1-year Major Adverse Cardiac Events Research Articles

CLINICAL EFFECTS OF BETA-BLOCKERS IN HYPERTENSIVE PATIENTS WITH ACUTE MYOCARDIAL INFARCTION AFTER ONE YEAR

Objective: Although the oral beta-blocker therapy is recommended at least 3 years after acute myocardial infarction (AMI), especially in hypertensive patients to control blood pressure, the evidence to support its clinical benefit is very poor. This study aimed to investigate the long-term clinical effects of beta-blockers in hypertensive patients with AMI who had no major adverse cardiac events (MACE) until 1 year after the initial attack. Design and method: Among 13,624 patients who were enrolled in nationwide AMI database of South Korea, the KAMIR-NIH Registry, 4,610 hypertensive patients, who underwent echocardiographic study and had no MACE (a composite of cardiac death, MI, revascularization or readmission due to heart failure) until 1 year, were selected in this study. Results: Beta-blockers were prescribed in 4,237 hypertensive patients (92%) at 1 year after AMI. On multivariable Cox-proportional hazard analysis, beta-blockers further reduced 1-year cardiac death (1.4 vs. 7.5/100 person-year; HR 0.23; 95% CI 0.14–0.38; p < 0.001), MI (1.1 vs. 3.1/100 person-year; HR 0.33; 95% CI 0.16–0.68; p = 0.002), and MACE (5.8 vs. 11.1/100 person-year; HR 0.54; 95% CI 0.37–0.79; p = 0.001). However, clinical outcomes showed a significant interaction with left ventricular ejection fraction (LVEF). Beta-blockers decreased 1-year MACE of patients with LVEF =<40% (11.3 vs. 24.5/100 person-year; HR 0.40; 95% CI 0.19–0.84; p = 0.015) and 40% <LVEF <50% (6.3 vs. 18.9/100 person-year; HR 0.43; 95% CI 0.22–0.85; p = 0.015, but not those with LVEF >=50% (4.7 vs. 5.8/100 person-year; HR 0.77; 95% CI 0.42–1.43; p = 0.411). ∗HR; hazard ratio, CI; confidence interval. Conclusions: Beta-blockers improved the clinical outcomes in hypertensive patients with mid-range as well as reduced LVEF until 2 years after AMI. However, its benefit in hypertensive patients with preserved LVEF was questionable.

Comparing conventional and high sensitivity troponin T measurements in identifying adverse cardiac events in patients admitted to an Asian emergency department chest pain observation unit.

BackgroundHigh sensitive cardiac troponin assays can be used for prediction of major adverse cardiac events (MACE) in patients with chest pain.MethodsWe included patients with symptoms suggestive of acute coronary syndrome in the emergency department observation unit. We compared the accuracy of conventional troponin T (cTnT) with high sensitive troponin T (hsTnT) at various ranges, as well as the utility of hsTnT and cTnT in prediction of 30-day and 1-year MACE.Results1023 patients were included (68.1% male, median age 56 years). There were 2712 hsTnT and cTnT values compared. hsTnT had a higher AUC than cTnT for 30-day and 1-year MACE. The optimal cut-off of 0-hour hsTnT for 30-day (PPV 34%, NPV 96.6%) and 1-year MACE (PPV 40.2%, NPV 94.2%) was 16 ng/L.For 844 patients who had values for both 0 and 2 h hsTnT, we proposed a rule-out cut-off of 0 and 2 h hsTnT < 16 ng/L (NPV 97.0%, 95%CI 95.5–98.1%) and a rule-in cut-off of 0 and 2 h hsTnT ≥ 26 ng/L (PPV 58.8%, 95%CI 40.7%-75.4%) for 30-day MACE. Negative 0–2 h delta-hsTnT had poor predictive discriminant capabilities on 30-day (PPV 8.2%) and 1-year MACE (PPV 12.3%).ConclusionThe cut off values of hsTnT used in the 0 and 2-hour algorithm to rule-out (16 ng/L) and rule-in MACE (26 ng/L) are in the range that previous cTnT assays are unable to measure accurately. Risk scores can be used to further improve NPV of the rule-out group. A fall in hsTnT level acutely is not predictive of MACE.

Donor Heart Coronary Calcification: Do We Take This Donor Heart?

<h3>Purpose</h3> The donor shortage in heart transplantation (HTx) has led to programs accepting older donors. Coronary calcification is common in older people and is known to correlate with underlying coronary artery disease. It is not known whether these donors with coronary calcification impart an increased risk for the recipient to develop cardiac allograft vasculopathy. <h3>Methods</h3> Between 2010 and 2017, we assessed 31 heart transplant patients who were found to have coronary calcification within the first 3 months after heart transplantation, either by coronary angiography or chest CT scans. These patients were compared to a contemporary cohort of 192 patients (transplanted with donors >30 years old) without coronary calcification for the following outcomes: 3-year survival, 3-year freedom from cardiac allograft vasculopathy (CAV, as defined by stenosis ≥30% by angiography), 3-year non-fatal major adverse cardiac events (NF-MACE: myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke), and 1-year freedom from any treated rejection (ATR), acute cellular rejection (ACR), and antibody-mediated rejection (AMR). <h3>Results</h3> Those patients with donor coronary calcification compared to those without had a significantly lower 3-year freedom from CAV (64.5% vs 85.9%, P=0.001). There was no significant difference in 3-year survival, freedom from NF-MACE, and 1-year rejection episodes. The severity of CAV observed in the donor coronary calcification group included: CAV1 = 13, CAV2 = 1, CAV3 = 0. <h3>Conclusion</h3> Donor coronary artery calcification appears to be a marker for greater risk for developing CAV after heart transplantation. Caution must be taken to accept these organs and if accepted, early modification of immunosuppression with a proliferation signal inhibitor may be indicated.

Prasugrel versus ticagrelor in patients with myocardial infarction undergoing percutaneous coronary intervention

ObjectiveThe comparative efficacy and safety of prasugrel and ticagrelor in patients with myocardial infarction (MI) treated with percutaneous coronary intervention (PCI) remain unclear. We aimed to investigate the association of...

Effect of left ventricular ejection fraction on the prognostic impact of chronic total occlusion in a non-infarct-related artery in patients with acute myocardial infarction.

BackgroundChronic total occlusion (CTO) in a non-infarct-related artery (IRA) in patients with acute coronary syndrome (ACS) is associated with a poor prognosis. However, whether the prognostic impact of non-IRA CTO differs according to left ventricular ejection fraction (LVEF) is unclear.Methods and resultsA total of 2060 consecutive acute myocardial infarction (AMI) patients who underwent primary percutaneous coronary intervention (PCI) were classified into 2 groups according to their LVEF (reduced EF: LVEF < 50%, preserved EF: LVEF ≥ 50%) and further subdivided according to the presence of concomitant non-IRA CTO. In the reduced EF group, patients with CTO had a higher 1-year all-cause death rate (20.3% vs. 34.3%, P = 0.001) and major adverse cardiac event rate (MACE: 19.6% vs. 39.6%, P < 0.001) compared to those without CTO, but they were similar between patients with and without CTO in the preserved EF group. Non-IRA CTO was an independent predictor of all-cause death (HR 1.58, 95% CI 1.06–2.33, P = 0.02) and MACE (HR 1.67, 95% CI 1.14–2.46, P = 0.009) only in the reduced EF group. In addition, the outcomes of successful CTO-PCI seemed to be similar to those without CTO in the reduced EF group.ConclusionsCTO in a non-IRA may contribute to a poor prognosis only in AMI patients with reduced LVEF.

Hemoglobin A1c and Cardiovascular Outcomes Following Percutaneous Coronary Intervention: Insights From a Large Single-Center Registry.

The aim of this study was to evaluate post-percutaneous coronary intervention (PCI) outcomes in relation to pre-procedural glycated hemoglobin (HbA1c) levels from a large, contemporary cohort. There are limited data evaluating associations between HbA1c, a marker of glycemic control, and ischemic risk following PCI. All patients with known HbA1c levels undergoing PCI at a single institution between 2009 and 2017 were included. Patients were divided into 5 groups on the basis of HbA1c level:≤5.5%, 5.6% to 6.0%, 6.1% to 7.0%, 7.1% to 8.0%, and >8.0%. The primary endpoint was major adverse cardiac events (MACE), a composite of all-cause death or myocardial infarction (MI), at 1-year follow-up. A total of 13,543 patients were included (HbA1c≤5.5%, n=1,214; HbA1c 5.6% to 6.0%, n=2,202; HbA1c 6.1% to 7.0%, n=4,130; HbA1c 7.1% to 8.0%, n=2,609; HbA1c >8.0%, n=3,388). Patients with both low (HbA1c≤5.5%) and high (HbA1c >8.0%) levels displayed an increased risk for MACE compared with those with values between 6.1% and 7.0%. Excess risk was driven primarily by higher rates of all-cause death among those with low HbA1c levels, while higher values were strongly associated with greater MI risk. Patterns of risk were unchanged among patients with serial HbA1c levels and persisted after multivariate adjustment. Among patients undergoing PCI, pre-procedural HbA1c levels display a U-shaped association with 1-year MACE risk, a pattern that reflects greater risk for death in the presence of low HbA1c (≤5.5%) and higher risk for MI with higher values (>8.0%).

Coronary Artery Bypass Grafting Transit Time Flow Measurement: Graft Patency and Clinical Outcomes

This subanalysis of the Randomized On-Off Bypass (ROOBY) trial examined transit time flow measurement (TTFM) use and its impact on graft patency and long-term clinical outcomes after coronary artery bypass graft surgery. Use of TTFM for ROOBY centers and surgeons was assessed. Comparative patient outcomes based on TTFM use included 1-year graft patency and 1-year and 5-year major adverse cardiac events: all-cause mortality, nonfatal myocardial infarction, and revascularization (percutaneous coronary intervention or repeat coronary artery bypass graft surgery). Transit time flow measurement was used in 1067 patients (TTFM group) and not used in 501 patients (non-TTFM group); of the TTFM group, median percentage TTFM use was 79% (interquartile range, 41% to 98%) among 18 Veterans Affairs Medical Centers, and 74% (interquartile range, 13% to 98%) among 48 surgeons. Patients were comparable in age (63 ± 8.5 years TTFM vs 62 ± 8 years non-TTFM, P= .30) and estimated 30-day mortality risk (1.8 ± 1.7 TTFM vs 1.9 non-TTFM, P= .53). One-year FitzGibbon A patency was 83% (1600 of 1988 grafts) for TTFM assessed grafts and 78% (629 of 803) for non-TTFM assessed grafts (P < .01). Fewer TTFM patients had an occluded graft (29%, vs 38% non-TTFM; P= .01). Comparing TTFM patients with non-TTFM patients, 5-year major adverse cardiac event rates were 30% vs 25% (P= .06). Individual component rates were 14% vs 11% for death (P= .06), 12% vs 8.8% for myocardial infarction (P= .07), and 13% vs 12% for revascularization (P= .62). The association of TTFM use with graft patency and clinical outcome is uncertain. Future randomized studies that account for patient risk factors and practice variation would help address this knowledge gap.

The impact of angiotensin-converting-enzyme inhibitors versus angiotensin receptor blockers on 3-year clinical outcomes in patients with acute myocardial infarction without hypertension

This study aimed to investigate the impact of angiotensin-converting-enzyme inhibitors (ACEI) and angiotensin II type 1 receptor blockers (ARB) on 3-year clinical outcomes in acute myocardial infarction (AMI) patients without a history of hypertension who underwent successful percutaneous coronary intervention (PCI) with drug-eluting stents (DES). A total of 13,104 AMI patients who were registered in the Korea AMI registry (KAMIR)-National Institutes of Health (NIH) were included in the study. The primary endpoint was 3-year major adverse cardiac events (MACE), which was defined as the composite of all-cause death, recurrent myocardial infarction (MI), and any repeat revascularization. To adjust baseline potential confounders, an inverse probability weighting (IPTW) analysis was performed. The patients were divided into two groups: the ACEI group, n = 4,053 patients and the ARB group, n = 4,107 patients. During the 3-year clinical follow-up, the cumulative incidences of MACE (hazard ratio [HR], 0.843; 95% confidence interval [CI], 0.740–0.960; p = 0.010), any repeat revascularization (HR, 0.856; 95% CI, 0.736–0.995; p = 0.044), stroke (HR, 0.613; 95% CI, 0.417–0.901; p = 0.013), and re-hospitalization due to heart failure (HF) (HR, 0.399; 95% CI, 0.294–0.541; p <0.001) in the ACEI group were significantly lower than in the ARB group. In Korean patients with AMI without a history of hypertension, the use of ACEI was significantly associated with reduced incidences of MACE, any repeat revascularization, stroke, and re-hospitalization due to HF than those with the use of ARB.

Gender differences in clinical outcomes of acute myocardial infarction undergoing percutaneous coronary intervention: insights from the KAMIR-NIH Registry.

BackgroundThere are numerous but conflicting data regarding gender differences in outcomes following percutaneous coronary intervention (PCI). Furthermore, gender differences in clinical outcomes with acute myocardial infarction (AMI) following PCI in Asian population remain uncertain because of the under-representation of Asian in previous trials.MethodsA total of 13, 104 AMI patients from Korea Acute Myocardial Infarction Registry-National Institute of Health (KAMIR-NIH) between November 2011 and December 2015 were classified into male (n = 8021, 75.9%) and female (n = 2547, 24.1%). We compared the demographic, clinical and angiographic characteristics, 30-days and 1-year major adverse cardiac and cerebrovascular events (MACCE) in women with those in men after AMI by using propensity score (PS) matching.ResultsCompared with men, women were older, had more comorbidities and more often presented with non-ST segment elevation myocardial infarction (NSTEMI) and reduced left ventricular systolic function. Over the median follow-up of 363 days, gender differences in both 30-days and 1-year MACCE as well as thrombolysis in myocardial infarction minor bleeding risk were not observed in the PS matched population (30-days MACCE: 5.3% vs. 4.7%, log-rank P = 0.494, HR = 1.126, 95% CI: 0.800-1.585; 1-year MACCE: 9.3% vs. 9.0%, log-rank P = 0.803, HR = 1.032, 95% CI: 0.802-1.328; TIMI minor bleeding: 4.9% vs. 3.9%, log-rank P= 0.215, HR = 1.255, 95% CI: 0.869-1.814).ConclusionsAmong Korean AMI population undergoing contemporary PCI, women, as compared with men, had different clinical and angiographic characteristics but showed similar 30-days and 1-year clinical outcomes. The risk of bleeding after PCI was comparable between men and women during one-year follow up.

Abstract 13128: Development and Initial Utilization of a Multi-institutional Distributed Data Network Designed to Evaluate Real-world Clinical Outcomes in Patients Presenting for Percutaneous Coronary Intervention (PCI): Results From the Building the Unique Device Identifier (UDI) Into Longitudinal Data for Medical Device Evaluation (BUILD) Network

Introduction: Generating real-world evidence for regulatory and research purposes is a fundamental transformation of healthcare. To develop and demonstrate the operational components, we created the BUILD network, a framework for the longitudinal follow-up of all patients undergoing PCI at three large health systems, Mercy, Geisinger, and Intermountain. It leverages consistent data through a standardized common data model using distributed analyses without site-specific programming or external transfer of clinical data. To demonstrate BUILD’s potential, we evaluated clinical outcomes between two commonly used drug-eluting coronary stents. Methods: We included all patients receiving zotarolimus, or everolimus stents from 2012-19. Data were compiled from registries and electronic health/billing records systems without explicit chart abstraction, and retained at each site in the BUILD analysis database. A common query examined 32 baseline covariates, created propensity-matched cohorts, assessed for balance, and compared 1-year major adverse cardiac event (MACE) rates between groups, with weighted data combined to create event-free survival plots. Results: We identified 11,030 patients (Mercy=4,906, Geisinger=4,109, Intermountain=127; mean age 65±12, 69% males, 23% zotarolimus). Figure 1 shows hazard ratios and survival curves for the composite endpoints in matched cohorts. Differences in subsequent PCI, mortality, and composite MACE were not significantly different between stent types. Conclusions: This large real-world, multicenter demonstration project showed no statistical differences in 1-year clinical outcomes of patients receiving zotarolimus versus everolimus stents—results similar to other studies. More importantly, it demonstrated that multi-institutional data networks can be successfully developed to provide clinically relevant evidence while maintaining the source data locally on-premise at each institution.

Optimization of GRACE Risk Stratification by N-Terminal Pro-B-type Natriuretic Peptide Combined With D-Dimer in Patients With Non-ST-Elevation Myocardial Infarction

We aimed to explore the utility of multiple biomarkers with GRACE risk stratification for non-ST-elevation myocardial infarction (NSTEMI). A total of 1,357 patients diagnosed with NSTEMI were enrolled in this study at multiple medical centers in Tianjin, China. The outcomes were 1-year all-cause death and major adverse cardiac events (MACE: all-cause death, hospital admission for unstable angina, hospital admission for heart failure, nonfatal recurrent myocardial infarction, and stroke). C-index, net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were calculated to verify that the biomarkers improve the predictive accuracy of the GRACE score. A total of 57 participants died, while 211 participants experienced 231 MACEs during follow-up (mean: 339 days). For all-cause death, the combination of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and D-dimer improved the predictive accuracy of GRACE the most, with C-index, IDI, and NRI values of 0.88, 0.085, and 1.223, respectively. For MACE, trigeminal combination of NT-proBNP, fibrinogen, and D-dimer resulted in C-index, IDI, and NRI values of 0.80, 0.079, and 0.647, respectively. As a result, NT-proBNP, D-dimer, fibrinogen, and GRACE comprise a new scoring system for assessing 1-year clinical events. Kaplan-Meier analysis revealed a significant increase in 1-year mortality (score ≥3.85 vs <3.85, p < 0.0001) and 1-year MACE (score ≥1.72 vs <1.72, p < 0.0001) between different score groups. In conclusion, the combination of NT-proBNP and D-dimer added prognostic value to GRACE for all-cause death. Combining NT-proBNP, fibrinogen, and D-dimer increased the prognostic value of GRACE for MACE. This newly developed scoring system is strongly correlated with all-cause mortality and MACE, and can be easily utilized in clinical practice.

Determinants and prognostic implication of periprocedural myocardial injury after successful recanalization of coronary chronic total occlusion.

Periprocedural myocardial injury (PMI) has been generally associated with major adverse cardiac events (MACE), however, limited studies addressed its clinical implications following chronic total occlusion (CTO) percutaneous coronary intervention (PCI). To evaluate the determinants and prognostic implication of PMI following CTO-PCI. Retrospective single-centre study of 125 consecutive patients undergoing CTO-PCI was attempted between December 2013 and December 2017. Angiographic success was achieved in 115 patients (92.0%) and cTn-I values were obtained 12-24h following PCI. PMI was defined as an elevation of cTn-I above 5 times the 99th-percentile upper reference limit. Baseline demographic, clinical, angiographic and procedural characteristics were compared. Multivariate analysis was performed to determine the predictors of PMI and the correlates of PMI and 1-year MACE, a composite of all-cause death, non-fatal myocardial infarction, and target lesion revascularization. Overall, mean age was 67 ± 17years; 25 patients (21.7%) were female; and PMI occurred in 41 patients (35.7%). Multivessel coronary artery disease (MVD) (odds ratio [OR], 3.41; 95% confidence interval [CI], 1.09-10.67; p = 0.04) and procedural complications (a composite of iatrogenic coronary artery dissection/haematoma or perforation) (OR, 19.08; 95% CI, 3.77-96.65; p < 0.01) predicted PMI. Significant collateralization (Rentrop 3) (hazard ratio, [HR], 0.19; 95% CI, 0.06-0.64; p < 0.01) and procedural complications (HR, 8.86; 95% CI, 2.66-29.46; p < 0.01) were independently associated with 1-year MACE, while PMI was not (p = 0.26). In this contemporary cohort, PMI following successful CTO-PCI was a common finding and was predicted by MVD and procedural complications. PMI was not independently associated with 1-year MACE.

Indoleamine 2,3 dioxygenase (IDO) as a new predictor for advance coronary artery diseases

Abstract Background Indoleamine 2,3 dioxygenase (IDO), the rate-limiting enzyme in in the kynurenine (Kyn) pathway of tryptophan (Trp) degradation, is modulated by inflammation and regarded as a key molecule driving immunotolerance and immunosuppressive mechanisms. This response accelerates the resolution of inflamed tissues to protect them against collateral damage and facilitate tissue healing. A growing body of evidence indicates that IDO-mediated Trp metabolism is involved directly or indirectly in atherogenesis. Little is known about IDO activity in patients with active coronary artery disease (CAD). Purpose We hypothesized that IDO activity as reflected by Kyn/Trp ratio and Kyn levels correlated with coronary artery disease (CAD) severity and predicted 1-year major adverse cardiac events (MACE). Method We prospectively enrolled the patients whom underwent coronary angiography in our institute. We excluded the patients whom might have other non-cardiac causes of elevated inflammatory biomarkers such as rheumatoid arthritis, allergic asthma, and so on. Measurements of IDO, hs-troponin and hs-CRP levels were performed at baseline and IDO activity was monitored every 6 month at interval. Baseline demographic, coronary angiogram/interventions data were recorded. Significant CAD defined as &amp;gt;70% stenosis in major epicardial vessel. Patients were followed up for 1-year. MACE were pre-specified. Results Three-hundred and five patients were enrolled. Ninety-eight patients (32%) presented with acute coronary syndrome. There was a significant difference in IDO, kynurenine, and hs-troponin between patients with and without significant CAD (Table 1). In addition, baseline IDO activity, kynurenine and hs-troponin levels were significantly higher in significant CAD patients with 3-vessel, 2-vessel and 1-vessel involvements than those with insignificant CAD; (0.17 vs 0.14 vs 0.14 vs 0.04, p&amp;lt;0.01), (5.8 vs 4.5 vs 5.1 vs 2.9 μM/g, p&amp;lt;0.01) and (18.2 vs 12.4 vs 12.7 vs 11.1 mg/dL, p&amp;lt;0.001), respectively. Preliminary data in 287 patients with completion of 1-year follow up showed that 1-year mortality was 2.9%. In comparison between patients who survived and death, it demonstrated markedly higher baseline kynurenine (5.12 vs 0.54 μM/g, p&amp;lt;0.03) and IDO (0.15 vs 0.01, p&amp;lt;0.02) in the patients without 1-year mortality. Conclusion Immunometabolic response mediated through IDO function were enhanced in patients with CAD and correlated with the severity and extent of the disease. Patient with inadequate IDO response had a higher 1-year mortality. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): The Siriraj grant for research development and medical education of the Faculty of Medicine Siriraj Hospital

External validation of a clinical decision rule to identify patients at low risk for acute coronary syndrome who do not need objective coronary artery disease testing

Abstract Background Rapid high-sensitivity cardiac troponin (hs-cTn) based algorithms have substantially improved the early rule-out of acute myocardial infarction (AMI) and thereby facilitated the selection of patients eligible for outpatient management. However, it remains unclear, which patients after rule-out of AMI should still undergo objective anatomic or functional cardiac testing for the detection of relevant coronary artery disease. A pilot study has derived a clinical decision rule for the selection of patients who do not need objective anatomic or functional cardiac testing for coronary artery disease (“No Objective Testing” (NOT) rule). Purpose To externally validate the performance of the NOT-rule in a multicentre study. Methods Patients presenting to the ED with symptoms suggestive of an acute coronary syndrome (ACS) were enrolled in a large prospective international multicentre study at 12 study sites in five European countries. Two independent cardiologists centrally adjudicated the final diagnosis using all clinical data including cardiac imaging and at least 90-day follow-up. The NOT-rule is applied in patients, in whom a 2h accelerated diagnostic protocol (using hs-cTnI concentrations at 0h/2h and ECG data) has ruled-out AMI and based on clinical variables. In brief, the first rule is a weighted score derived from independent predictors of ACS that classifies patients as low-risk if they score ≤4 points. The second rule was simplified and ruled patients out if they were younger than 50 years, had no history of an AMI or known CAD, and no prescribed nitrates. The third rule equals the second except nitrate use was omitted. Primary objective was the safety and efficacy of the NOT-rules for rule-out of major adverse cardiac events (MACE) including AMI, unstable angina pectoris, urgent or emergency revascularisation or cardiovascular death at 30-days of follow-up. Secondary objective was the safety and efficacy for rule-out of MACE at 2-years. Results Out of 3188 enrolled patients, 2162 (68%) had hs-cTnI concentrations at 0h and 2h below the 99th centile as well as a non-diagnostic ECG and were therefore eligible for the analysis. MACE at 30-days occurred in 302 (14%) patients. The second and third rule offered highest safety and efficacy for rule-out of MACE at 30-days. Both identified 492 (23%) patients at low-risk with a sensitivity of 99.7% (95% CI 98.2–99.9%) and a negative predictive value (NPV) of 99.8% (95% CI 98.6–99.9%). One MACE was missed within 30-days (revascularisation of a one-vessel CAD). Sensitivity 98.9% (95% CI 97.1–99.7%) and NPV 99.2% (95% CI 97.8–99.7) were also very high for 1-year MACE, as well as 2-year MACE 98.4% (95% CI 96.5–99.4%) and 98.4% (95% CI 96.5–99.3%), respectively. Conclusions The NOT rules proved to be a safe tool that identifies nearly one-fourth of patients at very low risk for MACE, who may not need objective anatomic or functional cardiac testing for coronary artery disease. Performance of NOT rules Funding Acknowledgement Type of funding source: Other. Main funding source(s): Swiss National Science Foundation, the Swiss Heart Foundation, the KTI, the European Union, the Stiftung für kardiovaskuläre Forschung Basel, the University of Basel, the University Hospital Basel

Optimization of GRACE risk stratification by NT-proBNP combined with D-dimer in patients with non-ST-elevation myocardial infarction

Abstract Background GRACE risk score is the most widely used tool to predict the risk of death and myocardial infarction in patients with Non-ST-elevation myocardial infarction (NSTEMI). Some biomarkers have been shown to have a high predictive value for prognosis. But the models constructed using these studies have some drawbacks, including the using biomarkers that are not routinely monitored. Aims To explore the optimizing role of multiple biomarkers in GRACE risk stratification in NSTEMI and then develop a new scoring system based on GRACE. Methods 1.This multi-center, prospective, cohort study enrolled 1357 patients (mean age 65±12 years; 57% male). Common clinical indicators were collected within the first 12h after admission. 2.The outcome was 1-year all-cause mortality and major adverse cardiac events (MACE: all-cause death,unstable angina, heart failure, recurrent myocardial infarction and stroke). 3.Cox multivariate anlysis was used to quantify the biomarker effect. C-index, NRI and IDI were calculated to verify that the biomarkers improve the predictive accuracy of GRACE. Results 1. During follow-up (mean: 339 days), 57 participants died and 211 participants had 231 MACE. In COX analysis, NT-proBNP (P&amp;lt;0.0001), and d-dimer (P=0.0092) were significant independent biomarkers for death. NT-proBNP (P&amp;lt;0.0001), fibrinogen (P=0.0177) and d-dimer (P&amp;lt;0.0001) were significant independent biomarkers for MACE. 2. For all-cause death, the combination of NT-proBNP and D-dimer improved the predictive accuracy of GRACE the most. For MACE, trigeminal combination of NT-proBNP, fibrinogen, and D-dimer improved GRACE the most 3. NT-proBNP, D-dimer, fibrinogen, and GRACE comprise a new scoring system for assessing 1-year clinical events. Kaplan-Meier analysis revealed a significant rise in 1-year mortality and MACE between different score groups. Conclusions The combination of NT-proBNP, and d-dimer added the prognostic value of GRACE for all-cause death and MACE. Our newly developed scoring system can be easily calculated in clinical practice and strongly correlated with all-cause mortality and MACE. Risk score and survival curve Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Major Science and Technology Projects of Tianjin Science and Technology Commission in 2016; Key Project of Healthcare Industry of Tianjin in 2016

Impact of baseline conduction abnormalities on outcomes after transcatheter aortic valve replacement with SAPIEN-3.

Baseline conduction abnormalities are known risk factors for permanent pacemaker (PPM) implantation after transcatheter aortic valve replacement (TAVR). We sought to determine the impact of baseline right bundle branch block (RBBB), left bundle branch block (LBBB), left anterior hemiblock (LAHB), first-degree atrioventricular block (AVB) and atrial fibrillation/flutter (AF) on TAVR outcomes. Consecutive patients who underwent transfemoral TAVR with SAPIEN-3 (S3) were included. We excluded patients with prior PPM, nontransfemoral access or valve-in-valve. Among 886 patients, baseline RBBB was seen in 15.9%, LBBB in 6.3%, LAHB in 6.2%, first-degree AVB in 26.3% and AF in 37.5%. The rate of 30-day PPM was 10.1%. Baseline RBBB (OR 4.005; 95% CI 2.386-6.723; p< .001) and first-degree AVB (OR 1.847; 95% CI 1.133-3.009; p= .014) were independent predictors of 30 day PPM. LAHB also resulted in higher PPM rates but only in unadjusted analysis (21.8% vs. 9.4%; p= .003). Baseline LBBB and AF were associated with lower left ventricular ejection fraction (LVEF) at both baseline and 1year after TAVR. However, Δ LVEF over time were noted to be similar with baseline LBBB (1.8% vs. 1.4%; p= .809) and AF (1.1% vs. 1.7%; p= .458). Moreover, baseline AF was also associated with higher stroke/transient ischemic attack (TIA) at 1year (4.4% vs. 1.8%; p= .019), 1-year major adverse cardiac and cerebrovascular events (MACCE) (19.5% vs. 13.3%; p= .012) and 2year mortality (23.5% vs. 15.2%; p= .016). None of the other baseline conduction defects affected long-term mortality or MACCE. In our S3 TAVR population, baseline RBBB and first-degree AVB predicted higher PPM risk. Prior LBBB and AF were associated with lower LVEF at both baseline and 1 year. Lastly, preexisting AF was associated with higher rates of mortality, stroke/TIA, and MACCE.

Prognostic Value of Quantitative Flow Ratio Based Functional SYNTAX Score in Patients With Left Main or Multivessel Coronary Artery Disease.

The potential impact of quantitative flow ratio (QFR) based functional Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score (FSSQFR) on prognostication and revascularization strategy choice has not been fully investigated, and the discriminant ability of FSSQFR needs further validation. QFR was retrospectively analyzed in left main or patients with multivessel coronary artery disease from the PANDA III trial. A total of 607 patients with analyzable QFR in all vessels were included. FSSQFR was counted by summing the individual scores only in ischemia-producing lesions (vessel QFR ≤0.8). Patients were stratified according to tertiles of SYNTAX score (SS), and 3 groups of FSS were divided by the same cutoff score. The primary end point was 2-year major adverse cardiac events (a composite of cardiac death, any myocardial infarction, or ischemia-driven revascularization). After calculating the FSSQFR, 16% (96/607) of study patients moved from higher-risk group by SS to lower-risk group. In the low, intermediate, and high FSSQFR group, the cumulative incidence of 2-year major adverse cardiac events was 9.1%, 13.5%, and 22.3% (P=0.0004), and the rate of a composite of cardiac death or myocardial infarction (3.8%, 7.3%, and 13.7%, P=0.0006) was also increased. Compared with SS, FSSQFR significantly improved risk classification and prognostication (area under the curve of the receiver-operating characteristics 0.65 versus 0.62, P=0.0009). Moreover, 6% (38/607) of patients, for whom coronary artery bypass grafting would be recommended according to SS, converted to favor percutaneous coronary intervention after FSSQFR calculation. After multivariate adjustment, FSSQFR was an independent predictor of 2-year major adverse cardiac events (adjusted hazard ratio, 1.05 [95% CI, 1.02-1.07]; P=0.0001). Among patients with left main or multivessel coronary artery disease, FSSQFR showed applicability in prognostication and revascularization strategy choice. An improved scoring system combining anatomy and physiology (FSSQFR) discriminated the risk of adverse events modestly better than anatomic assessment (SS) alone. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02017275. Graphic Abstract: A graphic abstract is available for this article.

Impact of cardiovascular risk stratification strategies in kidney transplantation over time.

BackgroundKidney transplant recipients exhibit a dramatically increased cardiovascular (CV) risk. In 2007, Austrian centres implemented a consensus of comprehensive CV screening programme prior to kidney transplantation (KT). The consensus placed a particular emphasis on screening for coronary artery disease (CAD) with cardiac computed tomography (CT) or coronary angiography (CAG) in patients with diabetes mellitus, known CAD or those having multiple conventional CV risk factors. Here, we investigate if this affected risk stratification and post-transplant CV outcomes. MethodsIn a retrospective chart review, we evaluated 551 KTs performed from 2003 to 2015 in our centre. Patients were categorized into three groups: KT before (2003–07), directly after (2008–11) and 5 years after (2012–15) implementation of the consensus. We analysed clinical characteristics, the rate of cardiac CTs and CAGs prior to KT as well as major adverse cardiac events (MACEs) during a 2-year follow-up after KT. ResultsThe three study groups showed a homogeneous distribution of comorbidities and age. Significantly more cardiac CTs (13.6% versus 10.2% versus 44.8%; P = 0.002) and CAGs (39.6% versus 43.9% versus 56.2%; P = 0.003) were performed after the consensus. Coronary interventions were performed during 42 out of 260 CAGs (16.2%), the cumulative 2-year MACE incidence was 8.7%. Regarding MACE occurrence, no significant difference between the three groups was found.ConclusionCV risk stratification has become more rigorous and invasive after the implementation of the consensus; however, this was not associated with an improvement in CV outcome.

Cangrelor as an Effective Bridge in Patients Requiring Percutaneous Coronary Intervention and Temporary Mechanical Support

Objectives Describe the experience at our institution using cangrelor during T-MCS as a bridge to durable support or weaning, including hematological complications and mortality. Background In patients with cardiogenic shock, temporary mechanical circulatory support (T-MCS) devices can provide cardiac or cardiopulmonary support as a bridge to myocardial recovery or need for long-term support. Intravenous cangrelor presents a promising drug therapy for maintaining adequate platelet inhibition while bridging to decision Methods This retrospective, cohort study included all patients from 06/22/2015 through 01/31/2018 who received cangrelor as a second antiplatelet therapy in addition to aspirin while being supported with a T-MCS device at a single large tertiary care center. The primary outcome was major bleeding according to the ELSO definition. Secondary endpoints included all cause index hospitalization mortality, decision to withdraw care, minor bleeding, stent thrombosis confirmed by angiography, and thromboembolic event confirmed by imaging during the patient's index hospitalization. Additional secondary endpoints were 1-year survival, and 1-year major adverse cardiac event rate. Results The primary outcome major bleeding occurred in four of ten cases. Four of the remaining six cases had a minor bleeding event. There were no episodes of acute/subacute stent thrombosis in the eight patients who received a drug-eluting stent. All cause index hospitalization mortality occurred in 60%, of which 5 patients had care withdrawn due to futility. None of the patients had a catastrophic bleeding event. Conclusions Our case series suggests a potential benefit of cangrelor as a bridge in patients requiring PCI and temporary mechanical support.

Higher risk of major adverse cardiac events after acute myocardial infarction in patients with schizophrenia

BackgroundPatients with schizophrenia are a high-risk population due to higher prevalences of cardiovascular risk factors and comorbidities that contribute to shorter life expectancy.PurposeTo investigate patients with and without schizophrenia experiencing...