUDY

Background

Sodium-glucose co-transporter 2 inhibitors (SGLT2-i) have shown significant cardiovascular benefits in patients with and without type 2 diabetes mellitus (T2DM). They have also gained interest for their potential anti-arrhythmic role and their ability to reduce the occurrence of atrial fibrillation (AF) and ventricular arrhythmias (VAs) in T2DM and heart failure patients.

Objectives

To investigate in-hospital new-onset cardiac arrhythmias in a cohort of T2DM patients presenting with acute myocardial infarction (AMI) treated with SGLT2-i vs. other oral anti-diabetic agents (non-SGLT2-i users).

Methods

Patients from the SGLT2-I AMI PROTECT registry (NCT05261867) were stratified according to the use of SGLT2-i before admission for AMI, divided into SGLT2-i users vs. non SGLT2-i users. In-hospital outcomes included the occurrence of in-hospital new-onset cardiac arrhythmias (NOCAs), defined as a composite of new-onset AF and sustained new-onset ventricular tachycardia (VT) and/or ventricular fibrillation (VF) during hospitalization.

Results

The study population comprised 646 AMI patients categorized into SGLT2-i users (111 patients) and non-SGLT2-i users (535 patients). SGLT2-I users had a lower rate of NOCAs compared with non-SGLT2-i users (6.3 vs.15.7%, p=0.010). Moreover, SGLT2-i was associated with a lower rate of AF and VT/VF considered individually (p = 0.032). In the multivariate logistic regression model, after adjusting for all confounding factors, the use of SGLT2-i was identified as an independent predictor of the lower occurrence of NOCAs (OR=0.35; 95%CI 0.14–0.86; p = 0.022). At multinomial logistic regression, after adjusting for potential confounders, SGLT2-I therapy remained an independent predictor of VT/VF occurrence (OR=0.20; 95%CI 0.04–0.97; p = 0.046) but not of AF occurrence.

Conclusions

In T2DM patients, the use of SGLT2-i was associated with a lower risk of new-onset arrhythmic events during hospitalization for AMI. In particular, the primary effect was expressed in the reduction of VAs. These findings emphasize the cardioprotective effects of SGLT2-i in the setting of AMI beyond glycemic control.

Trial registration: Data are part of the observational international registry: SGLT2-I AMI PROTECT. ClinicalTrials.gov Identifier: NCT05261867.

1025 PROGNOSTIC IMPACT OF STATINS AND DUAL ANTIPLATELET THERAPY ON LONG-TERM PROGNOSIS IN MINOCA PATIENTS

Background

Myocardial Infarction with Non-Obstructive Coronary Artery disease (MINOCA) is a heterogeneous entity with relevant long-term major adverse cardiovascular events (MACE). There is solid evidence that secondary prevention strategies improve prognosis of patients with obstructive myocardial infarction. However, evidence-based treatments for MINOCA are lacking as no published randomized clinical trials have ever exclusively enrolled this population. In fact, treatment recommendations in current guidelines are mainly based on expert opinions and MINOCA patients are frequently discharged with statins and dual antiplatelet therapy (DAPT).

Purpose

To evaluate the effects of statins and DAPT as secondary prevention treatments on long-term outcomes in MINOCA patients.

Methods

We enrolled all consecutive MINOCA patients admitted to our Centre from 2016 to 2021. The diagnosis of MINOCA was made according to the current European Society of Cardiology diagnostic criteria (angiographic conventional cut-off of &lt; 50% coronary stenosis without a clinically apparent alternative diagnosis). Second-level diagnostic work-up including cardiac magnetic resonance was performed to exclude non-ischemic troponin elevation cause.

All-cause mortality and MACE (a composite of all-cause mortality, hospitalization for heart failure, myocardial re-infarction and stroke) were collected during follow-up. The prognostic impact of statins and DAPT at discharge was assessed. The relationship between treatments and outcomes was evaluated by using Kaplan-Meier survival analysis.

Results

278 MINOCA patients were enrolled, of whom 203 (73%) were discharged on statins and 123 (44.2%) on DAPT. After a median follow-up of 36 ± 14.8 months, the overall all-cause mortality was 11.8% and the composite endpoint (MACE) was achieved in 28.4% of the entire population. Kaplan-Meier curves showed that patients treated with statins had a significantly lower rate of all-cause mortality (9.3% vs 18.2%, p=0.04) and MACE (24.6% vs 39.2%, p=0.02). On the other hand, rates of death (9.8% vs 13.2%, p=0.4) and MACE (23.6% vs 31.6%, p=0.1) were similar in MINOCA patients treated with DAPT or single antiplatelet therapy.

Conclusions

Among MINOCA patients, DAPT at discharge neither reduced long-term all-cause mortality nor MACE. In contrast, statin treatment provided beneficial effects on long-term outcomes. These results should be considered preliminary and require confirmation from randomized clinical trials.

857 DEVELOPMENT AND VALIDATION OF A DIAGNOSTIC ECHOCARDIOGRAPHIC MASS (DEM) SCORE IN THE COMPLEX APPROACH TO CARDIAC MASSES

Background

Cardiac masses (CM) are an extremely heterogeneous clinical entity, including benign and malignant neoformations. 2D Echocardiography is, nowadays, the first-line approach to define nature and management of CM.

Purpose

The purpose of our study was to identify the echocardiographic predictors of malignancy and create a multiparametric score to further increase the diagnostic yield and accurately suggest the nature of CM.

Materials and methods

249 consecutive patients undergoing a complete echocardiographic assessment for suspected cardiac mass in our center were enrolled from January 2004 to December 2020. A definitive diagnosis was achieved by histological examination or, in case of cardiac thrombi, with radiological evidence of thrombus resolution after an appropriate anticoagulant treatment. Logistic regression was performed to evaluate the ability of echocardiography to discriminate benign versus malignant masses.

Results

A scoring system was developed in a derivation cohort of 178 (70%) and validated in 71 (30%) patients. A weighted score [Diagnostic Echocardiographic Mass (DEM) Score] ranging from 0 to 9 was obtained from 6 variables: infiltration, polylobate mass, moderate-severe pericardial effusion, inhomogeneity, sessile and non-left localization. The AUC for the score was 0.965 (95% CI 0.938-0.993). In a logistic regression analysis using the DEM score as a predictor, the likelihood of malignancy increased more than 4 times for a 1-unit increase of the score (OR=4.468; 95% CI 2.733-7.304). The prognostic validity of the score was confirmed by its ability to predict survival during follow-up (median time of 31 months).

Conclusions

The application of a multiparametric echocardiographic score in the approach to CM accurately predicts mass malignancy, thereby reducing the need for second-level investigations, and minimizing the diagnostic delay in such a complex clinical scenario.

225 PROGNOSTIC ROLE OF EARLY CARDIAC MAGNETIC RESONANCE IN MYOCARDIAL INFARCTION WITH NON-OBSTRUCTIVE CORONARY ARTERIES (MINOCA)

Background

Myocardial infarction with non-obstructive coronary arteries (MINOCA) represents a significant proportion of acute myocardial infarction (AMI) population. MINOCA is a working diagnosis and an accurate investigation of the underlying causes should always be performed. In this setting, cardiac magnetic resonance (CMR) imaging plays a pivotal diagnostic role. However, a prognostic stratification based on the CMR findings in ischemic MINOCA is still unavailable.

Purpose

To evaluate the potential prognostic impact of specific CMR findings - especially ischemic late gadolinium enhancement (LGE) patterns - in order to look for measurable parameters that may guide the management of this still troubled clinical entity.

Methods

We assessed 461 MINOCA from January 2016 to June 2021. We excluded acute myocarditis, Tako-tsubo syndromes, cardiomyopathies, or non-pathological CMR. According to CMR findings, MINOCA were classified in two phenotypes: LGE-positive (an ischemic subendocardial or transmural LGE pattern) or LGE-negative (cases without LGE but exhibiting regional myocardial injury defined by myocardial edema in a coronary territory with a typically ischemic "wave-front" and/or regional wall motion abnormality consistent with coronary distribution).

All-cause mortality, re-infarction, stroke, heart failure (HF) and the composite endpoint (MACE) were evaluated. Extended LGE was considered as the presence of &gt;2 segments with transmural LGE. The mean follow-up was 36.1 ± 15.2 months and CMR was performed at a mean of 6 ± 2.9 days from the acute presentation.

Results

The final cohort included 175 MINOCA with a likely-ischemic etiology: 121 (69.1%) constituted the LGE-positive group. The mean age of the study population was 62.3 ± 12.9 years and more than 61% were females. During follow-up, HF (15.7% vs 1.9%, p=0.008) and MACE (20.7% vs 7.4%, p=0.029) occurred more frequently in MINOCA "LGE-positive" compared to the "LGE-negative" ones. Extended LGE was significantly more prevalent in patients with versus without subsequent HF. On multivariable Cox regression, extended LGE was an independent predictor of HF occurrence (HR 18.49, 95%CI 4.65–73.61, p &lt; 0.001) and MACE (HR 14.64, 95%CI 3.91–54.86, p &lt; 0.001).

Conclusions

Our data suggest that in MINOCA patients the detection of LGE is correlated with the incidence of major cardiovascular events and heart failure during long-term follow-up. In fact, LGE extension was identified as the strongest predictor of cardiac adverse events. The early execution of CMR is useful in the prognostic stratification of MINOCA and this could guide the subsequent clinical and therapeutic management.

1054 GENDER DIFFERENCES IN MINOCA POPULATION

Background

Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) is a clinical condition that includes acute myocardial infarction (AMI) occurring with non-obstructive coronary disease. This entity accounts above 6% (from 1% to 14%) of all patients presenting with AMI and it's known to be more prevalent in females. However, differences in terms of clinical features and prognosis in MINOCA patients according to gender have been poorly understood.

Purpose

To evaluate differences in clinical characteristics at admission and during follow-up between males and females with MINOCA.

Methods

We included all consecutive patients with AMI undergoing coronary angiogram between 2016 and 2020 at our center. According to 2016 ESC Position Paper criteria, we considered as MINOCA all patients with AMI and coronary stenosis &lt;50% at coronary angiography without clinically apparent alternative diagnoses such as Takotsubo syndrome and myocarditis. Then, we analyzed the baseline clinical characteristics of MINOCA patients by dividing the population into two groups according to gender. Variables with a statistical significance lower than p&lt;0.05 in univariable analysis were included in a logistic regression analysis to determine independent predictors of MINOCA. The predictive value of both groups was evaluated using Kaplan-Meier survival curves. Our aim was to evaluate composite endpoint of death, re IMA, stroke and heart failure in a follow up time mean of 36 ± 14.8 months.

Results

Among 289 patients affected by MINOCA according to the 2016 ESC criteria, 98 were male (34%) and 191 were female (66%). Females were older than males (68.9 ± 13.1 vs 58.4 ± 14.5 years, p =0.0001). About the traditional cardiovascular risk factors males were more frequently smokers (56.1% vs 33.9%, p=0.001) while there were no significant differences in others risk factors. Females were more frequently on beta-blockers (39% vs 20%, p=0.002) and statins (33% vs 19%, p=0.015) compared to males. No differences were found between the two groups regarding clinical characteristics and instrumental findings (EKG and echocardiography). At coronary angiography, males had more frequently severe coronary stenosis than females (15.5 ± 26.4 VS 9.1 ± 21.5, p =0.019). During follow up we did not find any differences in terms of death, reinfarction, stroke and heart failure while females had more MACEs than males (33% vs 19.4%, p=0.015); and this data was confirmed at Kaplan Meier curves (p = 0.014). Finally, the multivariate analysis showed that age is an independent predictor of MINOCA (HR 1.04, CI 1.01-2.07, p=0.006), rather than sex, diabetes, and hypertension.

Conclusions

In our MINOCA population we found that females were older than males, more frequently on statins and beta blockers at admission and they showed a lower degree of atherosclerotic disease. Nevertheless, after 36 ± 14.8 months of follow-up, we found a higher incidence of MACE in females than in males. We hypothesize that these findings could reflect the different pathogenesis of myocardial damage in our subgroups. Actually, statins and estrogens have a well-known protective role towards the progression of atherosclerosis, but they have no impact on other mechanisms of myocardial infarction which are more frequent in females, such as spontaneous coronary artery dissections, epicardial spasms or microvascular dysfunction.

Predictors of late gadolinium enhancement development and extension in myocardial infarction with non-obstructive coronary arteries

Background

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous clinical entity and in its complex diagnostic approach cardiovascular magnetic resonance (CMR) plays a pivotal role.

Purpose

To characterize the differences of MINOCA patients with and without late gadolinium enhancement (LGE) at CMR and to identify the predictors for ischemic LGE development and extension.

Methods

We assessed 461 MINOCA cases from January 2016 to June 2021. MINOCA were defined according to the current European guidelines criteria. We excluded acute myocarditis, Tako-tsubo syndromes, cardiomyopathies, or non-pathological CMR. According to CMR imaging findings, our cohort was divided into two CMR phenotypes based on regional myocardial necrosis detected throughout LGE (“LGE-positive MINOCA”) or regional ischemic injury without LGE (“LGE-negative MINOCA”). Extended LGE was considered as the presence of &gt;2 segments with transmural LGE. Multivariate logistic regression analysis was used to determine the predictors of LGE and extended LGE.

Results

The final cohort included 175 MINOCA: 121 (69.1%) constituted the LGE-positive group. The mean time delay between acute clinical presentation and CMR was 6±2.9 days. At admission MINOCA LGE-patients more frequently presented angina and ST segment elevation (24% vs 7.4%, p=0.01), compared to LGE negative ones. Furthermore, the LGE positive group had a significantly greater infarct size, measured by peak hs-Troponin I values and left ventricular function (LVEF). The only predictor of LGE was the peak troponin value (OR 1.64, 95% CI 1.18–2.28, p=0.003), while predictors of extended LGE were ST-segment elevation at admission (OR 7.44, 95% CI 1.57–35.22, p=0.01), peak troponin values (OR 1.07, 95% CI 1.02–1.13, p=0.01) and the presence of non-obstructive coronary artery disease at coronary angiography (OR 5.49, 95% CI 1.20–25.09, p=0.028).

Conclusion

The presence and extension of LGE at early CMR evaluation is an important feature in the setting of MINOCA. In addition, simple baseline characteristics (such as ST elevation, peak troponin value and LVEF) may aid the identification of a greater ischemic necrosis burden at CMR and therefore these high-risk MINOCA subjects could be benefit from a stricter management effort.

Funding Acknowledgement

Type of funding sources: None.

Prognostic role of acute myocardial infarction diagnostic criteria in patients presenting with non-ST segment elevation myocardial infarction

Background

The Fourth Universal Definition of Myocardial Infarction (UDMI) defines acute myocardial infarction (AMI) as an acute myocardial injury associated with clinical evidence of acute myocardial ischemia. However, the prognostic role of each single diagnostic criteria has never been explored.

Purpose

To evaluate the prognostic role of the different diagnostic criteria of AMI according to the Fourth UDMI in patients with non-ST-segment elevation myocardial infarction.

Methods

We enrolled all consecutive patients with NSTEMI undergoing coronary angiography at our Centre. The admission diagnosis was performed according to the current guidelines criteria, namely the detection of an increase and/or decrease of high-sensitivity cardiac troponin I, with at least one value above the 99th percentile of the upper reference limit and at least one of the following: symptoms of ischemia, ECG changes (new ST depression or negative T-waves), echocardiographic evidence of new regional wall motion abnormality. Patients with very high-risk NSTEMI were excluded. Patients were then divided into different subgroups according to the combination of diagnostic criteria presented at admission. A composite endpoint of all-cause mortality, re-hospitalization for myocardial reinfarction or heart failure was collected. The predictive value of AMI diagnostic criteria alone and their combination were evaluated using Kaplan-Meier survival curves and subsequent Cox-regression analysis to find independent predictors of major adverse events.

Results

Our study population consisted of 2791 patients. The mean age was 68.3±13.4 and 31.5% were female. The mean follow-up time was 23.3±14.5 months. Depending on the AMI diagnostic criteria and their combination, patients were divided into three subgroups: 196 patients fulfilling only clinical criteria (group A), 187 with clinical and ECG-graphic criteria (group B) and 829 patients with clinical, ECG-graphic and echo-graphic criteria (group C). Baseline characteristics of the three groups were similar. At two-year follow-up, patients with clinical criteria alone exhibited the best outcome, whereas those with all three criteria fulfilled showed the worse prognosis (14.8% for group A vs 23.6% for group B vs 28.0% for group C; p-value &lt;0.001). In multivariable Cox-regression model, the presence of clinical criteria alone was the independent predictor of better prognosis compared to the other diagnostic criteria combination (HR=0.48; CI 95% 0.31–0.74; p&lt;0.001).

Conclusions

In non-very high-risk NSTEMI, not all diagnostic criteria have the same prognostic value. In fact, prognosis is significantly more favorable in patients exhibiting only the clinical criteria at admission. We hypothesize that the absence of ECG-graphic and echocardiographic alterations may indirectly indicate smaller infarct sizes that contribute to patients' outcomes. These findings could enhance the current risk stratification in patients admitted with NSTEMI.

Funding Acknowledgement

Type of funding sources: None.

Prognostic role and predictors of high Killip class in myocardial infarction with non-obstructive coronary artery

Background

Killip classification is a simple clinical tool for risk stratification in patients with acute myocardial infarction (AMI). However, predictors of high Killip class at admission and its prognostic role in myocardial infarction with non-obstructive coronary artery (MINOCA) are still poorly explored.

Purpose

To identify clinical predictors of high Killip class and its potential prognostic role in patients with MINOCA compared to patients with myocardial infarction with obstructive coronary artery (MIOCA).

Methods

We included patients with AMI undergoing coronary angiogram from January 2016 to June 2021. MINOCA were defined according to the current European guidelines criteria. We compared the Killip classes of MINOCA with those of MIOCA and defined a high Killip class if greater than 1. Kaplan-Meier (KM) curves were developed for the comparison of all-cause mortality among MIOCA and MINOCA with high Killip class (&gt;1) compared to the others. Multivariate logistic regression analysis was used to determine the predictors of high Killip class.

Results

Among 3261 AMI, 261 were MINOCA. The median follow-up time was 36.1±15.2 months. Killip class &gt;1 occurred in 24 (8.8%) MINOCA patients compared to 518 (17.3%) MIOCA cases (p=0.001). During long-term follow-up, a high Killip class was associated with a 3-fold increased mortality both in MIOCA and MINOCA populations (p&lt;0.001 and p=0.001). Furthermore, in both groups, the KM survival curves were significantly worse for patients with high Killip class compared to lower classes (p&lt;0.001). Within MIOCA multivariate logistic regression showed that predictors of a high Killip class at admission were older age [OR 1.04, 95% CI (1.03–1.06), p&lt;0.001], diabetes [OR 1.60, 95% CI (1.24–2.07), p&lt;0.001], ST-segment-elevation [OR 1.53, 95% CI (1.12–2.10), p=0.008], left ventricular ejection fraction (LVEF) [OR 0.95, 95% CI (0.94–0.96), p&lt;0.001] and elevated cardiac troponin [OR 1.01, 95% CI (1.00–1.01), p=0.01]. Instead, in MINOCA only older age [OR 1.08, 95% CI (1.03–1.14), p=0.003], ST-segment-elevation [OR 7.40, 95% CI (1.08–50.65), p=0.04] and diabetes [OR 3.60, 95% CI (1.09–11.96), p=0.04] were predictors of a high Killip class whereas LVEF (p=0.3) and elevated cardiac troponin (p=0.6) exhibited a neutral impact in these patients.

Conclusions

High Killip class at admission is a high-risk marker of adverse cardiovascular events even in patients with MINOCA. Simple baseline characteristics (such as older age, diabetes, ST-segment-elevation) predict a high Killip class in MINOCA subjects and can help to identify a high-risk population who might benefit from a stricter management. Furthermore, LVEF and elevated cardiac troponin were identified as predictors of a high Killip class in MIOCA but they did not show a similar impact in the setting of MINOCA. This may reflect the different pathogenesis and myocardial damage extent in MINOCA compared to MIOCA.

Funding Acknowledgement

Type of funding sources: None.

Infarct size, inflammatory burden and admission hyperglycemia in diabetic patients with acute myocardial infarction treated with SGLT2-inhibitors: a multicenter international registry

Background

Sodium-glucose co-transporter 2 inhibitors (SGLT2-I) currently receive intense clinical interest in patients with and without diabetes mellitus (DM) with pleiotropic beneficial effects. Nowadays, the inflammation response in the setting of acute myocardial infarction (AMI) has been proposed as a potential pharmacological intervention target. In this setting, we tested the hypothesis that the SGLT2-I displays anti-inflammatory effect along with glucose-lowering properties. We investigated the relationship between stress hyperglycemia, inflammation burden and infarct size in a cohort of type 2 diabetic AMI patients treated with SGLT2-I versus other oral anti-diabetic (OAD) agents alone.

Methods

In this multicenter international registry, all diabetic patients with AMI treated with percutaneous coronary intervention (PCI) between 2018 and 2021 were enrolled. Based on the admission anti-diabetic therapy, patients were divided into those receiving SGLT2-I versus other OAD agents alone. Patients on insulin therapy alone or combined with OAD agents were excluded from the study. The following inflammatory markers were evaluated at different time points: total white blood cell, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR) and neutrophil-to-platelet ratio (NPR), C-reactive protein. Infarct size was assessed by peak troponin levels and echocardiographic parameters.

Results

The final study population consisted of 583 patients hospitalized for AMI (both STEMI and NSTEMI) classified as SGLT2-I users (n=98) versus other OAD agents alone (n=485). Admission hyperglycemia was more prevalent among the other OAD agents group. Reduced infarct size was detected in patients treated with SGLT2-I compared to those treated with other OAD agents alone. Both at admission, and after 24 hours, inflammatory indices were significantly higher in patients treated with other OAD agents alone, with a significant increase in neutrophils levels at 24 hours, compared to the SGLT2-I group. In multivariate analysis, SGLT2-I emerged as a significant predictor of reduced inflammatory response (OR 0.45, 95% CI 0.27–0.75, p=0.002), together with peak troponin values, independently of age, admission creatinine values and admission glycemia.

Conclusions

Type 2 Diabetic patients hospitalized for AMI and receiving SGLT2-I exhibited modest inflammatory response and myocardial damage/infarct size compared to other OAD agents alone, independently of glucose-metabolic control. Our findings pave the way for new pathophysiological and therapeutic insights regarding the cardioprotective effect of SGLT2-I in the setting of coronary artery disease.

Funding Acknowledgement

Type of funding sources: None.

Prognostic role of early cardiac magnetic resonance in myocardial infarction with non-obstructive coronary arteries

Background

Myocardial infarction with non-obstructive coronary arteries (MINOCA) represents a significant proportion of acute myocardial infarction (AMI) population. MINOCA is a working diagnosis and an accurate investigation of the underlying causes should always be performed. In this setting, cardiac magnetic resonance (CMR) imaging plays a pivotal diagnostic role. However, a prognostic stratification based on the CMR findings in ischemic MINOCA is still unavailable.

Purpose

To evaluate the potential prognostic impact of specific CMR findings - especially ischemic late gadolinium enhancement (LGE) patterns - in order to look for measurable parameters that may guide the management of this still troubled clinical entity.

Methods

We assessed 461 MINOCA from January 2016 to June 2021. We excluded acute myocarditis, Tako-tsubo syndromes, cardiomyopathies, or non-pathological CMR. According to CMR findings, MINOCA were classified in two phenotypes: LGE-positive (an ischemic subendocardial or transmural LGE pattern) or LGE-negative (cases without LGE but exhibiting regional myocardial injury defined by myocardial edema in a coronary territory with a typically ischemic “wave-front” and/or regional wall motion abnormality consistent with coronary distribution).

All-cause mortality, re-infarction, stroke, heart failure (HF) and the composite endpoint (MACE) were evaluated. Extended LGE was considered as the presence of &gt;2 segments with transmural LGE. The mean follow-up was 36.1±15.2 months and CMR was performed at a mean of 6±2.9 days from the acute presentation.

Results

The final cohort included 175 MINOCA with a likely-ischemic etiology: 121 (69.1%) constituted the LGE-positive group. The mean age of the study population was 62.3±12.9 years and more than 61% were females. During follow-up, HF (15.7% vs 1.9%, p=0.008) and MACE (20.7% vs 7.4%, p=0.029) occurred more frequently in MINOCA “LGE-positive” compared to the “LGE-negative” ones. Extended LGE was significantly more prevalent in patients with versus without subsequent HF. On multivariable Cox regression, extended LGE was an independent predictor of HF occurrence (HR 18.49, 95% CI 4.65–73.61, p&lt;0.001) and MACE (HR 14.64, 95% CI 3.91–54.86, p&lt;0.001).

Conclusions

Our data suggest that in MINOCA patients the detection of LGE is correlated with the incidence of major cardiovascular events and heart failure during long-term follow-up. In fact, LGE extension was identified as the strongest predictor of cardiac adverse events. The early execution of CMR is useful in the prognostic stratification of MINOCA and this could guide the subsequent clinical and therapeutic management.

Funding Acknowledgement

Type of funding sources: None.

In-hospital arrhythmic burden reduction in diabetic patients with acute myocardial infarction treated with SGLT2-inhibitors: Insights from the SGLT2-I AMI PROTECT study

Background

Sodium-glucose co-transporter 2 inhibitors (SGLT2-i) have shown significant cardiovascular benefits in patients with and without type 2 diabetes mellitus (T2DM). They have also gained interest for their potential anti-arrhythmic role and their ability to reduce the occurrence of atrial fibrillation (AF) and ventricular arrhythmias (VAs) in T2DM and heart failure patients.

Objectives

To investigate in-hospital new-onset cardiac arrhythmias in a cohort of T2DM patients presenting with acute myocardial infarction (AMI) treated with SGLT2-i vs. other oral anti-diabetic agents (non-SGLT2-i users).

Methods

Patients from the SGLT2-I AMI PROTECT registry (NCT05261867) were stratified according to the use of SGLT2-i before admission for AMI, divided into SGLT2-i users vs. non-SGLT2-i users. In-hospital outcomes included the occurrence of in-hospital new-onset cardiac arrhythmias (NOCAs), defined as a composite of new-onset AF and sustained new-onset ventricular tachycardia (VT) and/or ventricular fibrillation (VF) during hospitalization.

Results

The study population comprised 646 AMI patients categorized into SGLT2-i users (111 patients) and non-SGLT2-i users (535 patients). SGLT2-i users had a lower rate of NOCAs compared with non-SGLT2-i users (6.3 vs. 15.7%, p = 0.010). Moreover, SGLT2-i was associated with a lower rate of AF and VT/VF considered individually (p = 0.032). In the multivariate logistic regression model, after adjusting for all confounding factors, the use of SGLT2-i was identified as an independent predictor of the lower occurrence of NOCAs (OR = 0.35; 95%CI 0.14-0.86; p = 0.022). At multinomial logistic regression, after adjusting for potential confounders, SGLT2-i therapy remained an independent predictor of VT/VF occurrence (OR = 0.20; 95%CI 0.04-0.97; p = 0.046) but not of AF occurrence.

Conclusions

In T2DM patients, the use of SGLT2-i was associated with a lower risk of new-onset arrhythmic events during hospitalization for AMI. In particular, the primary effect was expressed in the reduction of VAs. These findings emphasize the cardioprotective effects of SGLT2-i in the setting of AMI beyond glycemic control.

Trial registration

Data are part of the observational international registry: SGLT2-I AMI PROTECT. ClinicalTrials.gov, identifier: NCT05261867.

[Cardiac masses: classification, clinical features and diagnostic approach]

The term cardiac mass refers to benign or malignant cardiac tumors and cardiac metastases but also to pseudotumors, which is a heterogeneous group consisting of thrombi, vegetations and normal variant structures. While primitive cardiac tumors are rare, metastases and pseudotumors are relatively common. The non-invasive diagnostic approach has not been well established in the literature yet. The first-line non-invasive approach consists of echocardiography, which provides good diagnostic accuracy for masses like thrombi, vegetations and some tumors (mainly myxoma and fibroelastoma). In contrast, for other masses, it does not provide information about the potential malignancy because of poor tissue characterization. Second-line (cardiac computed tomography and cardiac magnetic resonance) or third-line (positron emission tomography-computed tomography) evaluations have been validated in the diagnostic approach to cardiac masses by many studies. In fact, a comprehensive diagnostic approach may establish the diagnosis of malignancy without histological report, which is pivotal for the subsequent therapeutic strategy.The aim of this narrative review is to describe the commonly available non-invasive diagnostic techniques for cardiac masses, their potential and limitations and to suggest a diagnostic pathway for common practice.

P212 PROGNOSTIC ROLE OF ACUTE MYOCARDIAL INFARCTION DIAGNOSTIC CRITERIA IN NON–ST SEGMENT ELEVATION MYOCARDIAL INFARCTION

Background

Although the majority of patients with NSTEMI share similar risk factors and similar pathophysiology, their outcomes differ considerably. The Fourth Universal Definition of Myocardial Infarction (UDMI) defined acute myocardial infarction (AMI) by an acute myocardial injury together with clinical evidence of acute myocardial ischaemia. However, the prognostic role of each single diagnostic criteria has never been explored.

Purpose

To evaluate the prognostic role of the different diagnostic criteria of AMI according to the Fourth UDMI in NSTEMI patients.

Methods

We enrolled all consecutive patients with AMI undergoing coronary angiogram at our Centre. We used a combination of criteria, according to the current ESC guidelines, to meet the diagnosis, namely the detection of an increase and/or decrease of high–sensitivity cardiac troponin I, with at least one value above the 99th percentile of the upper reference limit and at least one of the following: symptoms of ischaemia; ECG changes (new ST–T changes or new LBBB); development of pathological Q waves in the ECG; echocardiographic evidence of new loss of viable myocardium or new regional wall motion abnormality. Patients with STEMI and very high risk NSTEMI were excluded. A composite endpoint of all–cause mortality, re–hospitalization for heart failure, and myocardial reinfarction was collected. The predictive value of diagnostic criteria alone and their association were evaluated using Kaplan–Meier survival curves and subsequent Cox–regression analysis to find independent predictors of adverse events.

Results

2791 patients with NSTEMI were evaluate. At admission 196 had clinical criteria alone, 187 had clinic + ECG and 829 had clinic + ECG + echo. The total number of events was 689. The median follow–up was 23.3±14.5 months. We found that patients with clinical criteria alone had a better prognosis at 2 years follow–up (p &lt; 0.001). No other significant prognostic correlation was found. Multivariable Cox–regression model demonstrated that clinical criteria was the only independent predictor of better prognosis in patients with NSTEMI (HR = 0.48; CI 95% 0.31–0.74; p &lt; 0.001).

Conclusions

Our data suggest that in NSTEMI the prognosis is considerably better if clinical criteria alone is present at admission. We hypothesize that the absence of electrocardiographic and echocardiographic alterations in NSTEMI could indirectly indicate smaller infarct sizes or other causes of acute myocardial injury.

P412 SCAD: A PLANET TO DISCOVER IN THE UNIVERSE OF ACS

We hereby present the case of a 36–year–old woman with neither a history of cardiovascular disease nor any cardiovascular risk factors. Her only past medical history included a pregnancy from in vitro fertilization and endometriosis treated with progestin. She was admitted to A&E for sudden onset severe stabbing thoracic pain, which occurred at rest and was exacerbated by respiratory efforts, and with spontaneous resolution shortly after admission. While the ECG did not show any signs of ischemic, blood tests revealed a minor rise in inflammatory markers and a significant rise in troponin values, the latter consistent with acute myocardial injury.

Given the clinical suspicion of myopericarditis vs acute coronary syndrome, the patient was admitted to cardiac intensive care unit. Bedside echocardiogram performed shortly after admission demonstrated minor pericardial effusion and regional wall motion abnormalities. Thus, the patient underwent urgent coronary angiography, which revealed pronounced vasospasm at the proximal segment of the circumflex artery, which subsided after administration of nitrate, as well as spontaneous dissection of the mid left anterior descending artery extending to its apical branch. Since no high–risk features were identified (single vessel, mid–distal coronary lesion, no symptoms of persistent ischemia), revascularisation was not attempted and conservative therapy was undertaken. During the following days, genetic evaluation and further diagnostic tests were performed to exclude vascular abnormalities in other anatomical sites, which all resulted negative. Outpatient follow–up with CT coronary angiogram demonstrated full patency of left anterior descending artery with spontaneous resolution of the former dissection.

This clinical scenario represents an example of an uncommon and thus often overlooked cause of acute coronary syndrome with yet limited evidence on optimal therapeutic and follow–up strategies.

P322 A MISLEADING SAM

A 66–year–old woman with a history of anxious–depressive syndrome and osteoporosis, without significant cardiological history, reported onset of cardiopalmus and dyspnoea for a few days due to moderate efforts, in conjunction with a period of strong emotional stress. Due to the persistence of these symptoms and the onset of epigastric pain, she underwent a cardiological examination which found low blood pressure values associated with the presence of a systolic murmur. The ECG showed diffuse changes in repolarization compatible with ischemia. Access to the emergency room (ER) was recommended. In ER, the first high–sensitivity troponin value was significantly high (1542 ng/L). Therefore, in the suspect of ACS, the patient was transferred to the cardiological intensive care unit. Echocardiogram showed akinesia of the mid–apical segments, hypercontractility of the bases (EF 35%) and a SAM (systolic anterior motion) with a dynamic outflow tract pressure gradient of 80 mmHg which resulted in severe mitral regurgitation. During the first days of hospitalization, persistent hypotension was observed requiring intravenous infusion of fluids to maintain systolic blood pressure values between 90–100 mmHg. Coronary angiography showed only severe ostial stenosis of a branch of the first diagonal branch. At the same time, ventriculography was performed which showed basal hypercontractility with muscle salience at the base and systolic obliteration of the outflow tract with a small apical aneurysm. 5 days after admission, another echocardiogram showed the almost complete normalization of the global systolic function (EF 68%) with apical hypokinesia and hypercontractility of the basal segments. However, the SAM persisted with a dynamic outflow tract pressure gradient of 140 mmHg with the presence of multiple and dislocated papillaries, accessory tendon cords and insertion of muscle tendon at the level of the septum. To complete the diagnosis, cardiac MRI was performed which documented a diffuse increase in T2 relaxation times more evident in the apical area, absence of LGE areas and normalization of contractility of the left ventricle with disappearance of the SAM. These findings, together with the absence of significant hypertrophy and the complete regression of the ECGgraphic changes, allowed us to exclude the presence of an unrecognized hypertrophic cardiomyopathy and to diagnose Takotsubo syndrome.

P215 PROGNOSTIC IMPACT OF EARLY VERSUS DEFERRED CORONARY ANGIOGRAPHY IN MINOCA PATIENTS

Background

Although an early invasive strategy (coronary angiography performed &lt; 24 hours) is associated with a lower risk of recurrent/refractory ischaemia among patients with acute myocardial infarction (AMI) and obstructive coronary arteries, the optimal timing of invasive examination in patients with non–obstructive coronary arteries and non–ST–segment elevation presentation (NSTE–MINOCA) has not been explored.

Purpose

This study tested the hypothesis that, compared to early (&lt; 24 h) invasive strategy, deferred (≥ 24 h) coronary angiography has an equivalent prognostic impact in patients with NSTE–MINOCA.

Methods

From 2016 to 2020, all consecutive MINOCA patients diagnosed according to the current ESC diagnostic criteria (angiographic conventional cut–off of &lt; 50% coronary stenosis without a clinically apparent alternative diagnosis) and admitted to our Centre with non–ST–segment elevation myocardial infarction (NSTEMI) presentation were enrolled. Very high–risk NSTEMI patients had been excluded from the study. The prognostic value of an early (&lt; 24 h) vs. deferred (≥ 24 h) coronary angiography was assessed. All–cause mortality and a composite endpoint (MACE) of all–cause mortality, stroke, re–hospitalization for heart failure and myocardial re–infarction were evaluated.

Results

198 NSTE–MINOCA patients were enrolled, of which 79 underwent coronary angiography &lt; 24 hours and 119 ≥ 24 hours. MINOCA patients were more frequently females (64%) and the mean age was 66.8±13.2 years. After a median follow–up of 26 [14–40] months, the overall all–cause mortality was 13,6% and the composite endpoint (MACE) was achieved in 27.3% of the entire population. Kaplan–Meier curves showed that there was no statistically significant difference (p = 0.88) between the two study groups depending on the time of invasive strategy adopted. Specifically, rates of death (11.4% vs. 15.1%) and MACE (25.3% vs. 28.6%) were similar in MINOCA patients undergoing early versus deferred coronary angiography.

Conclusions

We demonstrated for the first time that in the MINOCA population the prognosis is not influenced by an early versus deferred coronary angiography, as opposed to AMI patients with obstructive coronary arteries. These results add another piece to the puzzle and pave the way for the initial use of a non–invasive imaging strategy (eg. Coronary–CT), mostly in patients with NSTEMI and high clinical suspicion of non–obstructive coronary arteries.

P210 VENTRICULAR FIBRILLATION IN AN ELDERLY WOMAN WITH APPARENTLY UNREMARKABLE PAST CARDIOLOGICAL HISTORY: AN UNEXPECTED CULPRIT

An 85–year–old woman experienced cardiac arrest while she was at the supermarket. Cardiopulmonary resuscitation was promptly performed with ROSC after DC shock on ventricular fibrillation and immediate hemodynamic and neurological recovery. The first ECG performed by the rescuers did not show acute ischemic changes and the patient was admitted to the Cardiological Intensive Care Unit. Past medical history revealed only a previous episode of acute pulmonary embolism for which she was on oral anticoagulant therapy for a limited period of time. She had not family history of sudden cardiac death or cardiomyopathies. Before admission she was completely asymptomatic and she never complained of angina pectoris, palpitation or dyspnoea. The echocardiogram at admission showed moderate left atrial enlargement and hypokinesia of left ventricle apex and mid–apical lateral wall with global EF of 50%. Pulmonary and aortic CT angiography showed no pathological findings. In order to rule out an ACS, the patient underwent a coronary angiography which documented the absence of critical coronary stenosis. Finally, a cardiac MRI with gadolinium was performed, revealing the presence of two small areas of transmural LGE affecting inferior basal and lateral mid–apical segments with no edema, consistent with ischaemic myocardial scars. In light of this findings and to rule out paradoxical coronary artery embolism we decided to perform a transcranial echocolordoppler that showed the absence of a patent foramen ovale. Furthermore, continuous ECG monitoring during the hospital stay did not document arrhythmic recurrences. In consideration of the high probability of ischemic heart disease, therapy with antiplatelet agent, beta–blocker, ace–inhibitor and statin was introduced and the patient was discharged after ICD implantation. Three months later, during her first follow–up visit, we documented short episodes of atrial fibrillation at ICD interrogation. This was in line with the hypothesis of a ventricular fibrillation and cardiac arrest in the contest of an ischemic heart disease with myocardial scars probably due to undatale coronary artery embolism. Oral anticoagulant therapy was started in addition to previous therapy.

Infarct size, inflammatory burden, and admission hyperglycemia in diabetic patients with acute myocardial infarction treated with SGLT2-inhibitors: a multicenter international registry

BACKGROUND

The inflammatory response occurring in acute myocardial infarction (AMI) has been proposed as a potential pharmacological target. Sodium-glucose co-transporter 2 inhibitors (SGLT2-I) currently receive intense clinical interest in patients with and without diabetes mellitus (DM) for their pleiotropic beneficial effects. We tested the hypothesis that SGLT2-I have anti-inflammatory effects along with glucose-lowering properties. Therefore, we investigated the link between stress hyperglycemia, inflammatory burden, and infarct size in a cohort of type 2 diabetic patients presenting with AMI treated with SGLT2-I versus other oral anti-diabetic (OAD) agents.

METHODS

In this multicenter international observational registry, consecutive diabetic AMI patients undergoing percutaneous coronary intervention (PCI) between 2018 and 2021 were enrolled. Based on the presence of anti-diabetic therapy at the admission, patients were divided into those receiving SGLT2-I (SGLT-I users) versus other OAD agents (non-SGLT2-I users). The following inflammatory markers were evaluated at different time points: white-blood-cell count, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), neutrophil-to-platelet ratio (NPR), and C-reactive protein. Infarct size was assessed by echocardiography and by peak troponin levels.

RESULTS

The study population consisted of 583 AMI patients (with or without ST-segment elevation): 98 SGLT2-I users and 485 non-SGLT-I users. Hyperglycemia at admission was less prevalent in the SGLT2-I group. Smaller infarct size was observed in patients treated with SGLT2-I compared to non-SGLT2-I group. On admission and at 24 h, inflammatory indices were significantly higher in non-SGLT2-I users compared to SGLT2-I patients, with a significant increase in neutrophil levels at 24 h. At multivariable analysis, the use of SGLT2-I was a significant predictor of reduced inflammatory response (OR 0.457, 95% CI 0.275-0.758, p = 0.002), independently of age, admission creatinine values, and admission glycemia. Conversely, peak troponin values and NSTEMI occurrence were independent predictors of a higher inflammatory status.

CONCLUSIONS

Type 2 diabetic AMI patients receiving SGLT2-I exhibited significantly reduced inflammatory response and smaller infarct size compared to those receiving other OAD agents, independently of glucose-metabolic control. Our findings are hypothesis generating and provide new insights on the cardioprotective effects of SGLT2-I in the setting of coronary artery disease.

TRIAL REGISTRATION

Data are part of the ongoing observational registry: SGLT2-I AMI PROTECT.

CLINICALTRIALS

gov Identifier: NCT05261867.

305 Usefulness of CHA2DS2-VASc scoring system for predicting risk of embolism in patients with cardiac tumours: a single-centre study

Aims

The link between pro-protein convertase subtilisin/kexin 9 (PCSK9) and inflammatory-related disease has been supported in several experimental and human studies, which show how the protein could acts independent its canonical mechanism, by activation of inflammatory, apoptotic and immune pathways. Among these, TLR4/NFKB signalling pathway has been found to be one of the main pathways mediating the PCSK9-induced increase of pro-inflammatory and pro-thrombotic molecules, such as TNF-alpha, IL-6, IL-1, MCP-1, and TF. To investigate the direct involvement of hTLR4 in recognition of exogenous human recombinant (hr) PCSK9.

Methods and results

Experiments were carried out in three cell line: (i) HEK293-hTLR4-GFP cell lines obtained by stable co-transfection of HEK293 cells with the pUNO1-hTLR4-GFP, a plasmid expressing the hTLR4 gene fused to a GFP gene; (ii) HEK293-hTLR4+ cells obtained by co-transfection of hTLR4 receptor and its accessory proteins MD-2 and CD14, and an inducible secreted embryonic alkaline phosphatase (SEAP) reporter gene; (iii) HEK293-Null2 cells, a cell line lacking TLR4 expression, used as negative control. NFkB activity were measured by the SEAP reporter gene assay using a fluorescence detection method, while localization of hTLR4 and exogenous hrPCSK9 by confocal microscopy. hrPCSK9 (1 µg/mL) activates NFkB in HEK293-hTLR4+ cells [SEAP activity-OD 620 nm: from a baseline of 0.18 ± 0.06 to 0.68 ± 0.05 (N = 8), P &lt; 0.001] to an extent comparable to lipopolysaccharide, the specific agonist of TLR4. Co-localization of hrPCSK9 and TLR4s was clearly documented by quantitative confocal microscopy in HEK293-hTLR4-GFP cell line, that comprises the analysis of more than 80 fields in ∼2.105 cells/well and showing a percentage of co-localization of ∼4% in membrane spots (P &lt; 0.01).

Conclusions

Our data support the results reported in previous studies that attribute to PCSK9 a pathophysiological role in development of chronic inflammation and related-diseases such as atherothrombosis. A behavior that extends far beyond LDLR degradation, via a mechanism that might be mediated at least in part by recognition of PCSK9 by the TLRs and later activation of NFkB intracellular pathway. Future studies will be important to better investigate the specific binding site engaged in the PCSK9-TLR interaction and to discriminate the intracellular transduction pathways involved in this response, in order to provide a theoretical basis for the development of innovative therapeutic strategies.

258 Cancer incidence during follow-up in patients with new onset atrial fibrillation treated with DOACs and its impact on bleeding risk

Aims

Cancer is increasingly recognized as strictly related to atrial fibrillation (AF). In patients with AF, the relationship between cancer and cardioembolic or bleeding risk during oral anticoagulant therapy is unknown. To assess the bleeding and ischaemic burden of a baseline or newly diagnosed cancer in patients treated with direct oral anticoagulants (DOACs) for non-valvular AF (NVAF).

Methods and results

All consecutive patients treated with DOACs were enrolled among those with new-onset AF and indication for oral anticoagulant between January 2017 and March 2019. During follow-up, bleeding events, newly diagnosed primitive or metastatic malignancy and major cardiovascular events (MACEs) were evaluated. At baseline, CHA2DS2-VASc, HAS-BLED, ATRIA, and ORBIT scores were used to assess the haemorrhagic and ischaemic risk. Major bleedings (MBs) were defined according to the ISTH definition. Anaemia was defined as haemoglobin levels below 11 g/dl in women and 12 mg/dl in men. 1258 patients constituted the study population and followed for a mean time of 21.6 ± 9.5 months. Overall, 66 patients (5.2%) were affected by malignant neoplasia at baseline, whereas 59 (4.7%) were diagnosed with a malignancy during follow-up. Among baseline characteristics, anaemia was associated with cancer at enrolment (43.9% vs. 22.5%, P &lt; 0.001) but not at follow-up (29.3% vs. 23.4%, P = 0.341). MACEs were not associated with cancer at baseline (5.3% vs. 5.2%, P = 1.0) and at follow-up (5% vs. 4.9%, P = 1.0). No association was observed between major ischaemic events and cancer at enrolment or follow-up (5.3% vs. 4.4%, P = 0.83 and 4.4% vs. 5%, P = 0.82). Despite no statistically significant differences in haemorrhagic risk at baseline, the overall bleeding events and MB were associated with newly diagnosed cancer (9.2% vs. 3.9%, P = 0.001 and 13.8% vs. 4.5%, P = 0.001, respectively) but not at baseline (5.2% vs. 5.5%, P = 0.82 and 9.2% vs. 5.2%, P = 0.162). At multivariate analysis adjusted for age, hypertension and renal function, anaemia, and a newly diagnosed cancer during follow-up remained independent predictor of MB [respectively, HR: 1.27, 95% CI: 1.52–1.06, P = 0.009 and HR: 3.53, 95% CI: 7.71–1.62, P = 0.001].

Conclusions

Bleeding risk assessment is an ongoing challenge in patients with NVAF on DOACs. During follow-up, newly diagnosed primitive or metastatic cancer is a strong predictor of bleeding regardless of baseline haemorrhagic risk assessment. In contrast, such association is not observed with malignancy at baseline. A proper diagnosis and treatment could therefore decrease cancer-related bleeding risk. On the contrary, our study shows that cancer is not an ischaemic risk modifier, either diagnosed at baseline or follow-up.

742 Myocarditis after SARS-CoV-2 vaccine: is that so simple?

SARS-CoV-2 vaccination is associated with potential side effects, particularly following second vaccine dose. Recent case series have reported a potential association between SARS-CoV-2 vaccination and acute myocarditis, predominantly in young males. We hereby describe a previously healthy 17-year-old man, with no past cardiac history, who presented to the emergency department with persistent chest pain and fever (up to 38 °C). The patient had received the first dose of Cominarty (BioNTech/Pfizer) vaccine 10 days before symptom onset and reported flu-like symptoms and conjunctivitis involving both eyes one week before administration of the first vaccine dose. On that occasion, no COVID test was performed and the patient was treated with anti-inflammatory drugs and antibiotic eye drops. On admission, laboratory tests were performed (Troponin-I Δ 19 500–23 270 ng/l. CRP 23 mg/dl, ESR 43 s, WBC 17 570 cell/mm³) as well as COVID-19 PCR, Serological tests and Autoimmune disorders panel all resulting negative. CT coronary angiogram did not reveal any spontaneous coronary artery dissection or anomalous origin of coronary arteries and Calcium Score was 0. Transthoracic echocardiography showed a depressed LVEF (36%) with concomitant posterior and inferior wall as well as posterior and anterior basal interventricular septum hypokinesia. Endomyocardial biopsy revealed multifocal lymphocytic myocarditis with sub-endomyocardial and interstitial fibrosis. CMR was also performed (1-week after presentation) demonstrating mildly depressed systolic function (LVEF 47%), with hypokinesia of the posterior and inferior wall, increased signal intensity on T2 maps (58 ms, n.v. <55 ms), prolonged native T1 values (1083 ms, n.v. <1030 ms) as well as subepicardial and intramyocardial LGE enhancement of infero-lateral segments reflecting intercellular fibrosis. Thereafter, the patient was discharged with medical therapy including ACE-inhibitor, colchicine, and ibuprofen. Given the close proximity between SARS-CoV-2 vaccine administration and the absence of other predisposing conditions, the aetiology of myocarditis was attributed to the vaccine. In addition, as the patient suffered from flu-like symptoms and conjunctivitis 1 week before the vaccine, a previous paucisymptomatic SARS-CoV-2 infection was suspected and anti-SARS-Coronavirus Nucleocapsid Protein antibody test revealed high antibody levels with low IgG avidity. Given that myocarditic symptoms evolved after complete Sars-Cov2 symptom resolution, our first hypothesis is that the infection is unlikely to be the cause of acute myocarditis in this patient. Indeed, current literature on COVID-related myocarditis reports close temporal association between respiratory symptoms and myocarditis onset. In support to our hypothesis, recent trials have reported that myocarditis more frequently occurs following administration of mRNA vaccines especially in male adolescents and young adults like our patient. However, cardiac side effects typically occur after full vaccination and symptoms appear within three days following the second dose, which does not fully apply to this case. Notwithstanding this, more recent studies have reported myocarditis even after first vaccination dose in patients with previous COVID-19 infection, analogously to the case described. This case suggests a complex interaction between immunological factors and covid infection/vaccination with potential significant implications on the cardiovascular system. From current literature, much uncertainty remains regarding time interval criteria for reliable post-vaccination myocarditis diagnosis, hence large-scale clinical trials are needed to address this issue.

588 Prognostic impact of early vs. deferred angiography in MINOCA patients

Aims

Although an early invasive strategy (coronary angiography performed &lt;24 h) is associated with a lower risk of recurrent/refractory ischaemia among patients with acute myocardial infarction (AMI) and obstructive coronary arteries, the optimal timing of invasive examination in patients with non-obstructive coronary arteries and non-ST-segment elevation presentation (NSTE-MINOCA) has not been explored. This study tested the hypothesis that, compared to early (&lt;24 h) invasive strategy, deferred (≥24 h) coronary angiography has equivalent prognostic impact in patients with NSTE-MINOCA.

Methods and results

From 2016 to 2020, all consecutive MINOCA patients diagnosed according to the current ESC diagnostic criteria (angiographic conventional cut-off of &lt; 50% coronary stenosis without a clinically apparent alternative diagnosis) and admitted to our Centre with non-ST-segment elevation myocardial infarction (NSTEMI) presentation were enrolled. Very high-risk NSTEMI patients have been excluded from the study. The prognostic value of an early (&lt;24 h) vs. deferred (≥24 h) coronary angiography was assessed. All-cause mortality and a composite endpoint of all-cause mortality, stroke, re-hospitalization for heart failure, and myocardial re-infarction were evaluated. 198 NSTE-MINOCA patients were enrolled. MINOCA patients were more frequently females (64%) and the mean age was 68.6 ± 13.2 years. The median follow-up time was 26 (14–40) months. The total number of events was 54 (27.3%). Kaplan–Meier curves showed that there was no statistically significant difference (P = 0.88) between the two study groups depending on the time of invasive strategy adopted. Specifically, the rates of death (15% vs. 11.3%) and MACEs (28.3% vs. 25%) were similar in MINOCA patients undergoing early vs. deferred angiography.

Conclusions

We demonstrate for the first time that in the MINOCA population the prognosis was not influenced by an early vs. deferred coronary angiography, unlike in AMI patients with obstructive coronary arteries. These results add another piece to the puzzle and pave the way for the initial use of a non-invasive imaging strategy (e.g. Coronary-CT), mostly in patients with NSTEMI and high clinical suspicion of non-obstructive coronary arteries.

251 Prognostic role of acute myocardial infarction diagnostic criteria in non-ST segment elevation myocardial infarction

Aims

Although patients with ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI) share similar risk factors and similar pathophysiology, their outcomes differ considerably. The Fourth Universal Definition of Myocardial Infarction (UDMI) defined acute myocardial infarction (AMI) by an acute myocardial injury together with clinical evidence of acute myocardial ischaemia. However, the prognostic role of each single diagnostic criteria has never been explored. To evaluate the prognostic role of the different diagnostic criteria of AMI according to the Fourth UDMI in patients with STEMI vs. NSTEMI.

Methods and results

We enrolled all consecutive patients with AMI undergoing coronary angiogram at our Centre. We used a combination of criteria, according to the current ESC guidelines, to meet the diagnosis, namely the detection of an increase and/or decrease of high-sensitivity cardiac troponin I, with at least one value above the 99th percentile of the upper reference limit and at least one of the following: symptoms of ischaemia; ECG changes (new ST-T changes or new left bundle branch block); development of pathological Q waves in the ECG; echocardiographic evidence of new loss of viable myocardium, or new regional wall motion abnormality. According to the ECG presentation at admission, patients with AMI were divided into STEMI and NSTEMI subgroups. All-cause mortality and a composite endpoint of all-cause mortality, re-hospitalization for heart failure, and myocardial re-infarction were collected. The predictive value of diagnostic criteria alone and their association was evaluated using Kaplan–Meier survival curves and subsequent Cox-regression analysis to find independent predictors of adverse events. 2345 patients were evaluated (41.6% STEMI and 58.4% NSTEMI). The two groups had similar baseline characteristics. The total number of events was 689 (292 in STEMI group and 397 in NSTEMI group). We found that clinical criteria alone showed a positive predictive value in NSTEMI (P &lt; 0.001). Moreover, electrocardiographic and echocardiographic criteria correlated with a worse prognosis in STEMI group (P &lt; 0.01). No other significant prognostic correlation was found. Multivariable Cox-regression model demonstrated that clinical criteria were the only independent predictors of better prognosis in patients with NSTEMI (HR = 0.48; 95% CI: 0.31–0.74; P &lt; 0.001). We did not find any predictor of outcome in patients with STEMI (HR = 0.6; 95% CI: 0.3–1.5, P = 0.3; HR = 1.1; 95% CI: 0.5–2.6, P = 0.7; HR = 0.6; 95% CI: 0.3–1.2, P = 0.2 for clinical and echocardiographic criteria alone and their combination, respectively).

Conclusions

Our data suggest that in NSTEMI the prognosis is considerably better if clinical criteria alone are present at admission. We hypothesize that the absence of electrocardiographic and echocardiographic alterations in NSTEMI could indirectly indicate smaller infarct sizes or other causes of acute myocardial injury.

551 Killip class predictors and prognostic role in acute myocardial infarction

Aims

Killip classification is a simple and fast clinical tool for risk stratification in patients with acute coronary syndrome (ACS). However, predictors of high Killip class at admission and its prognostic impact in the clinical contest of myocardial infarction with nonobstructive coronary artery (MINOCA) are still poorly known. To identify the clinical predictors of high Killip class and its potential prognostic role on in-hospital and follow-up outcomes in patients with MINOCA compared to patients with myocardial infarction with obstructive coronary artery (MIOCA).

Methods and results

We included all consecutive patients with myocardial infarction (MI) undergoing coronary angiogram between 2016 and 2019 at our hospital. According to 2016 ESC Position Paper criteria, we considered as MINOCA all patients with acute MI and with the angiographic conventional cut-off of &lt; 50% coronary stenosis without clinically apparent alternative diagnosis (e.g. sepsis, stroke, pulmonary embolism, myocarditis, and Tako-tsubo). We analysed Killip class of MINOCA patients comparing with those of MIOCA (coronary stenosis ≥50%). Kaplan–Meier (KM) curves were developed for the comparison of overall-mortality among MINOCA with high Killip class (major than 1) compared to other. Multivariate logistic regression analysis was used to determine the predictors of high Killip class both in the MINOCA and MIOCA populations. Among 3165 MI, 260 patients fulfilled the 2016 ESC criteria for MINOCA. Overall, 62.3% were males and the mean age was 68.6 ± 13.2 years. The median follow-up time was 23.3 ± 14.5 months. Killip class &gt;1 occurred in 24 patients in MINOCA group and 507 in MIOCA group (17.5% vs. 9.2%, P = 0.001). The KM survival distributions were significantly different across Killip class &gt;1 (P &lt; 0.001) in both populations with higher mortality in patients with higher Killip class. Finally, the multivariate logistic regression showed that the predictors of high Killip class at time of presentation in MIOCA population were older age [odds ratio: 1.04, 95% CI: (1.03–1.06), P &lt; 0.001], diabetes [odd ratio 0.63, 95% CI (0.48–0.81), P &lt; 0.001], ST elevation [odds ratio: 0.65, 95% CI (0.48–0.89), P = 0.008], left ventricle ejection fraction [odds ratio: 0.95, 95% CI (0.94–0.96), P &lt; 0.001], and elevated cardiac troponin [odds ratio: 1.00, 95% CI (1.00–1.00), P = 0.01]. Older age [odds ratio: 1.08, 95% CI (1.03–1.14), P = 0.003], ST elevation [odd ratio 0.14, 95% CI (0.02–0.93), P = 0.042], and diabetes [odd ratio 3.60, 95% CI (1.08–1.96), P = 0.037] were predictors of high Killip class in MINOCA, however left ventricle ejection fraction (P = 0.3) and elevated cardiac troponin (P = 0.6) did not predict the high Killip class in MINOCA patients.

Conclusions

Our data suggest that Killip classification performed at the time of admission is a useful clinical marker of a high risk of early and late adverse cardiovascular events even in patients with MINOCA. The predictors of the high Killip class at time of presentation in MIOCA were older age, diabetes, ST elevation, left ventricle ejection fraction, and elevated cardiac troponin. Older age, ST elevation, and diabetes were predictors of high Killip class even in MINOCA, however left ventricle ejection fraction and elevated cardiac troponin did not predict the high Killip class in MINOCA patients. These results could reflect the different pathogenetic myocardial damage in MINOCA and MIOCA populations. Further studies are needed to evaluate these pathological mechanisms.

741 A complex clinical mosaic of severe autoimmune calcific constrictive pericarditis with striking haemodynamic response to immunosuppressive therapy

Autoimmune constrictive pericarditis constitutes a conundrum to modern cardiology with much uncertainty surrounding both pathophysiology and optimal treatment strategies. We hereby describe the case of a 35-year-old woman of Nigerian origin with severe right heart failure secondary to calcific constrictive pericarditis. Her past medical history included coagulation factor XI deficiency, leukopenia, 2nd trimester miscarriage and premature labour due to placenta previa with fibrin deposition. Further investigations revealed atrial fibrillation, severe biatrial enlargement, moderate tricuspid and mitral regurgitation, pericardial thickening, post-capillary pulmonary hypertension and right ventricular dip-and-plateau pattern, compatible with severe constrictive pericarditis. Extensive screening for infectious and autoimmune causes only revealed borderline positive ANA (1:80). Thereafter, the patient underwent complete surgical pericardiectomy with pericardial biopsies revealing fibrous thickening, diffuse calcification and lymphocyte/macrophage infiltrates, in the absence of giant multinucleated cells or granulomas. The patient was later discharged but soon experienced relapse of exertional dyspnoea presenting with right-sided haemo-pneumothorax (requiring pleural drainage), diffuse alveolar haemorrhage, large right-sided basal and infrascissural pleural effusion, and ascites. She was treated with high dose iv furosemide, oral ibuprofen and colchicine, suspension of rate control medications, achieving initial reduction in pulmonary oedema and ascites, relapsing however after attempts to switch to oral diuretic therapy. Due to the finding of persistent lymphopenia, further immunological tests were conducted, revealing raised IgG1 levels as well as altered peripheral lymphocyte populations (raised CD4+/CD8+ ratio and CD8+ central memory, reduced CD8 effector memory). This finding in conjunction with the history of factor XI deficiency, 2nd trimester miscarriage and placental fibrin deposition as well as the observation of painful cutaneous nodules at sites of venepuncture, suggestive of Koebner’s phenomenon, veered the diagnostic focus to a potential autoimmune aetiology and in particular to systemic lupus erythematosus (&gt;10 ACR-EULAR score points with case reports describing all the above as potential disease manifestations). Furthermore, revision of thoracic CT scans, demonstrated bilateral migratory peribronchovascular nodules with ground-glass halo. CT- guided biopsies thereof were performed revealing focal alveolar damage with capillaritis and alveolar haemorrhage, further corroborating the clinical suspicion of autoimmune disease and justifying the introduction of high-dose oral corticosteroid therapy. In liaison with our tertiary rheumatology centre, the patient was later switched to mycophenolate with gradual weaning from corticosteroid. Concurrent cardiological follow-up revealed persistence of good haemodynamic status (NYHA class II, absence of pulmonary oedema and ascites) with oral diuretic therapy, regression of cutaneous symptoms and echocardiography demonstrating consistent reduction in both mitral and tricuspid regurgitation. This constitutes to our knowledge the first report of autoimmune calcific constrictive pericarditis with significant haemodynamic response to immunosuppressive therapy. Despite the relative rarity of this disease entity, early recognition and instatement of immunosuppressive treatment may prove fundamental to halt and potentially reverse the haemodynamic progression of this highly morbid condition.

249 Prognostic role of diagnostic criteria of acute myocardial infarction

Aims

The term acute myocardial infarction (AMI) reflects cell death of cardiac myocytes caused by ischaemia. The Fourth Universal Definition of Myocardial Infarction (UDMI) defined AMI by a typical rise and fall in the level of biochemical markers of myocardial necrosis together with criteria of myocardial ischaemia. However, the prognostic role of each single diagnostic criteria has never been explored. To evaluate the prognostic role of the different diagnostic criteria of AMI according to the Fourth UDMI.

Methods and results

We enrolled all consecutive patients with AMI admitted from 2016 to 2019. We used a combination of criteria, according to the current ESC guidelines, to meet the diagnosis, namely the detection of an increase and/or decrease of high-sensitivity cardiac troponin I, with at least one value above the 99th percentile of the upper reference limit and at least one of the following: symptoms of ischaemia; ECG changes (new ST-T changes or new left bundle branch block); development of pathological Q waves in the ECG; imaging evidence of new loss of viable myocardium or new regional wall motion abnormality, in our study evaluated by transthoracic echocardiogram. All-cause mortality and a composite endpoint of all-cause mortality, re-hospitalization for heart failure, and myocardial re-infarction were collected. The predictive value of diagnostic criteria alone and its association were evaluated using Kaplan–Meier survival curves and subsequent Cox-regression analysis to find independent predictors of adverse events. 2386 patients were evaluated. The median follow-up time was 23.3 ± 14.5 months. The total number of events was 703 (29.5%). Kaplan–Meier curves showed that major adverse cardiac events (MACEs) were statistically different depending on the diagnostic criteria of AMI at admission. Particularly, clinical criteria alone showed a better predictive value (P &lt; 0.001) than other diagnostic AMI criteria. Multivariable Cox-regression model demonstrated that clinical criteria were the independent predictor of good prognosis in patients with AMI (HR = 0.43; 95% CI: 0.28–0.67; P &lt; 0.001). Conversely, the other diagnostic criteria (electrocardiographic and echocardiographic) and the combination of all diagnostic criteria were not independent prognostic factors of MACEs (HR = 1.1; 95% CI: 0.6–2.4, P = 0.6; HR = 1.1; 95% CI: 0.7–1.9, P = 0.6; HR = 0.9; 95% CI: 0.7–1.0, P = 0.2, respectively).

Conclusions

Our data suggest that the prognosis is considerably better among patients with a diagnosis of AMI if clinical criteria alone are present at admission. We also demonstrated that clinical criteria are a strong prognostic predictor of good outcomes in patients with AMI. We hypothesize that the absence of electrocardiographic and echocardiographic alterations could indirectly indicate a smaller infarct sizes that contribute to patients’ outcome.

184 The presence of atrial fibrillation in acute myocardial infarction patients and hyperglycaemia

Aims

In patients with acute myocardial infarction (AMI), hyperglycaemia is a common feature determining a worse prognosis. Few studies have examined the relationship between hyperglycemic status and atrial fibrillation in-hospital stay. To evaluate the relationship between admission hyperglycaemia (aHGL) and occurrence of atrial fibrillation (AF) in-hospital stay in patients with AMI, categorized as myocardial infarction with obstructive coronary artery disease (MIOCA) and myocardial infarction with nonobstructive coronary artery disease (MINOCA).

Methods and results

Hyperglycaemia was defined as a serum glucose level ≥140 mg/dl at the time of hospital admission. AF was defined as a beat-to-beat variability in cycle length and morphology with irregular fibrillatory waves on surface ECG. Among 2702 patients (32.1% were female, mean age was 70.1 ± 13.4 years), 24.2% were diabetic. Out of 2702 patients, 2457 were MIOCA and 245 (9.1%) were MINOCA patients. At admission, the mean value of serum glucose levels was 146 ± 66 mg/dl. At hospital admission, hyperglycemic status was present in 37.7% of patients and 8.3% presented atrial fibrillation. At hospital admission, atrial fibrillation (aAF) was significantly frequent in hyperglycemic than normoglycaemic patients (11.5% vs. 6.3%, respectively; P &lt; 0.001). In aHGL MIOCA patients had a higher rate of aAF (10.7%) than normoglycaemic MIOCA (6.4%; P &lt; 0.001). In aHGL MINOCA patients had 31% aAF than normoglycaemic MINOCA patients (7.5%; P &lt; 0.001). During the hospital stay, the new onset of atrial fibrillation was higher in aHGL than normoglycaemic status in total population (6.3% vs. 2.9%, P &lt; 0.001), in MIOCA subgroup (6.3% vs. 3.1%, P &lt; 0.001) and MINOCA subgroup (7.3% vs. 1.5%, P = 0.003). Multivariate analysis adjusted for age, sex, and diabetes revealed that the presence of hyperglycaemia was an independent predictor for the onset of atrial fibrillation (OR: 1.7; 95% CI: 1.1–2.6; P = 0.02).

Conclusions

Hyperglycaemia was an independent predictor of new atrial fibrillation during hospitalization in patients with AMI. Moreover, at hospital admission, patients with hyperglycemic status presented a higher incidence of atrial fibrillation, both in MIOCA and MINOCA subgroups. Further studies are needed to understand the biological mechanisms involved in these associations.