30-day Major Adverse Cardiac Events Research Articles

The prognostic value of HEART score in patients with known heart failure evaluated at the emergency department for acute chest pain

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Heart Lung and Blood Institute (United States). Background Chest pain is a common and concerning symptom in emergency care, often necessities further risk stratification for adverse cardiovascular events on short-term follow up. Patients with known heart failure (HF) constitutes a unique sub-population that would greatly benefit from short-term risk stratification to guide appropriate clinical interventions and optimize resource allocation. HEART (History, ECG, Age, Risk factors, Troponin) is a well-validated risk score that has been shown to outperform other clinical risk scores in patients with chest pain. It remains unknown if HEART score can be safely used in patients with known HF presenting to the emergency department with chest pain. Purpose We sought to evaluate the prognostic value of HEART score in patients with known HF compared to their counterparts. Method This was a prospective observational cohort study of consecutive adult patients evaluated at the emergency department for non-traumatic chest pain. HEART score was computed from charts by independent physician reviewers. The primary study outcome was major adverse cardiac events (MACE) defined as acute coronary syndrome, invasive revascularization, reinfarction, death, cardiac arrest, ventricular tachyarrhythmia, or acute exacerbation within 30 days of indexed admission. Outcomes were adjudicated by two independent reviewers (Kappa = 0.908). Classification performance between groups was compared using area under receiver operator characteristic curve (AUROC), sensitivity, and negative predictive value (NPV). Results Our cohort included 4,132 patients (age 59±16, 47% female, 33% Black). Overall, 921 patients (22.3%) experienced 30-day MACE. The classification performance of HEART score in those without HF (n = 3,329, 81%) was AUROC of 0.831 (95% CI 0.813-0.848), compared to only 0.633 (95% CI 0.592-0.673) in those with known HF (n = 803, 19%) (z score = 8.771, p < 0.001, Figure). The sensitivity and NPV of HEART score among those without HF were 87.4% and 95.3%, compared to 81.2% and 73.3%, respectively, among those with known HF. Conclusion Our findings suggest that the prognostic value of HEART score for predicting 30-day MACE is inferior and suboptimal in patients with known HF evaluated for chest pain at the emergency department compared to their counterparts. These findings emphasize the need for more tailored risk assessment and management strategies in this specific patient population. Further research is warranted to better understand the limitations and potential enhancements of the HEART score in patients with HF.Classification Performance of HEART score

Cardiovascular Outcomes Among Patients with Acute Coronary Syndromes and Diabetes: Results from ACS QUIK Trial in India.

Despite cardiovascular disease being the leading cause of death in India, limited data exist regarding the factors associated with outcomes in patients with diabetes who suffer acute myocardial infarction (AMI). We examined 21,374 patients with AMI enrolled in the ACS QUIK trial. We compared in-hospital and 30-day major adverse cardiac events including death, re-infarction, stroke, or major bleeding in those with and without diabetes. The associations between diabetes and cardiac outcomes were adjusted for presentation and in-hospital management using logistic regression. Mean ± SD age was 60.1 ± 12.0 years, 24.3% were females, and 44.4% had diabetes. Those with diabetes were more likely to be older, female, hypertensive, and have higher Killip class but less likely to present with STEMI. Patients with diabetes had longer symptoms onset-to-arrival (median 225 vs 290 min; P < 0.001) and, in case of STEMI, longer door-to-balloon times (median, 75 vs 91 min; P < 0.001). Diabetes was independently associated with higher in-hospital death (adjusted odds ratio [aOR], 1.46; 95% CI, 1.12-1.89), in-hospital reinfarction (aOR, 1.52; 95% CI, 1.15-2.02), 30-day MACE (aOR, 1.33; 95% CI, 1.14-1.55) and 30-day death (aOR, 1.40; 95%CI, 1.16-1.69) but not 30-day stroke or 30-day major bleeding. Among patients presenting with AMI in Kerala, India, a considerable proportion has diabetes and are at increased risk for in-hospital and 30-day adverse cardiovascular outcomes. Increased awareness of the increased cardiovascular risk and attention to the implementation of established cardiovascular therapies are indicated for patients with diabetes in lower-middle-income countries who develop AMI. ClinicalTrials.gov Unique identifier: NCT02256658.

Management of depth to achieve timely arteriovenous fistula utilization

ObjectiveFailure to achieve timely arteriovenous fistulae (AVFs) utilization due to excessive depth (>6 mm) remains an ongoing concern for dialysis access. This study evaluates the outcomes of radiocephalic (RCF) and brachiocephalic (BCF) fistula elevation required for access utilization. MethodsA retrospective review of all patients undergoing first-time autologous access over 10 years was undertaken. RCF and BCF were analyzed, and cases of initial access failure due to depth alone were selected for study. Primary and staged brachio-basilic AVF were excluded. Outcomes of early thrombosis, line placement, maturation (successful progression to hemodialysis [HD), reintervention, and functional dialysis (continuous HD for 3 consecutive months) were examined. ResultsFrom January 2012 to December 2022, 1733 patients (67% female; mean age, 61 ± 14 years) underwent autologous AVF placement. Of these, 298 patients (17%) had depth-related AVF access issues (BCF, 71% and RCF, 29%). Nineteen percent of these AVFs underwent a primary balloon-assisted maturation (BAM), and 2% had side branch coil embolization before consideration for elevation. The average time to intervention for depth was 11 ± 4 weeks after primary creation. During elevation, side branch ligation occurred in 38% of cases, and 15% underwent intraoperative BAM, The pre-elevation depth was 8.2 ± 3.1 mm, and the mean post-elevation depth was 4.7 ± 2.9 mm (P = .002). Early thrombosis (<18 days) occurred in 4% of cases. There was no mortality, and the 30-day major adverse cardiac event rate was 2%, with a 30-day morbidity of 5%, which was driven by wound issues. Six percent of the AVFs underwent follow-up BAM within 3 months. Mean maturation of the AVFs was 74% ± 3% vs 72% ± 3% (P = .58) for the elevation vs no-elevation groups at 24 weeks, respectively. However, there was an increase in tunneled central line placement in pre-emptive fistula patients due to the delay in maturation (elevation, 17% vs no-elevation, 8%; P = .008). There was a mean successful access time of 6 ± 3 weeks after elevation (16 ± 4 weeks after access creation). There was a median of 2.4 secondary interventions per year after elevation compared with a median of 2.7 secondary interventions per year without elevation. Mean access functionality was 68% ± 8% vs 75% ± 8% at 3 years for the elevation vs no-elevation groups, respectively (P = .25). ConclusionsElevation of deep BCF and RCF occurs late after placement but can be successfully achieved with low morbidity and satisfactory long-term functionality. It results in an increase in tunneled central line placement in pre-emptive fistula patients. Elevation is a valuable adjunct to AVF maturation and enhances an autologous access policy.

Clinical Outcomes of Renal Transplant Recipients Undergoing Percutaneous Coronary Intervention

Clinical outcomes of patients with renal transplant (RT) undergoing percutaneous coronary intervention (PCI) remain poorly elucidated. Between 2014 and 2021, data were analysed for the following three groups of patients undergoing PCI enrolled in a multicentre Australian registry: (1) RT recipients (n=226), (2) patients on dialysis (n=992), and (3) chronic kidney disease (CKD) patients (estimated glomerular filtration rate [eGFR], 30‒60 mL/min per 1.73 m2) without previous RT (n=15,534). Primary outcome was 30-day major adverse cardiac and cerebrovascular events (MACCEs)-composite of mortality, myocardial infarction, stent thrombosis, target vessel revascularisation, and stroke. RT recipients were younger than dialysis and patients with CKD (61±10 vs 68±12 vs 78±8.2 years, p<0.001). Patients with RT less frequently had severe left ventricular dysfunction compared with dialysis and CKD groups (6.7% vs 14% and 8.5%); however more, often presented with acute coronary syndrome (58% vs 52% and 48%), especially STEMI (all p<0.001). Patients with RT and CKD had lower rates of 30-day MACCE (4.4% and 6.8% vs 11.6%, p<0.001) than the dialysis group. Three-year survival was similar between RT and CKD groups, however was lower in the dialysis group (80% and 83% vs 60%, p<0.001). After adjustment, dialysis was an independent predictor of 30-day MACCE (odds ratio [OR] 1.90, 95% confidence interval [CI] 1.44‒2.50, p<0.001), however RT was not (OR 0.91, CI 0.42‒1.96, p=0.802). Both RT (hazard ratio [HR] 2.07, CI 1.46‒2.95, p<0.001) and dialysis (HR 1.35, CI 1.02‒1.80, p=0.036) heightened the hazard of long-term mortality. RT recipients have more favourable clinical outcomes following PCI compared with patients on dialysis. However, despite having similar short-term outcomes to patients with CKD, the hazard of long-term mortality is significantly greater for RT recipients.

SVEAT score: Acute chest pain risk stratification

ObjectiveWe aimed to compare the predictive ability of the newly introduced Symptoms, history of Vascular disease, Electrocardiography, Age, and Troponin (SVEAT) score with the widely used History, ECG, Age, Risk factors, and Troponin I (HEART) score in risk stratification for 30-day major adverse cardiac events (MACE) development among patients presenting to the emergency department with acute chest pain complaints. MethodsThis prospective, observational, single-center study was conducted at an emergency department of a tertiary care hospital between June 2022 and January 2023. We recruited all adult patients aged 24 years and above with a primary complaint of non- traumatic chest pain at the critical care unit of the Emergency Department. Inclusion Criteria: Patients aged 24 years and above with a primary complaint of chest pain lasting >5 min. Exclusion Criteria: Patients with STEMI, pregnant individuals, those with traumatic chest pain, and those without 30-day MACE data were excluded. HEART and SVEAT scores were calculated for each participant.The performance of the SVEAT score in identifying the low-risk patient group was compared to that of the HEART score. ResultsIn the study, out of 809 patients, 589 (72.8%) were categorized as low-risk based on the SVEAT score, and 377 (46.6%) based on the HEART score. Out of these 809 patients, 115 (14.2%) experienced MACE. Within the group classified as low risk by the SVEAT score, 6 (0.7%) patients experienced MACE, while within the group classified as low risk by the HEART score, 8 (1%) patients experienced MACE. The SVEAT score had an Area Under the Curve (AUC) of 0.916 (95% CI 0.890 to 0.942), which was found to be higher than the AUC of the HEART score (0.856, 95% CI 0.822 to 0.890). In our study, the sensitivity of the SVEAT and HEART scores was found to be 94.7% (95% CI 88.9%–98.0%) and 93.0% (95% CI 86.7%–96.9%), respectively. The specificity of both scores was 84.1% (95% CI 81.0%–86.6%) and 53.17% (95% CI 49.3%–56.6%), respectively. ConclusionWhile our study indicated a higher predictive power for MACE development with the SVEAT score compared to the HEART score, further extensive studies are necessary for its reliable implementation in emergency departments for chest pain risk classification.

High-Sensitivity Cardiac Troponin T and Frailty Predict Short-Term Mortality in Patients ≥75 Years Undergoing Emergency Abdominal Surgery: A Prospective Observational Study.

An elevated cardiac troponin concentration is a prognostic factor for perioperative cardiac morbidity and mortality. In elderly patients undergoing emergency abdominal surgery, frailty is a recognized risk factor, but little is known about the prognostic value of cardiac troponin in these vulnerable patients. Therefore, we investigated the prognostic significance of elevated high-sensitivity cardiac troponin T (hs-cTnT) concentration and frailty in a cohort of elderly patients undergoing emergency abdominal surgery. We included consecutive patients ≥75 years of age who presented for emergency abdominal surgery, defined as abdominal pathology requiring surgery within 72 hours, in a university hospital in Norway. Patients who underwent vascular procedures or palliative surgery for inoperable malignancies were excluded. Preoperatively, frailty was assessed using the Clinical Frailty Scale (CFS), and blood samples were measured for hs-cTnT. We evaluated the predictive power of CFS and hs-cTnT concentrations using receiver operating characteristic (ROC) curves and Cox proportional hazard regression with 30-day mortality as the primary outcome. Secondary outcomes included (1) a composite of 30-day all-cause mortality and major adverse cardiac event (MACE), defined as myocardial infarction, nonfatal cardiac arrest, or coronary revascularization; and (2) 90-day mortality. Of the 210 screened and 156 eligible patients, blood samples were available in 146, who were included. Troponin concentration exceeded the 99th percentile upper reference limit (URL) in 83% and 89% of the patients pre- and postoperatively. Of the participants, 53% were classified as vulnerable or frail (CFS ≥4). The 30-day mortality rate was 12% (18 of 146). Preoperatively, a threshold of hs-cTnT ≥34 ng/L independently predicted 30-day mortality (hazard ratio [HR] 3.14, 95% confidence interval [CI], 1.13-9.45), and the composite outcome of 30-day mortality and MACE (HR 2.58, 95% CI, 1.07-6.49). In this model, frailty (continuous CFS score) also independently predicted 30-day mortality (HR 1.42, 95% CI, 1.01-2.00) and 30-day mortality or MACE (HR 1.37, 95% CI, 1.02-1.84). The combination of troponin and frailty, 0.14 × hs-cTnT +4.0 × CFS, yielded apparent superior predictive power (area under the receiver operating characteristics curve [AUC] 0.79, 95% CI, 0.68-0.88), compared to troponin concentration (AUC 0.69, 95% CI, 0.55-0.83) or frailty (AUC 0.69, 95% CI, 0.57-0.82) alone. After emergency abdominal surgery in elderly patients, increased preoperative troponin concentration and frailty were independent predictors of 30-day mortality. The combination of increased troponin concentration and frailty seemed to provide better prognostic information than troponin or frailty alone. These results must be validated in an independent sample.

Evaluating the performance of the HEART score in a Tanzanian emergency department.

The HEART score successfully risk stratifies emergency department (ED) patients with chest pain in high-income settings. However, this tool has not been validated in low-income countries. This is a secondary analysis of a prospective observational study that was conducted in a Tanzanian ED from January 2019 through January 2023. Adult patients with chest pain were consecutively enrolled, and their presenting symptoms and medical history were recorded. Electrocardiograms and point-of-care troponin assays were obtained for all participants. Thirty-day follow-up was conducted, assessing for major adverse cardiac events (MACEs), defined as death, myocardial infarction, or coronary revascularization (coronary artery bypass grafting or percutaneous coronary intervention). HEART scores were calculated for all participants. Likelihood ratios, sensitivity, specificity, and negative predictive values (NPVs) were calculated for each HEART cutoff score to predict 30-day MACEs, and area under the curve (AUC) was calculated from the receiver operating characteristic curve. Of 927 participants with chest pain, the median (IQR) age was 61 (45.5-74.0) years. Of participants, 216 (23.3%) patients experienced 30-day MACEs, including 163 (17.6%) who died, 48 (5.2%) with myocardial infarction, and 23 (2.5%) with coronary revascularization. The positive likelihood ratio for each cutoff score ranged from 1.023 (95% CI 1.004-1.042; cutoff ≥ 1) to 3.556 (95% CI 1.929-6.555; cutoff ≥ 7). The recommended cutoff of ≥4 to identify patients at high risk of MACEs yielded a sensitivity of 59.4%, specificity of 52.8%, and NPV of 74.7%. The AUC was 0.61. Among patients with chest pain in a Tanzanian ED, the HEART score did not perform as well as in high-income settings. Locally validated risk stratification tools are needed for ED patients with chest pain in low-income countries.

Early and Long-Term Clinical Outcomes of Ductal Stenting Versus Surgical Aortopulmonary Shunt Among Young Infants with Duct-Dependent Pulmonary Circulation.

Surgical aortopulmonary shunting (SAPS) and ductal stenting (DS) are the main palliations in infants with cyanotic congenital heart diseases (CHD). We aimed to study the safety and efficacy of DS and to compare it with SAPS as a palliative procedure in infants with CHD and duct-dependent pulmonary circulation. Retrospective institutional clinical data review of consecutive infants aged < 3months who underwent DS or SAPS over 5years. The primary outcome was procedural success which was defined as event-free survival (mortality, need for re-intervention, procedural failure) at 30days post-procedure. The secondary outcome was defined by a composite of death, major adverse cardiovascular events, or need for re-intervention at 6months and on long-term follow-up. We included 102 infants (DS, n = 53 and SAPS, n = 49). The median age at DS and SAPS was 4days (IQR 2.0-8.5) and 8days (IQR 4.0-39.0), respectively. The median weight at intervention was 3.0kg (IQR 3.0-3.0) and 3.0kg (IQR 2.5-3.0) in the two respective arms. Tetralogy of Fallot with pulmonary atresia was the most common indication for DS and SAPS. The 30-day mortality was significantly higher in SAPS group as compared with DS group (p < 0.05). However, 30-day major adverse cardiac events (MACE) rates were similar in both groups (p = 0.29). DS was associated with shorter duration of mechanical ventilation, duration of stay in the intensive care and hospital stay than with SAPS. At 6months, there was no significant difference in terms of mortality or event-free survival. Long-term MACE-free survival was also comparable (p = 0.13). DS is an effective and safer alternative to SAPS in infants with duct-dependent pulmonary circulation, offering reduced procedure-related mortality and morbidity than SAPS. Careful study of ductal anatomy is crucial to procedural success. However, long-term outcomes are similar in both procedures.

Sex-disparities in chest pain workup: a retrospective cohort review of a university based clinical decision pathway

BackgroundFemales have historically lower rates of cardiovascular testing when compared to males. Clinical decision pathways (CDP) that utilize standardized risk-stratification methods may balance this disparity. We sought to determine whether clinical decision pathways could minimize sex-based differences in the non-invasive workup of chest pain in the emergency department (ED). Moreover, we evaluated whether the HEART score would minimize sex-based differences in risk-stratification.MethodsWe conducted a retrospective cohort review of adult ED encounters for chest pain where CDP was employed. Primary outcome was any occurrence of non-invasive imaging (coronary CTA, stress imaging), invasive testing, intervention (PCI or CABG), or death. Secondary outcomes were 30-day major adverse cardiac events (MACE). We stratified HEART scores and primary/secondary outcomes by sex.ResultsA total of 1078 charts met criteria for review. Mean age at presentation was 59 years. Females represented 47% of the population. Low, intermediate, and high-risk patients as determined by the HEART score were 17%, 65%, and 18% of the population, respectively, without any significant differences between males and females. Non-invasive testing was similar between males and females when stratified by risk. Males categorized as high risk underwent more coronary angiogram (33% vs. 16%, p = 0.01) and PCI (18% vs. 8%, p = 0.04) than high risk females, but this was not seen in patients categorized as low or intermediate risk. Males experienced more MACE than females (8% vs. 3%, p = 0.001).ConclusionsWe identified no sex-based differences in risk-stratification or non-invasive testing when the CDP was used. High risk males, however, underwent more coronary angiogram and PCI than high risk females, and consequently males experienced more overall MACE than females. This disparity may be explained by sex-based differences in the pathophysiology driving each patient’s presentation.

Systematic review of risk factors and outcomes of post-implantation syndrome following endovascular aortic repair

ObjectivePost implantation syndrome (PIS) is an early systemic inflammatory response following endovascular aortic repair (EVAR). The response is variable in patients and the clinical significance of PIS upon outcomes is unknown. This study aims to evaluate the incidence, risk factors, and prognostic implication of PIS. MethodsSystematic literature review and analysis was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) and Cochrane guidelines of PubMed, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials. Eligible English-language studies regarding PIS after infrarenal EVAR were included, after removing duplicates. ResultsAfter screening, 31 studies were included. A total of 2847 patients were reviewed, with mean age of 70.7 years, of which 2012 (90.4%) were male, with a pooled mean follow-up of 26.1 months. PIS was reported in 25.3% of cases, with mean aneurysm diameter of 56.4 cm. Polytetrafluoroethylene (PTFE) grafts were utilized in 794 patients (27.9%) with polyester in 1839 (64.6%). White blood cell count, C-reactive protein, interleukin (IL)-6, IL-8, and IL-10 levels were all significantly elevated postoperatively. Thirty-day outcomes included type I endoleak rate of 0.8%, type II endoleak rate of 1.7%, reintervention rate of 0.35%, and mortality rate of 0.25%. Subgroup pooled analysis of patients with PIS (n = 309) vs No-PIS (n = 691) revealed that polyester (n = 642), rather than PTFE (n = 234) grafts, were associated with a higher rate of PIS (94.8% vs 3.7%; P = .0001), White blood cell count was higher in the PIS group both preoperatively (7.61 vs 6.76 × 109/L; P = .04) and postoperatively (15.0 vs 9.8 × 109/L; P = .0007) and IL-6 levels were higher in the PIS group postoperatively (98.6 vs 25.2 pg/mL; P = .02). Aneurysm diameter and amount of chronic or new thrombus within the aneurysm sac was not identified as a risk factor for PIS. Pooled outcomes of patients with PIS vs No-PIS demonstrated a significantly higher rate of 30-day mortality (0.6% vs 0%; P = .03) and major adverse cardiac events (5.8% vs 0.43%; P < .0001) without any differences seen in reintervention or 30-day type I or type II endoleaks. ConclusionsThis systematic review suggests that polyester grafts are strongly associated with PIS compared with PTFE. Interestingly, this report is suggestive of an association between 30-day mortality and major adverse cardiac events and PIS. Given these clinical sequelae, consideration for use of PTFE over polyester grafts to reduce the incidence of PIS may be a simple step to improve overall outcome. Further, exploration of the relationship between inflammatory mediators associated with PIS and mortality and cardiac complications may engender deeper understanding of risks, leading to eventual mitigation of harm for patients experiencing PIS.

ROMIAE (Rule-Out Acute Myocardial Infarction Using Artificial Intelligence Electrocardiogram Analysis) trial study protocol: a prospective multicenter observational study for validation of a deep learning-based 12-lead electrocardiogram analysis model for detecting acute myocardial infarction in patients visiting the emergency department.

Based on the development of artificial intelligence (AI), an emerging number of methods have achieved outstanding performances in the diagnosis of acute myocardial infarction (AMI) using an electrocardiogram (ECG). However, AI-ECG analysis using a multicenter prospective design for detecting AMI has yet to be conducted. This prospective multicenter observational study aims to validate an AI-ECG model for detecting AMI in patients visiting the emergency department. Approximately 9,000 adult patients with chest pain and/or equivalent symptoms of AMI will be enrolled in 18 emergency medical centers in Korea. The AI-ECG analysis algorithm we developed and validated will be used in this study. The primary endpoint is the diagnosis of AMI on the day of visiting the emergency center, and the secondary endpoint is a 30-day major adverse cardiac event. From March 2022, patient registration has begun at centers approved by the institutional review board. This is the first prospective study designed to identify the efficacy of an AI-based 12-lead ECG analysis algorithm for diagnosing AMI in emergency departments across multiple centers. This study may provide insights into the utility of deep learning in detecting AMI on electrocardiograms in emergency departments. Trial registration ClinicalTrials.gov identifier: NCT05435391. Registered on June 28, 2022.

Differences in risk and costs between prehospital identified low-risk men and women with chest pain

ObjectivePrehospital rule-out of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in low-risk patient with a point-of-care troponin measurement reduces healthcare costs with similar safety to standard transfer to the hospital. Risk...

Retrospective Multicenter Analysis of Intravascular Lithotripsy Use During Calcified Left Main Coronary Artery Percutaneous Coronary Interventions

BackgroundIntravascular lithotripsy (IVL) safely and effectively modifies calcified coronary lesions during percutaneous coronary interventions (PCI). Data regarding its utility in modifying calcified left main coronary artery (LMCA) disease are limited. This study aimed to evaluate short-term outcomes of IVL-assisted LMCA PCI. MethodsThis retrospective multicenter all-comers study analyzed patients who underwent intravascular imaging-guided, IVL-assisted PCI for calcified LMCA disease. Clinical and procedural characteristics were obtained, including intravascular imaging measurements. Technical success was defined as successful stent deployment with <30% residual diameter stenosis. Major adverse cardiac events (MACE) was a composite of all-cause death, myocardial infarction, and target vessel revascularization evaluated immediately postprocedure and at 30-day follow-up. ResultsAmong 184 patients treated at 7 centers from 2019-2023, IVL-assisted LMCA PCI achieved 99.4% technical success. Calcium fracture was identified in 136/165 cases (82.4%) on post-IVL imaging. Pretreatment minimal luminal area increased significantly compared to post-PCI minimal stent area (MSA) (4.1 ± 1.3 to 9.3 ± 2.5 mm2, respectively; P < .001). There was a direct correlation between IVL balloon size and the final MSA (P = .002). In-hospital MACE was 4.4% and 30-day MACE was 8.8%. In multivariate logistic regression, presentation with troponin-positive myocardial infarction was the sole predictor of 30-day MACE. ConclusionsIVL-assisted PCI for calcified LMCA lesions was safe and resulted in high technical success rates, confirming its utility as an effective treatment in this challenging lesion subset.

Machine learning-based prediction of 30-day major adverse cardiac and cerebrovascular events in non-cardiac surgery patients

Abstract Background The number of non-cardiac surgeries performed worldwide has been steadily increasing, presenting a challenge for clinicians to accurately identify patients at high risk of complications and to allocate the appropriate level of perioperative care. Accurate prediction of postoperative mortality is crucial not only for successful patient care, but also for information-based shared decision-making with patients and efficient allocation of medical resources. Purpose In this study, we aimed to develop a novel predictive model using machine learning methods applied to electronic health record data. Our objective is to identify the risk factors most likely to lead to 30-day major adverse cardiac and cerebrovascular events after non-cardiac surgery Methods We conducted a retrospective analysis of data from a single tertiary care institution that included patients aged 65 years or over who underwent non-cardiac surgery from May 2003 and December 2020. The Observational Medical Outcomes Partnership (OMOP) common data model (CDM) data was used to build predictive models, which allowed for the utilization of demographic data, as well as preoperative characteristics such as diagnosis, lab results, vital signs, medications, and information on operations and procedures from the electronic health records (EHRs) in a standardized way. We employed machine learning models, which were developed and validated using the OHDSI Patient-Level-Prediction framework. Results We included a total of 47,915 patients to train (75%) and test (25%) our predictive models. To compare prediction performances, we applied gradient boosting machine (GBM), logistic regression (LR), random forest (RF), AdaBoost (AB), and decision tree (DT). Our results for a test data (Fig 1.) showed that the GBM model had the best performance in terms of the area under the receiver operating characteristic curve (AUROC) (0.903) and the area under the precision-recall curve (AUPRC) (0.395). Conclusions Our study demonstrates that applying machine learning algorithms to electronic health record data can effectively identify patients at high risk of major adverse cardiac and cerebrovascular events following non-cardiac surgery. This algorithm has the potential to support clinicians in effectively identifying patients at high risk and provide appropriate perioperative care. Further work is needed to validate and refine the proposed model to ensure its external validity and broader applicability in clinical practice.We plan to validate the proposed model externally by testing it on a cohort of approximately 280,000 patients from other tertiary care institution, and present the results at the 2023 ESC Congress.

Clinical outcomes of renal transplant recipients undergoing percutaneous coronary intervention

Abstract Background Cardiovascular disease is the leading cause of mortality among renal transplant (RT) recipients. Despite this, the clinical outcomes of patients with RT undergoing percutaneous coronary intervention (PCI) remain poorly elucidated. Purpose This study compared characteristics and outcomes among three groups of patients undergoing PCI: (1) RT recipients, (2) patients receiving dialysis and (3) patients with stage 3 chronic kidney disease (CKD) (estimated glomerular filtration rate 30–59 ml/min/1.73m²) without previous RT. Methods Data were analyzed for consecutive patients undergoing PCI enrolled in a large, multicenter Australian registry between 2014 and 2021 stratified into RT (n=226), dialysis (n=992) and CKD (n=15,534) groups. The primary outcome was 30-day major adverse cardiac and cerebrovascular events (MACCE) (composite of mortality, myocardial infarction, stent thrombosis, target vessel revascularization and stroke). Long-term mortality was derived from linkage with the Australian National Death Index. Multivariable logistic and Cox regression were performed to assess the risk of 30-day MACCE and long-term mortality, respectively. Results RT recipients were younger compared to dialysis and CKD patients (61±10 vs 68±12 vs 78±8.2 years, p&amp;lt;0.001). The majority of patients were male: 72%, 76% and 61% in RT, dialysis, and CKD groups, respectively (p&amp;lt;0.001). RT patients had fewer comorbidities (diabetes mellitus, peripheral vascular disease and previous cerebrovascular events) than dialysis patients, however more than the CKD group (all p&amp;lt;0.001). Compared to dialysis and CKD groups, RT patients less frequently had severe left ventricular dysfunction (14% and 8.5% vs 6.7%), however more often presented with acute coronary syndrome (52% and 48% vs 58%), especially ST-elevation myocardial infarction (12% and 17% vs 20%) (all p&amp;lt;0.001). RT and CKD patients had lower rates of in-hospital mortality (2.7% and 3.8% vs 6.4%), target vessel revascularization (0.4% and 0.7% vs 1.7%) and 30-day MACCE (4.4% and 6.8% vs 11.6%) compared to the dialysis group (all p&amp;lt;0.001). Three-year survival was similar between RT and CKD groups, however lower in the dialysis group (80% and 83% vs 60%) (p&amp;lt;0.001) (Figure 1). After adjustment, dialysis at baseline was an independent predictor of 30-day MACCE (OR 1.90, 95% CI 1.44–2.50, p&amp;lt;0.001), however RT status was not (0.91, 0.42–1.96, p=0.802). In contrast, both RT status (HR 2.07, 95% CI 1.46–2.95, p&amp;lt;0.001) and dialysis at baseline (1.35, 1.02–1.80, p=0.036) conferred a heightened long-term hazard for mortality (Figure 2). Conclusions RT recipients have more favorable clinical outcomes following PCI compared to patients receiving dialysis. Nevertheless, despite having similar short-term outcomes to those with CKD, the hazard of long-term mortality is significantly greater for RT recipients. Close follow-up is warranted in this high-risk population.Figure 1Figure 2

STANLEy score: a new predictive model of 3-year major adverse cardiac events following "Full Metal Jacket" using new-generation drug-eluting stents

Abstract Introduction Percutaneous Coronary Intervention (PCI) using a "Full Metal Jacket" (FMJ) procedure (≥60 mm of continuous stent length) is often required to treat very long lesions, but its clinical efficacy and safety using contemporary drug-eluting stents (DES) remains to be determined. Objectives To identify predictors of major adverse cardiac events (MACE) associated with FMJ using new-generation DES. We sought to develop a simple model capable of accurately predict 3-year MACE following FMJ PCI. Methods A retrospective single-centre analysis of consecutive FMJ PCI performed between January 2015 and December 2018. Exclusion criteria were use of non-third generation DES, unsuccessful procedure and loss to follow-up. The primary endpoint was a composite of all-cause death, myocardial infarction, and target vessel revascularization. Demographic, clinical, angiographic, and procedural variables were evaluated. Logistic regression analysis was performed to determine independent predictors of outcome. Based on the results, a weighted scoring system was developed. Results The derivation cohort included 162 patients, mean age 65.9 ± 11.1 years, 83% male. The mean stent length was 73.8 ± 12.3 mm (range 60 to 116 mm), and the average number of stents was 2.74 ± 0.74 (range 2 to 5). 30-day, 1-year and 3-year MACE were 5.5%, 12.9% and 29.0%, respectively. Multivariate analysis identified diabEtes mellitus (hazard ratio (HR) 5.92; 95% confidence interval (CI) 1.57-11.54; p=0.011), Smoking habits (HR 8.37; 95%CI 3.05-15.55; p=0.001), Acute coronary syndrome (HR 3.51; 95%CI 1.030-8.98; p=0.045), Non-right coronary artery (HR 4.38; 95%CI 1.09-7.68; p=0.038), osTial lesion (HR 10.01; 95%CI 2.91-19.14; p=0.006) and severe caLcification (HR 8.59; 95%CI 2.65-15.72; p=0.001) as independent predictors of 3-year MACE. A composite score based on these 6 variables (STANLEy score) was created, ranging from 0 to 10 (Fig.1). High acuity was verified by ROC curve analysis (AUC 0.941, p &amp;lt;0.001). A score ≤ 3 was associated with a reduced probability (&amp;lt;15%) and a score ≥ 7 with high probability (&amp;gt;90%) of 3-year MACE. Conclusion The STANLEy score is a good predictive model which relies on 6 simple clinical and angiographic characteristics. This score may assist physicians in selecting high-risk patients for closer monitoring or aggressive antithrombotic strategy.Figure 1

Abstract 18145: Meta-Analysis Comparing Immediate and Staged Complete Revascularization for Multivessel Disease in Acute Coronary Syndrome Patients

Background: Acute coronary syndrome (ACS) patients undergoing PCI often have severe non-culprit vessel involvement known as multivessel disease (MVD), which is linked to worse outcomes. While guidelines recommend complete revascularization, the optimal timing is unclear. Comparing immediate vs. staged approaches is crucial to identify the optimal approach to revascularization. Research question: Do outcomes differ between immediate complete revascularization (ICRV) and staged complete revascularization (SCRV) in patients with ACS and MVD? Methods: PubMed, Cochrane library and Web of Science were searched for studies comparing immediate vs. staged complete revascularization for ACS and MVD. Randomized controlled trials (RCTs) and prospective studies reporting all-cause mortality, major adverse cardiac events (MACE), myocardial infarction (MI), and revascularization were included. Thirty-day and extended-term outcomes were evaluated, and risk ratios (RR) with 95% confidence intervals (CIs) were calculated using a random-effects model. Results: The meta-analysis comprised 6 RCTs and 5 prospective studies, involving 3,631 patients (ICRV: 1,728; SCRV: 1,903) presenting with ACS (ST-elevation MI (STEMI)=9, NSTEMI=1; Mixed=2). The mean age was 62.4 ± 9.4 years, with 79.5% male. The ICRV group exhibited significantly higher 30-day mortality (RR: 2.19 [1.31-4.06], p=0.004), while the SCRV group had higher revascularization rates at 30 days and extended term (RR: 0.27 [0.10-0.69], p=0.007 and RR: 0.68 [0.48-0.96], p=0.03, respectively). No significant difference was found in 30-day and extended-term MACE and MI between the ICRV and SCRV groups. Conclusion: Although there was no significant difference in overall MACE between the two complete revascularization strategies for patients with ACS and MVD, the SCRV group showed lower 30-day all-cause mortality, while the ICRV group demonstrated a lower incidence of revascularization rates.

Traditional Chinese Medicine Compound (Tongxinluo) and Clinical Outcomes of Patients With Acute Myocardial Infarction

Tongxinluo, a traditional Chinese medicine compound, has shown promise in in vitro, animal, and small human studies for myocardial infarction, but has not been rigorously evaluated in large randomized clinical trials. To investigate whether Tongxinluo could improve clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). Randomized, double-blind, placebo-controlled clinical trial was conducted among patients with STEMI within 24 hours of symptom onset from 124 hospitals in China. Patients were enrolled from May 2019 to December 2020; the last date of follow-up was December 15, 2021. Patients were randomized 1:1 to receive either Tongxinluo or placebo orally for 12 months (a loading dose of 2.08 g after randomization, followed by the maintenance dose of 1.04 g, 3 times a day), in addition to STEMI guideline-directed treatments. The primary end point was 30-day major adverse cardiac and cerebrovascular events (MACCEs), a composite of cardiac death, myocardial reinfarction, emergent coronary revascularization, and stroke. Follow-up for MACCEs occurred every 3 months to 1 year. Among 3797 patients who were randomized, 3777 (Tongxinluo: 1889 and placebo: 1888; mean age, 61 years; 76.9% male) were included in the primary analysis. Thirty-day MACCEs occurred in 64 patients (3.4%) in the Tongxinluo group vs 99 patients (5.2%) in the control group (relative risk [RR], 0.64 [95% CI, 0.47 to 0.88]; risk difference [RD], -1.8% [95% CI, -3.2% to -0.6%]). Individual components of 30-day MACCEs, including cardiac death (56 [3.0%] vs 80 [4.2%]; RR, 0.70 [95% CI, 0.50 to 0.99]; RD, -1.2% [95% CI, -2.5% to -0.1%]), were also significantly lower in the Tongxinluo group than the placebo group. By 1 year, the Tongxinluo group continued to have lower rates of MACCEs (100 [5.3%] vs 157 [8.3%]; HR, 0.64 [95% CI, 0.49 to 0.82]; RD, -3.0% [95% CI, -4.6% to -1.4%]) and cardiac death (85 [4.5%] vs 116 [6.1%]; HR, 0.73 [95% CI, 0.55 to 0.97]; RD, -1.6% [95% CI, -3.1% to -0.2%]). There were no significant differences in other secondary end points including 30-day stroke; major bleeding at 30 days and 1 year; 1-year all-cause mortality; and in-stent thrombosis (<24 hours; 1-30 days; 1-12 months). More adverse drug reactions occurred in the Tongxinluo group than the placebo group (40 [2.1%] vs 21 [1.1%]; P = .02), mainly driven by gastrointestinal symptoms. In patients with STEMI, the Chinese patent medicine Tongxinluo, as an adjunctive therapy in addition to STEMI guideline-directed treatments, significantly improved both 30-day and 1-year clinical outcomes. Further research is needed to determine the mechanism of action of Tongxinluo in STEMI. ClinicalTrials.gov Identifier: NCT03792035.

Multicenter analysis to assess risk of major adverse cardiac events in patients undergoing high-sensitivity troponin testing in the emergency department.

Our objective was to evaluate 30-day major adverse cardiac events (MACE) in emergency department (ED) patients with normal high-sensitivity troponins (hs-trop). We hypothesized that MACE rates would be<1% in patients with (1) two normal troponins regardless of change in troponin (delta) and (2) index hs-trop below the limit of quantitation (LOQ) regardless of the institution modified HEART score. This was a multicenter, retrospective, cohort study of adult patients who presented to 1 of 18 EDs between July 2020 and April 2021 with acute coronary syndrome as defined by an institutional-modified HEART score completed by their treating physician or midlevel, no evidence of ST-elevation myocardial infarction, and an index or serial gender-adjusted hs-trop within normal limits. The primary outcome was MACE within 30 days of index ED encounter. A detailed case review was then performed for those patients experiencing a MACE. Of the 9084 patients who had single or serial normal troponins, 31 (0.34%; confidence interval [CI] 0.23%-0.48%) experienced MACE. Of the 6140 patients with 2 normal hs-trop and a delta (change in troponin)<4, 27 patients (0.44%; CI 0.29%-0.64%) experienced MACE. Only 1 of the 69 patients with 2 normal hs-trop results but delta (change in troponin) ≥ 4 (1.45%; CI 0.04%-7.81%) suffered MACE. This patient was classified as non-low risk by our institutional HEART score. Of 7498 patients with an index hs-trop<LOQ, 14 (0.19%; CI 0.10%-0.31%) experienced MACE, with 57% (N=8) deemed non-low risk by HEART score. Patients with 2 normal hs-trop values in the ED are unlikely to suffer 30-day MACE. Although it remains unclear whether patients with delta (change in troponin) ≥4 despite normal troponins will have a 30-day MACE, this situation is rare. Additionally, a single index hs-trop<6ng/L demonstrated a low risk for 30-day MACE independent of the institutional HEART score.

Predictors of Adverse Outcome in High-Risk Percutaneous Coronary Interventions Patients.

Identifying high-risk percutaneous coronary intervention (PCI) patients is challenging. We aimed to evaluate which high-risk patients are prone to adverse events. We performed a retrospective study including consecutive high-risk PCIs from 2005 to 2018 in a large tertiary medical centre. Patients with unprotected left main (LM) disease, last patent coronary vessel, or 3-vessel coronary artery disease with left ventricular ejection fraction < 35% were included. A predictive 30-day major adverse cardiac events (MACE) score consisting of any myocardial infarction, all-cause death, or target-vessel revascularisation was constructed. From 2005 to 2018, a total of 1890 patients who underwent PCI met the predefined high-risk PCI criteria. Mortality rate was 8.8% at 30 days and 20.7% at 1 year, and 30-day MACE rate was 14.2% and 33.5% at 1 year. Predictors of short-term MACE were New York Heart Association functional class (NYHA) 4 (hazard ratio [HR] 6.65; P<0.001), systolic blood pressure (SBP) < 90 mm Hg (HR 4.93; P<0.001), creatinine > 1.3 mg/dL (HR 3.57; P< 0.001), hemoglobin< 11.0 g/dL (HR 3.07; P < 0.001), pulmonary artery systolic pressure> 50 mm Hg (HR 2.06; P<0.001), atrial fibrillation (HR 1.74; P<0.001), and LM disease (HR 2.04; P<0.001) or last patent vessel (HR 1.70; P= 0.002). A score constructed from these parameters reached a sensitivity of 90% and a specificity of 81% with areas under the receiver operating characteristic curve of 0.92 for MACE and 0.94 with 89% sensitivity and 87% specificity for all-cause mortality. Specific features such as LM lesion or last patent conduit, pulmonary hypertension, atrial fibrillation, anemia, and renal failure, along with low SBP and NYHA 4, aid risk stratification and consideration of further treatment measures.