Risk prediction of major adverse cardiac events by high sensitivity troponin is modified by comorbidities

Influence of Second- and Third-Degree Heart Block on 30-Day Outcome Following Acute Myocardial Infarction in the Drug-Eluting Stent Era

CAN PATIENTS PRESENTING TO THE ED WITH CHEST PAIN WHO HAVE INTERMEDIATE-RISK HEART SCORES BE MANAGED AS OUTPATIENTS? A RETROSPECTIVE REVIEW OF TWO RAPID ACCESS CHEST PAIN CLINICS

BackgroundThere is a paucity of data regarding acute phase (in-hospital and 30-day) major adverse cardiac events (MACE) following ST-segment elevation myocardial infarction (STEMI) in Bangladesh. This study aimed to document MACE during the acute phase post-STEMI to provide information.MethodsWe enrolled STEMI patients of the National Institute of Cardiovascular Disease, Dhaka, Bangladesh, from August 2017 to October 2018 and followed up through 30 days post-discharge for MACE, defined as the composite of all-cause death, myocardial infarction, and coronary revascularization. Demographic information, cardiovascular risk factors, and clinical data were registered in a case report form. The Cox proportional hazard model was used for univariate and multivariate analysis to identify potential risk factors for MACE.ResultsA total of 601 patients, mean age 51.6 ± 10.3 years, 93% male, were enrolled. The mean duration of hospital stay was 3.8 ± 2.4 days. We found 37 patients (6.2%) to experience an in-hospital event, and 45 (7.5%) events occurred within the 30 days post-discharge. In univariate analysis, a significantly increased risk of developing 30-day MACE was observed in patients with more than 12 years of formal education, diabetes mellitus, or a previous diagnosis of heart failure. In a multivariate analysis, the risk of developing 30-day MACE was increased in patients with heart failure (hazard ratio = 4.65; 95% CI 1.64–13.23).ConclusionsA high risk of in-hospital and 30-day MACE in patients with STEMI exists in Bangladesh. Additional resources should be allocated providing guideline-recommended treatment for patients with myocardial infarction in Bangladesh.

Association Between Serum Uric Acid and Perioperative and Late Cardiovascular Outcome in Patients With Suspected or Definite Coronary Artery Disease Undergoing Elective Vascular Surgery

BackgroundAdjunctive techniques to modify calcium such as rotational atherectomy (RA) induce coronary artery trauma that may result in higher post-procedural troponin and creatinine kinase-MB (CK-MB) release. The clinical significance of...

BackgroundHigh-sensitivity cardiac troponin I (hs-cTnI) assays promise high diagnostic accuracy for myocardial infarction (MI). In an ED where conventional cTnI was in use, we evaluated an assessment pathway using the...

Background: Peripheral arterial disease (PAD) is associated with an increased risk of major adverse cardiovascular and limb events. However, the factors influencing major adverse cardiovascular events (MACE) and major adverse limb events (MALE) in patients with PAD remain unclear. Additionally, while some predictive models for MACE and MALE in patients with PAD have been developed, their performance is uncertain. This systematic review aims to identify the factors influencing MACE and MALE in patients with PAD and to systematically evaluate existing predictive models. Materials and methods: We conducted a literature search in PubMed, Embase, and the Cochrane Library to identify studies exploring risk factors for MACE and MALE, as well as predictive models for these outcomes. Data extraction focused on study design, patient demographics, reported influencing factors (e.g., clinical, biochemical), and characteristics of predictive models (e.g., variables, validation methods, performance metrics). We specifically evaluated the methodological quality and risk of bias of the identified predictive models using established tools such as PROBAST (Prediction model Risk Of Bias ASsessment Tool). This study aimed to synthesize evidence on determinants of MACE and MALE and critically appraise existing prediction models to inform future research and clinical decision-making. Results: One hundred and sixteen studies reported factors influencing MACE in patients with PAD. Six studies developed or validated predictive models. Three models were rated as having low risk of bias across all domains, while the other three had unclear or high risk of bias in at least one domain. A total of 118 influencing factors associated with MACE were identified. Common factors included: demographic characteristics (age, smoking); (2) comorbidities (diabetes mellitus (DM), coronary artery disease (CAD), prior stroke, heart failure); (3) clinical measures (body mass index (BMI), systolic blood pressure (SBP)); (4) diagnostic indicators (ankle-brachial index (ABI), estimated glomerular filtration rate (eGFR), C-reactive protein (CRP), serum creatinine); (5) medication use (statins); and (6) classification systems (Rutherford classification, Fontaine classification). Fifty-five studies reported factors influencing MALE in patients with PAD. Six studies developed or validated predictive models. Three models were rated as having low risk of bias across all domains, while the other three had unclear or high risk of bias in at least one domain. A total of 88 influencing factors were identified. Common factors across most studies included demographic characteristics (age, smoking, socioeconomic status), comorbid conditions (DM, chronic kidney disease, hypertension, cerebrovascular disease), clinical factors (degree of frailty, BMI), diagnostic indicators (hemoglobin, serum creatinine, serum albumin), medication use (statin), and other factors (Wound, Ischemia, and foot Infection (WIfI) classification, geriatric nutritional risk index (GNRI)). Conclusions: Building on these findings, we conclude that, although substantial research exists on factors influencing MACE and MALE in patients with PAD, significant variability persists in study design (patient population), external factors (healthcare environment), and research focus. Our review provides a concise yet comprehensive analysis of predictive models for MACE and MALE in patients with PAD, identifies key predictive factors, systematically evaluates these models, and offers recommendations for their improvement.

Background Cardiac troponin (cTn) is the preferred biomarker to aid in the diagnosis of myocardial infarction (MI). This study evaluated if cTnI predicts all-cause mortality (ACM) or major adverse cardiac events (MACE) (MI, cardiac death, heart failure hospitalization, or urgent revascularization) in the following year among ED patients presenting with chest pain suspected of acute coronary syndrome, but not diagnosed with MI. Methods Adult patients suspected of acute coronary syndrome (n=2374) at 29 U.S. sites between 2014–2016 were prospectively followed for up to one year to evaluate the association between cTnI, all-cause mortality (ACM) (inclusive of initial presentation visit events), and MACE (defined as post-discharge MI, cardiac death, heart failure hospitalization, and urgent [emergency] coronary revascularization). Patients with AMI at presentation (n=310; 13%) were excluded. Survival and proportional hazard regression analyses were performed on the primary analysis population (n=2064) made up of two subcohorts—one with (n=874) and the other without (n=1190) history of incident/prior MACE. cTnI concentrations were measured in lithium heparin plasma samples using the Atellica IM High-Sensitivity (hs) Troponin I (TnIH) assay. Pre- and post-test risk and unadjusted and adjusted hazard ratios (aHR) with 95% confidence intervals (CI) were calculated for baseline cTnI concentrations above, and at or below, the overall 99th percentile upper reference limit (URL). The adjusted models included the covariates of eGFR, hypertension, prior history of revascularization, prior heart failure, and sex. Results The median age of the primary analysis population was 56 (IQR, 47–64) years; 54.8% were males. Patients in the primary analysis population and both subcohorts with presentation baseline cTnI above the 99th percentile URL had greater rates of ACM/MACE at one year—primary analysis population: >99th percentile, 39.5% [75 events/190 patients] vs. <=99th percentile, 12.9% [242/1874], aHR was 1.85 [95%CI 1.39–2.47] at 365 days; subcohort without history of incident/prior MACE: 15.1% [8/53] vs. 4.4% [50/1137], aHR was 2.79 [1.28–6.08]; subcohort with history of incident/prior MACE, 48.9% [67/137] vs. 26.1% [192/737], aHR was 1.56 [1.15–2.12]. Conclusion The results of this study show that patients without MI but with cTnI above versus at or below the overall 99th percentile URL cutoff were at increased risk of ACM and MACE at one year.

Background: The purpose of this study was to determine the incidence of major adverse cardiac events (MACE) and mortality in lupus patients among peripartumin in Taiwan. Methods: A population-based cohort study was performed on 1,132,089 parturients during 1999 to 2003 using a dataset linking birth certificates and National Health Insurance hospital discharge data. Cumulated MACE-free rates, cumulated survival rate were estimated using the Kaplan-Meier method, and the log-rank test was used to examine the effect of systemic lupus erythromatosus (SLE) on the prevalence of MACE and mortality. Sociodemographic factors and obstetric complications were used in multivariate logistic regression models to determine the adjusted hazard ratios of SLE on the risk of MACE and mortality during pregnancy and at least within the first postpartum year. Results: Single independent variables that were statistically and clinically significant, including age, years of education, marital status, multiple gestation, birth-weight, parity, anemia, SLE, cesarean delivery, diabetes, chronic hypertension, pregnancy-related hypertension, antepartum hemorrhage, and postpartum hemorrhage were entered into a multivariable logistic regression mode. The incidence of any MACE and mortality in lupus group among peripartum was 0.88% and 1.98% respectively. The pregnant women with SLE have higher MACE including myocardial infarction, (Hazard ratio 56.4), heart failure (Hazard ratio 11.2), stroke (Hazard ratio 8.2), any MACE (Hazard ratio 10.2), maternal death (Hazard ratio 11.9) than those without SLE. Their risk remains significant at least 12 months postpartum. Conclusions: Although MACE and mortality are a rare events in women of reproductive age, pregnant women with SLE increases the risk 10 fold. Clinicians would be well advised to pay more attention to MACE in lupus patients even one year after delivery.

BackgroundIntraoperative hypotension (IOH) is an important risk factor for major adverse cardiac events (MACE) in patients undergoing noncardiac surgery. However, the IOH threshold in older adult patients remains controversial.ObjectiveThis study aimed to explore an appropriate IOH threshold in older adult patients to decrease the risk of MACE.MethodsThis study involved older adult patients undergoing noncardiac surgery (age ≥65 y) from January 2012 to August 2019 in the Chinese People’s Liberation Army General Hospital (PLAGH; 35,262 patients) and Shanghai Changhai Hospital from January 2024 to December 2024 (13,418 patients). Univariate moving-average plots and multivariate restricted cubic splines were used to determine the IOH thresholds associated with an increased risk of MACE. The relationship between the IOH threshold and MACE was assessed using univariate and multivariate logistic regression analyses by 3 different hypotension exposure forms (duration, area, and time-weighted average mean arterial pressure [MAP]).ResultsOut of 35,262 patients, 874 developed MACE in PLAGH, and 296 of 13,418 patients developed MACE in Changhai Hospital. In PLAGH, MAP below an absolute threshold of 70 mm Hg was associated with MACE. When the IOH absolute threshold was 70 mm Hg, the risk of MACE demonstrated a “dose-increasing” effect with changes in IOH exposure, and the risk of MACE was significantly increased when the duration lasted >15 minutes (odds ratio 1.51, 95% CI 1.22-1.88; P<.001). The stratified analysis showed that in patients younger than 80 years, when intraoperative MAP dropped below 70 mm Hg for more than 15 minutes, the odds ratio was 1.38 (95% CI 0.86‐2.28), P<.01. In Changhai hospital, intraoperative MAP <70 mm Hg was also significantly associated with MACE. Furthermore, IOH lasting longer than 15 minutes substantially increased the risk of MACE.ConclusionsFor older adult patients undergoing noncardiac surgery, intraoperative MAP should be kept above 70 mm Hg to reduce the risk of postoperative MACE.

Objective: Although smoking is an established risk factor for major cardiac adverse events (MACE), the relative risk of current versus past smoking is poorly understood. We evaluated coronary artery disease (CAD) extent, severity and risk of MACE for active smokers and past smokers undergoing coronary CT angiography (CCTA). Methods: From a prospective multicenter international study, we enrolled patients without known CAD who underwent CCTA [2853 current smokers (21%); 3175 past smokers who quit >3 months prior to CCTA (24%); and 7344 non-smokers (55%)]. By risk-adjusted Cox proportional hazards models, adjusting for age, gender, risk-factors, segment involvement score, ≥50% stenosis, we related smoking status to incident risk of MACE, as defined by death, myocardial infarction or unstable angina. We further performed 1:1:1 propensity matching for 1000 current smokers, past smokers and non-smokers each to evaluate MACE risk amongst individuals who were of similar age, gender, CAD risk factors and symptom presentation. Results: 13372 patients (56.2±12.8 years, 51% male) were followed for 2.0±0.9 years follow-up, with 279 (2.1%) MACE occurring. Compared to non-smokers, current and past smokers had higher prevalence of obstructive CAD (≥50%) [1-vessel disease (VD); 11.2% vs. 16.6% vs. 16.2%, p<0.001, 2VD; 4.8% vs. 7.3% vs. 7.8%, p<0.001, 3VD; 2.3% vs. 5.1% vs. 5.0%, p<0.001]. Current smokers experienced higher risk of MACE compared to non-smokers (HR 1.9, 95% CI 1.4-2.5, p<0.001), while past smokers did not (HR 1.2, 95% CI 0.9-1.6, p=0.29). Even amongst matched individuals, current smoking was associated with MACE risk (HR 2.3, 95% CI 1.2-4.4, p=0.01), while past smoking was not (HR1.0, 95% CI 0.5-2.1, p=0.98). Conclusion: While both current and past smokers possess a greater prevalence, extent and severity of CAD compared to non-smokers, current smokers experience higher risk of MACE than past smokers and non-smokers.

Risk scores for myocardial infarction and major adverse cardiac event following major amputation for limb ischemia with internal VQI validation.

BackgroundTo analyze the association between the hemoglobin glycation index (HGI) and the long-term prognosis of patients with coronary artery disease (CAD).MethodsHGI represented the difference between laboratory measured Hemoglobin A1c (HbA1c) and predicted HbA1c based on a liner regression between Hb1Ac and fasting plasma glucose (FPG). A total of 10 598 patients who treated with percutaneous coronary intervention (PCI) were stratified into three groups (low HGI group: HGI<-0.506, medium HGI group: -0.506 ≤ HGI < 0.179, and high HGI group: HGI ≥ 0.179). The primary endpoints includes all-cause mortality (ACM) and cardiac mortality (CM). The secondary endpoints were major adverse cardiac events (MACEs) and major adverse cardiac and cerebrovascular events (MACCEs).ResultsA total of 321 ACMs, 243 CMs, 774 MACEs, and 854 MACCEs were recorded during a 60-month follow-up period. After adjusting for confounders using a multivariate Cox regression analysis, the patients in the low HGI group had a significantly increased risk of ACM (adjusted HR = 1.683, 95%CI:1.179–2.404, P = 0.004) and CM (HR = 1.604, 95%CI:1.064–2.417, P = 0.024) as compared with patients in the medium HGI group. Similarly, the patients in the high HGI group had an increased risk of MACEs (HR = 1.247, 95% CI: 1.023–1.521, P = 0.029) as compared with patients in the medium HGI group. For ACM, CM, and MACEs, a U-shaped relation were found among these three groups. However, we did not find significant differences in the incidence of MACCEs among these three groups.ConclusionThe present study indicates that HGI could be an independent predictor for the risk of mortality and MACEs in patients with CAD.

Background: Studies have shown that acute coronary syndrome (ACS) has a higher incidence of MACE in diabetic patients than in nondiabetic patients by 39%. The complexity of the MACE limits clinical predictions, the success rate is shallow. Several existing MACE risk prediction models, including some developed specifically for ACS patients, also stuck with low accuracy and are not suitable for complications scenarios. The objective of this study is to develop and validate a model based on EHR data to predict MACE risk in patients with type 2 diabetes mellitus (T2DM) complicated with ACS. Methods: This study recruited 16,807 in-hospital T2DM patients with ACS from 38 urban and rural hospitals. Patients with 41 variables, including age, demographics, living habits, ACS type, and Killip class. The criteria for the diagnosis of MACE developed for this study consider cardiovascular death, myocardial infarction, or ischemic stroke. There are 711 MACE records diagnosed by doctors during patients’ hospitalization and recorded in medical records, only 4.2% of the total cohort. Very low morbidity inspires us to introduce a model called Support Vector Data Description (SVDD) to combat this uneven distribution of data. SVDD only maps the features of MACE patients to the high-dimensional space and constructs a minimum sphere to contain all the target data, taking the sphere as the boundary to classify the risk of newly admitted patients. Models were developed and validated on 80% and 20% of the sample, respectively. The model performance was assessed by C-statistics and the F1. Results: The model performed with C-statistics of 0.873 and F1 of 0.833. We found 5 variables had a significant univariate association with MACE included Age, Heart rate, Killip class, white blood cell count and Creatinine at p&amp;lt;10-4. Conclusions: This novel study suggests that the well trained SVDD model would be possible to predict the harmful MACE among T2DM patients with ACS. Disclosure P. Hu: None. X. Di: None. Y. Zhang: None. Z. Tang: None. S. Li: None. J. Mei: None. C. Ma: None.

The history, ECG, age, risk factor (HEAR) score has been proposed to identify patients at sufficiently low risk of acute coronary syndrome that they may not require troponin testing. The objective of this study was to externally validate a low HEAR score to identify emergency department (ED) patients with chest pain at very low risk of 30-day major adverse cardiac events (MACE). This was a secondary analysis of a prospective cohort of patients requiring troponin testing to rule out myocardial infarction (MI) in a large urban ED. HEAR scores were calculated in two cohorts: (1) patients with no known history of coronary arterydisease (CAD); and (2) all eligible patients. The proportion of patients classified as very low risk, sensitivity, specificity, predictive values and likelihood ratios at each cut-off were quantified for index acute myocardial infarction (AMI) and 30-day MACE at HEAR = 0 and HEAR ≤ 1 thresholds. Of the 1150 patients included in this study, 820 (71.3%) had no history of CAD, 97 (8.4%) had index AMI and 123 (10.7%) had 30-day MACE. In patients with no prior history of CAD, HEAR ≤ 1 identified 202 (24.6%) of patients as very low risk for 30-day MACE with 98.4% (95% CI 91.6-99.9%) sensitivity. Among all patients, HEAR ≤ 1 identified 202 (17.6%) patients as very low risk for 30-day MACE with 99.2% (95% CI 95.6-99.9%) sensitivity. A HEAR score ≤ 1 can identify more than 17% of all patients as very low risk for index AMI and 30-day MACE and unlikely to benefit from troponin testing. Broad implementation of this strategy could lead to significant resource savings.