Coronary plaque characteristics associated with major adverse cardiovascular events in atherosclerotic patients and lesions – a systematic review and meta-analysis

Background

The clinical value of high-risk coronary plaque characteristics (CPCs) to inform intensified medical therapy or revascularization of non-flow-limiting lesion remains uncertain.

Purpose

We performed a systematic review and meta-analysis to study the prognostic impact of CPCs on patient-level and lesion-level major cardiovascular adverse events (MACE).

Methods

We systematically reviewed MEDLINE, EMBASE, and the Cochrane database for studies evaluating the association of CPC with patient-level and lesion-level MACE. CPCs included high plaque burden, low minimal lumen area, thin cap fibroatheroma, high lipid core burden index, low attenuation plaque, spotty calcification, napkin ring sign, or positive remodelling.

Results

Thirty studies (21 retrospective, 9 prospective) with 30,369 patients were included. CPCs were evaluated by invasive intravascular techniques in 9 studies (optical coherence tomography=4, intravascular ultrasound imaging=3, near-infrared spectroscopy intravascular ultrasound imaging=2) and by coronary computed tomography angiography (CCTA) in 21 studies. CPCs significantly predicted patient-level and lesion-level MACE in both unadjusted and adjusted analyses. For each CPC, the risks were higher for lesion-level (HR range 3.2–16.8) as compared with patient-level MACE (HR range 1.8–4.1). Accuracy was modest to good for most CPCs at the patient-level (AUC for MACE ranging between 0.53 and 0.84) and moderate to good for most CPCs at the lesion-level (AUC for MACE ranging between 0.71 and 0.83). Plaques with more than one CPC had the highest accuracy for lesion-level MACE (AUC 0.87, 95% CI 0.84–0.90). The pooled sensitivities of CPCs for lesion-level MACE ranged between 40% and 63% and specificities between 73% and 98%. As the pooled prevalence of CPCs among plaques was low (3% to 28%), the estimated positive predictive values for lesion-level MACE were modest (range 1% to 26%).

Conclusions

CCTA and intravascular imaging characterization of CPCs identifies high-risk atherosclerotic plaques that place lesions and patients at risk for future MACE, albeit with modest sensitivity and positive predictive value (PROSPERO identifier: CRD42021251810).

Funding Acknowledgement

Type of funding sources: None.

P388 CORONARY PLAQUE CHARACTERISTICS ASSOCIATED WITH MAJOR ADVERSE CARDIOVASCULAR EVENTS AMONG ATHEROSCLEROTIC PATIENTS AND LESIONS: A SYSTEMATIC REVIEW AND META–ANALYSIS

Background

The clinical value of coronary plaque characteristics (CPCs) to inform intensified medical therapy or revascularization of non–flow–limiting lesion remains uncertain. We performed a systematic review and meta–analysis to study the prognostic impact of CPCs comprehensively assessed with invasive and non–invasive imaging technologies on patient–level and lesion–level major cardiovascular adverse events (MACE).

Methods

We systematically reviewed MEDLINE, EMBASE, and the Cochrane database for studies evaluating the association of CPC with patient–level and lesion–level (MACE). CPCs included high plaque burden, low minimal lumen area, thin cap fibroatheroma, high lipid core burden index, low attenuation plaque, spotty calcification, napkin ring sign or positive remodelling.

Results

Thirty studies (21 retrospective, 9 prospective) with 30.369 patients were included. CPCs were evaluated by invasive intravascular techniques in 9 studies (optical coherence tomography=4, intravascular ultrasound imaging=3, near–infrared spectroscopy intravascular ultrasound imaging=2) and by coronary computed tomography angiography (CCTA) in 21 studies. CPCs were significantly predictive of patient–level and lesion–level MACE, also when only adjusted data where considered. For each CPC, the odds appeared higher for lesion–level (HR range 3.2–16.8) as compared to patient–level MACE (HR range 1.8–4.1). Accuracy was modest to moderate for most CPCs at the patient–level (AUC for MACE ranging between 0.53 and 0.84) and moderate to good for most CPCs at the lesion–level (AUC for MACE ranging between 0.71 and 0.83). Plaques with more than one CPC had the highest accuracy for lesion–level MACE (AUC 0.87, 95%CI 0.84–0.90). CPC pooled sensitivities for lesion–level MACE ranged between 40% and 63% and specificities between 73% and 98%. As the pooled prevalence of CPCs among plaques was low (3% to 28%), the estimated positive predictive values for lesion–level MACE were modest (range 33% to 45%).

Conclusion

CCTA and intravascular imaging characterization of CPCs provides independent prognostic value among atherosclerotic patients and lesions. However, the modest sensitivity and positive predictive value observed across all CPCs seem to suggest modest clinical value, especially to predict lesion–level events (PROSPERO identifier: CRD42021251810).

C39 ECHOCARDIOGRAPHIC PREDICTORS OF MALIGNANT EVENTS IN ARRHYTHMIC MITRAL VALVE PROLAPSE POPULATION

Background

Bileaflet mitral valve prolapse (bMVP) has been linked to major arrhythmic events and sudden cardiac death (SCD). Solid evidence of consistent predictors of SCD in this setting is still lacking. Echocardiography is the best tool for the analysis of ventricle mechanics and for the correlation with electrical myocardial activation. The aim of this study was to find new predictors of malignant events within an arrhythmic MVP population.

Methods

We conducted a retrospective comparative analysis, selecting 22 patients with bMVP with a high arrhythmic risk profile. 6 of them had a previous major arrhythmic event (5 aborted SCD, one cardiogenic syncope) and previously received ICD implantation (ICD–MVP), while 16 presented with a high arrhythmic burden without major events (A–MVP). All patients underwent transthoracic echocardiography in the last year. Each echocardiogram followed a specific protocol focused on mitral valve anatomy and ventricular contraction using 2D imaging, 3D imaging, tissue doppler imaging and speckle tracking analysis.

Results

ICD–MVP group, compared with A–MVP group, presented a longer anterior leaflet (AML) length (28,6 mm, IQR: 24,1–31,1 mm; vs 21,4 mm, IQR: 20,4–24,0 mm; p = 0,03), larger mitral valve annulus (MVA) indexed area (6,88 cm2/m2, IQR 6,27–7,87 cm2/m2 vs 5,44 cm2/m2, IQR: 4,93–6,15 cm2/m2, p = 0,02), lower MVA anteroposterior diameter/AML length ratio (1,24, IQR: 1,21–1,41 vs 1,50, IQR 1,32–1,62; p = 0,049), higher inferolateral basal S3 velocity (26 cm/s, IQR: 20,8–29,6 cm/s vs 14,2 cm/s, IQR 10,1–21,3 cm/s; p = 0,02) and a greater mechanical dispersion (MD) of the basal and mid–ventricular segments calculated with speckle tracking (128 ms, IQR: 125–131 ms; vs 58 ms, IQR 45–106 ms; p = 0,03). Mitral regurgitation grading, instead, did not correlate with malignant events. Best predictors of malignant events were AML length and MD of basal and mid–ventricular segments. Cut–off values with highest sensibility and specificity above 80% were 26 mm for AML length and 122 ms for MD of basal and mid–ventricular segments. Logistic bivariate regression confirmed AML length as an independent predictor of malignant events (p = 0,01), while MD of basal and mid–ventricular segments showed a trend toward significancy (p = 0,07).

Conclusion

Five parameters were found to be predictors of malignant events in a high–risk MVP population. AML length and MD of the basal and mid–ventricular segments presented the best predictive value.

Prognostic value and usefulness of Pulmonary Artery Pulsatility index (PAPi) in evaluation of heart transplant candidates

Background

Heart transplantation (HTx) is considered the best available treatment for patients with end stage heart failure. Candidate evaluation with right heart catheterization (RHC) is fundamental in order to exclude pulmonary hypertension with irreversible high pulmonary vascular resistance (PVR), which is associated with elevated post-HTx mortality. PVR, rather than directly measured, is derived by cardiac output and pulmonary artery pressures, which are strictly dependent on right ventricular (RV) function. The pulmonary artery pulsatility index (PAPi) is a hemodynamic parameter integrating the information of RV function and of pulmonary circulation, which could be useful in pre-HTx evaluation.

Purpose

We designed this study to evaluate the potential predictive influence of pre-HTx PAPi on post-HTx survival and to assess whether this index could add useful information in the pre-HTx evaluation of patients with advanced heart failure.

Methods

Consecutive adult HTx recipient at two medium-large tranplant centers between 2000 and 2017 with available data on pre-HTx RHC were retrospectively included. PAPi was calculated as the ratio of pulmonary artery pulse pressure to right atrial pressure. PAPi values in the lowest quartile were defined as reduced (PAPi<1.67). The primary endpoint was all-cause mortality at 1-year post-HTx. The association of reduced PAPi with the primary endpoint was evaluated. Cox regression was used to adjust for clinical and hemodynamic variables. Analyses stratified by PVR status (≥3 WU vs. <3 WU) were also performed.

Results

Among 655 HTx recipients (female 20,8%, age 53±11 years), median pre-HTx PAPi was 3.0 (interquartile range 1.67–5.32). Patients in the lowest versus the remaining PAPi quartiles had significantly reduced 1-year survival (78.0% vs 87.2%, p=0.006), also after adjusting for age, estimated glomerular filtration rate, total bilirubin, high PVR and urgent transplantation (adj-hazard ratio: 0.64; 95% confidence interval 0.51–0.82). When stratifying patients by estimated PVR status, reduced PAPi was associated with worse 1-year survival among patients with normal PVR (78.3% vs. 88.3% p=0.011), but not in those with increased PVR (78.0% vs. 82.6%, p=0.36) (Figure 1).

Conclusions

Pre-HTx PAPi, integrating information of RV function and pulmonary circulation, provides incremental prognostic value over traditional clinical and hemodynamic parameters among HTx recipient. The prognostic value appears important among patients with normal estimated PVR, possibly due to an underestimation of PVR in patients with impaired RV function. The integration of PAPi in the pre-HTx evaluation may lead to better patient selection and post-HTx survival.

Figure 1. 1 year survival stratified by PVR status

Funding Acknowledgement

Type of funding source: None

Primary percutaneous coronary intervention in nonagenarian patients

Background

Given the continuous increase in life expectancy, elderly patients with ST segment elevation myocardial infarction (STEMI) are becoming a growing proportion of those referred for primary percutaneous coronary intervention (pPCI). However, this population is usually excluded from randomized trials and limited data are available to guide clinical decisions. The aim of this study-level meta-analysis was to describe and analyze the determinants of outcomes in this population.

Methods

We searched the literature for studies reporting ischemic and hemorrhagic outcomes and/or mortality in nonagenarian patients undergoing pPCI. An analysis of the heterogeneity between studies in outcome reports was performed with I2 test. A univariate meta-regression analysis was conducted to explore the relationship between outcomes of interest and classic cardiovascular risk factors, gender, previous myocardial infarction (MI), MI location, PCI characteristics, hemodynamic instability, vascular access, intra-aortic balloon pump (IABP) and Glycoprotein IIb/IIIa inhibitor (GPI) use.

Results

Overall, 15 observational studies met our inclusion criteria, with a total of 6787 patients; mean age was 92.4 and 35% were male.

The incidence of in-hospital death was 21.3%, 1.4% of our population suffered an in-hospital ischemic stroke and 11.1% faced acute renal failure; in-hospital major bleedings affected 1.7% of the population, but blood-transfusion was needed in 6.9%. Long-term mortality rate was 21.5%.

Killip III-IV at admission was related with increased in-hospital mortality (β: 0.2%; p: 0.041), but lower incidence of ARF (β: −0.6%; p: 0.004). Angiographic success was associated with a lower incidence of long-term all-cause mortality (β: −1.7%; p: 0.017) and higher incidence of ARF (β: 1.7%, p<0.001). A higher number of coronary stents implanted was associated with a lower incidence of long-term all-cause mortality (β: −73%; p: 0.01). A higher long-term all-cause mortality was related with male gender (β: 0.9%; p: 0.027) and previous MI (β: 1.5%; p: 0.007). Diabetes was associated with a lower incidence of long-term all-cause mortality (β: −0.8%; p: 0.014) despite a higher incidence of in-hospital blood transfusion (β: 0.5%, p: 0.05), while a history of MI (β: 0.1%; p: 0.049), as well as the use of GPI (β: 0.04) was related with a higher incidence of in-hospital major bleeding. The use of IABP was related with a lower incidence of long-term all-cause death (β: 6.5%; p<0.001) and in-hospital major bleeding (β: −0.4%; p: 0.038).

Discussion

Our meta-analysis, pooling the largest cohort of nonagenarians undergoing pPCI confirms the feasibility of urgent percutaneous coronary intervention also in this frail population. In particular, although angiographic success increased the incidence of in-hospital ARF, it was associated with a higher long-term survival underling the pivotal role of myocardial reperfusion.

Funding Acknowledgement

Type of funding source: None