30-day Major Adverse Cardiovascular Events Research Articles

The correlation between severe asymptomatic carotid artery stenosis and severe multi-organ dysfunction after off-pump coronary artery bypass grafting.

The current research aimed to demonstrate the independent association between preoperative severe asymptomatic carotid artery stenosis (ACAS) and severe multi-organ dysfunction after off-pump coronary artery bypass grafting (OPCAB), which may further indicate the relationship between severe ACAS and adverse 30-day postoperative outcomes of patients undergoing OPCAB. This was a single-center, retrospective observational study including patients without a history of stroke or Transient Ischemic Attacks (TIA) (asymptomatic), who underwent for an isolated OPCAB in the center for operative treatment of coronary artery disease of Beijing Anzhen Hospital from January 2020 to December 2021. All enrolled patients underwent carotid artery ultrasound prior to OPCAB. The information was extracted independently by two authors of the study from the medical records. Both univariate and multivariate analyses were conducted. A total of 562 patients met the inclusion criteria for the current study. 63 (11.2%) suffered from severe ACAS. The Sequential Organ Failure Assessment (SOFA) maximum in the severe ACAS group was significantly higher than that in the non-severe ACAS group (9.76 ± 3.03 vs. 7.75 ± 2.96, p < 0.0001), and a higher proportion of patients in the severe ACAS group exhibited severe multi-organ dysfunction (44.4% vs. 14.0%, p < 0.0001). In addition, severe ACAS was related to an increased rate of 30-day postoperative major adverse cardiovascular and cerebral events (MACCEs), including a 30-day postoperative stroke. Severe ACAS was associated with an elevated risk of delirium, and acute kidney injury (AKI). The results of the multivariate analysis demonstrated that severe ACAS may be independently associated with severe multi-organ dysfunction (OR, 7.37, 95% CI 4.80-14.30, p < 0.0001) after OPCAB. Also, severe ACAS may be independently associated with 30-day postoperative stroke (OR, 2.83, 95% CI 1.03-7.75, p = 0,043). Severe ACAS was independently associated with severe multi-organ dysfunction after OPCAB, which may be associated further with an increased rate of 30-day postoperative mortality and complications. This study highlights: (1) the importance of personalized assessment for potential advantages and disadvantages in prognosis of severe ACAS patients undergoing OPCAB with carotid endarterectomy; (2) the role of multi-organ parameters, especially cardio-cerebral factors, should be emphasized during the process of severe ACAS management.

Abstract 4119992: 12-lead electrocardiograms predict adverse cardiovascular outcomes of emergency department patients

Introduction: Chest pain is a common cause for presentation to the emergency department (ED). Identifying patients at increased risk of adverse cardiovascular outcomes may help guide testing. Aims: We sought to determine if deep learning enabled 12-lead electrocardiogram (ECG) analysis may improve prediction of adverse cardiovascular outcomes of ED patients presenting with chest pain compared to conventional approaches. Methods: A pretrained convolutional neural network was applied to derive numerical representations of the index ECG waveforms from patients presenting to the Brigham and Women’s Hospital (BWH) ED with chest pain. We trained a neural network model (‘CP-AI’) to predict 30-day major adverse cardiovascular events (MACE) defined as myocardial infarction (MI), pulmonary embolism (PE), aortic dissection (AD), or mortality using age, sex, cardiac biomarkers (troponin and d-dimer), and the numerical ECG representations as inputs ( Figure 1 ). In a holdout sample of Massachusetts General Hospital (MGH) ED patients, we compared the performance of the CP-AI model to alternative models fit on (1) demographics (‘Age and Sex’) (2) demographics + cardiac biomarkers (‘Biomarker Model’), and (3) demographics + numerical ECG representations (‘ECG Model’). Results: The BWH derivation sample included 18,811 individuals (51% female, mean age 65 ± 16 years). The MGH validation sample included 14,476 individuals (45% female, mean age 65 ± 15 years). The CP-AI model significantly outperformed the comparison models for prediction of 30-day MACE with an area under the receiver operating characteristic curve (AUROC) of 0.82 [95% CI 0.81-0.83] ( Figure 1 ). CP-AI also significantly outperformed the comparison models for classification of the 30-day MACE components including MI (AUROC 0.91 [95% CI 0.90-0.92]), PE (AUROC 0.74 [95% CI 0.72-0.76]), and mortality (AUROC 0.86 [95% CI 0.85-0.87]), but not aortic dissection (0.71 [95% CI 0.68-0.75]). Conclusions: The integration of deep learning ECG analysis with conventional assessment improved prediction of adverse cardiovascular of ED patients presenting with chest pain.

Abstract 4117834: Utility of Abdominal Aortic Calcification Assessment for the Prediction of Major Adverse Cardiovascular Events in Liver Transplant Patients

Background: Cardiovascular disease is a leading cause of postoperative morbidity and mortality following liver transplantation (LT). Presence of abdominal aortic calcification (AAC) has been linked to cardiovascular events in the general population. We investigated whether AAC on pre-transplant computed tomography (CT) predicts major adverse cardiovascular events (MACE) post-LT. Methods: Consecutive LT patients between 2010-2018 from the Victorian Liver Transplant Unit (Australia) were included. Extent of AAC was quantified in a blinded fashion, with high AAC defined as a calcium score of ≥500. MACE was defined as any recorded episodes of acute coronary syndrome (ACS), ventricular arrhythmia, decompensated heart failure, or stroke. The primary outcome was post-LT MACE at 30 days and the secondary outcome was all-cause mortality at maximal follow-up. Results: Of 461 patients undergoing LT, 350 had suitable CTs for analysis, of which 90 (25.7%) had also undergone CT coronary angiography. High AAC was identified in 98 patients (28.0%). This finding demonstrated a moderate correlation with high coronary artery calcium score (CACS) ≥400 (r=0.52, p&lt;0.001). Fifty-eight MACE occurred in 42 patients (12.0%) within 30-days. High AAC was associated with increased risk of 30-day MACE (OR=2.68 (95%CI 1.39-5.17), p=0.004), and long-term mortality (HR=2.52 (95%CI 1.29-4.92), p=0.007) at a median follow-up of 4.0 years. In addition, high AAC predicted an increased risk of ACS (OR 3.80 (95%CI 1.18-12.27), p=0.025), heart failure (OR 3.07 (95%CI 1.21-7.80), p=0.020) and atrial fibrillation (OR 2.04 (95%CI 1.02-4.07), p=0.048), with a trend to increased prevalence of ventricular arrhythmia (OR 2.67 (95%CI 0.84-8.50), p=0.10). Following multivariate analysis, high AAC remained a strong independent predictor of MACE (OR=3.49, 95%CI 1.21-10.06, p=0.021). Addition of AAC to the revised cardiac risk index (RCRI) improved model fit for predicting MACE (net reclassification improvement of 52.7% (p&lt;0.001)). Conclusions: This study demonstrates for the first time that high AAC on routine abdominal CT scans is associated with a 3-fold increased risk of 30-day MACE post-LT, and improves cardiovascular risk prediction compared to traditional risk scores. Quantification of AAC may offer a simple method of improving cardiovascular risk assessment and implementation of preventative strategies in liver transplant patients, using pre-existing scans without additional cost or patient risk.

Impact of comorbid coronary artery disease on short and medium-term outcomes after carotid artery stenting

Abstract Background Current recommendations acknowledge carotid artery disease as a clinical criteria for very high cardiovascular risk and carotid artery stenting (CAS) as one of the main therapeutic options for carotid artery stenosis. Carotid artery disease is often present in patients with coronary artery disease (CAD), presumably enhancing the cardiovascular risk of these patients. In this study, we aimed to appraise the prevalence and prognostic effects of comorbid CAD diagnosis in patients with significant carotid artery disease undergoing CAS. Methods We conducted a single-center retrospective analysis including consecutive patients that underwent CAS, between January 2007 and August 2023. Our main objective was to analyze the association of comorbid CAD in patients undergoing CAS, regarding 30-day major adverse cardiovascular events (MACE), 30-day global mortality, 1-year global mortality and major periprocedural complications. On a second perspective, we strived to identify if there was any modifiable factor that influenced worse outcomes in these populations, addressed by a Chi-Square Test. Data was collected by the medical team in our Centre, over the years of follow-up. Results A total of 380 patients were enrolled in this study, with a mean age of 72.1±8.3 years and no major differences concerning demographic characteristics. Based on the presence of previous CAD diagnosis, there was no statistical significance in 30-days MACE (p=0.442), 30-days global mortality (p=0.161), 1-year mortality (p=0.658) or periprocedural complications (p=0.062). Despite these results, there was a statistically significant difference in individuals with CAD and comorbid hypertension in 30-days CV death (p=0.002), 30-days global mortality (p=0.007) and 1-year global mortality (p=0.036). Conclusions Comorbid CAD in patients undergoing CAS due to carotid stenosis does not seem to be significantly associated with medium-term adverse events. Nevertheless, the results of this casuistry support the importance of rigorous blood pressure control in patients with significant carotid artery disease.Baseline CharacteristicsStudy outcomes

An artificial intelligence-enabled electrocardiogram model outperforms the revised cardiac risk index score for predicting major adverse cardiovascular events in patients undergoing noncardiac surgery

Abstract Background Existing clinical preoperative risk assessment tools such as the Revised Cardiac Risk Index (RCRI) have been used extensively to predict perioperative major adverse cardiovascular events (MACE). Electrocardiogram (ECG) analysis using Deep Learning can identify hidden features that human eyes cannot identify and might help further risk stratify patients undergoing noncardiac surgery. Objective We aimed to develop a Deep Learning model that predicts perioperative MACE in patients undergoing elective noncardiac surgeries. Methods We included patients ≥ 18-year-old who underwent elective non-cardiac surgery between 2000-2021. MACE was validated in duplicate and were defined as a composite of in-hospital myocardial infarction, cardiac arrest or mortality. A convolutional neural network was developed using ECGs within 30 days before surgery. We randomly split subjects into training, internal validation, and testing datasets in a 7:1:2 ratio. Performance was evaluated using the area under the receiver operator characteristics curve (AUC) values on the testing dataset. Models trained included AI-ECG models to predict in-hospital MACE and to predict in-hospital mortality, and AI-ECG+RCRI models to predict in-hospital MACE and to predict in-hospital mortality. All models were validated using 30-day validated outcomes (MACE or all-cause mortality) in a community-based cohort and were compared with the Revised Cardiac Risk Index (RCRI) score using AUC values. Findings: We included 195,214 patients who underwent a total of 241,999 surgeries. 169,214 ECGs were used in the training dataset, 24,234 in the internal validation dataset, and 48,551 in the testing dataset. In the test cohort, the AI-ECG algorithm discriminated risk for in-hospital MACE with an AUC of 0.82 (95% CI 0.79-0.85). The algorithm similarly discriminated 30-day MACE with an AUC value of 0.79 (95% CI 0.77-0.81) surpassing the discrimination of the RCRI score AUC of 0.69 (95% CI 0.66-0.72). All models’ performances are shown in Figure1A. The AI-ECG model to predict in-hospital mortality had an AUC of 0.83 (95% CI 0.80-0.86) and predicted 30-day mortality with an AUC of 0.80 (95% CI 0.77-0.82). Other models’ performances are shown Figure1B. Training the AI-ECG models including RCRI data did not improve the AI-ECG models’ performance. Conclusion AI-ECG models with no additional clinical data can improve perioperative risk prediction in non-cardiac surgery, outperforming a conventional and widely used risk stratification tool such as the RCRI.

Impact of admission glucose and 30-day major adverse cardiovascular events on patients with chest pain in an emergency setting: insights from the China EMPACT registry.

Although the association between admission glucose (AG) and major adverse cardiac events (MACE) is well-documented, its relationship with 30-day MACE in patients presenting with cardiac chest pain remains unclarified. In light of this, this study aims to examine the correlation between AG levels and the incidence of MACE in patients with chest pain in an emergency setting. We consecutively enrolled patients who presented to the emergency department for chest pain symptoms within 24 h from the EMPACT cohort in Eastern China (clinicaltrials.gov, Identifier: NCT02536677). The primary outcome was 30-day MACE, including all-cause death, recurrent myocardial infarction, urgent target vessel revascularization, stroke, cardiogenic shock, and cardiac arrest (CA). The associations of AG levels with 30-day MACE were analyzed using Kaplan-Meier analysis and Cox regression models. Among 1,705 patients who were included in this study, 154 (9.03%) patients met the primary outcome at 30 days. The average age of the patients was 65.23 ± 12.66 years, with 1,028 (60.29%) being male and 500 (29.33%) having diabetes. The median AG levels were 7.60 mmol/L (interquartile range: 6.30-10.20). Kaplan-Meier survival analysis revealed significant differences in the 30-day MACE risk (P < 0.001 according to the log-rank test). We found that the highest AG level (Q4) was associated with increased MACE risk compared with the lowest AG level [adjusted hazard radio (aHR): 2.14; 95% confidence interval (CI): 1.2-3.815; P = 0.010]. In addition, Q4 level was also associated with increased all-cause death risk (aHR: 3.825; 95% CI: 1.613-9.07; P = 0.002) and increased CA risk (aHR: 3.14; 95% CI: 1.251-7.884; P = 0.015). An elevated AG level significantly correlates with a higher incidence of 30-day MACE in patients with acute chest pain. The findings reveal the importance of managing AG levels to potentially reduce the risk of adverse cardiac events.

Outcomes of Patients Undergoing Elective Cancer Surgery After SARS-CoV-2 Infection: An Observational Cohort Study.

We evaluated the impact of preoperative SARS-CoV-2 infections on postoperative outcomes among patients undergoing elective cancer surgery. This ambidirectional (retrospective and prospective) study was conducted among patients undergoing elective cancer surgery between December 2022 and March 2023. Patients with different time intervals between SARS-CoV-2 infection and surgery (0-6 weeks and ≥7 weeks) were compared with those without SARS-CoV-2 infection. The primary outcome was 30-day postoperative pulmonary complications (PPCs). Secondary outcomes included 30-day postoperative mortality, major adverse cardiovascular events (MACE), and other postoperative adverse outcomes. Of the 830 patients analyzed, 239 (28.8%) had SARS-CoV-2 infection 0-6 weeks before cancer surgery, and they had a higher incidence of PPCs (4.6% in no SARS-CoV-2 infection, 12.1% in 0-6 weeks, and 5.1% in ≥7 weeks, p = 0.001). The logistic regression model revealed that, compared with patients without SARS-CoV-2 infection, surgery performed 0-6 weeks after SARSCoV-2 infection was associated with a higher risk of PPCs (adjusted odds ratio [aOR] 2.83; 95% confidence interval [CI] 1.34-5.98), and surgery performed ≥7 weeks after SARSCoV-2 infection was associated with a similar risk of PPCs (aOR 1.19; 95% CI 0.54-2.64). However, preoperative SARS-CoV-2 infection was not associated with a risk of 30-day postoperative mortality, MACE, or other adverse postoperative outcomes. In patients with preoperative Omicron variant infection, nonemergency cancer surgery can be scheduled ≥7 weeks after the infection to decrease the risk of PPCs, but it can be advanced if the risk of delay exceeds the risk of proceeding with the surgery.

Temporal trends in the treatment and outcome of nonagenarians with acute coronary syndrome.

Nonagenarians are a fast-growing age group among acute coronary syndrome (ACS) patients. While new therapeutic options have improved outcomes of ACS patients, data regarding very elderly ACS patients are limited. We aimed to evaluate temporal trends in the treatment and outcomes of nonagenarian ACS patients. Included were ACS patients aged below 90 years enrolled in ACS Israeli Survey. Patients were divided into two groups according to enrolment period: early (2000-2010) and recent (2012-2021). The primary endpoints were 30-day major adverse cardiovascular events and all-cause mortality. Secondary outcomes included in-hospital and 1-year all-cause mortality. Included were 316 elderly ACS patients. Of them, 184 were enrolled in the early and 132 in recent surveys. Patients enrolled in the recent period were more commonly referred for an invasive strategy and more commonly received guideline-based medical therapy. All-cause mortality at 30 days was significantly lower in the recent group compared with the early group (12.5 and 26.1%, respectively, P = 0.005). Rates of 30-day major adverse cardiovascular events were also significantly lower in the recent group (21.9 and 35.9%, respectively, P = 0.012). Patients in the recent group received more aggressive medical therapy in discharge but at 30-day follow-up, no difference in medical treatment was observed in the two groups. There were no significant differences in 1-year mortality rates. Treatment of nonagenarians with ACS has improved over the past decade. Treatment improvement was associated with a significant improvement in 30-day outcomes without any effect in 1 year. Nevertheless, even with contemporary treatment, nonagenarians with ACS remain a high-risk group with high mortality rates.

Blood Urea Nitrogen to Left Ventricular Ejection Ratio as a Predictor of Short-Term Outcome in Acute Myocardial Infarction Complicated by Cardiogenic Shock

Introduction: Cardiogenic shock (CS) is the most critical complication after acute myocardial infarction (AMI) with mortality above 50%. Both blood urea nitrogen and left ventricular ejection fraction were important prognostic indicators. We aimed to evaluate the prognostic value of admission blood urea nitrogen to left ventricular ejection fraction ratio (BUNLVEFr) in patients with AMI complicated by CS (AMI-CS). Methods: 268 consecutive patients with AMI-CS were divided into two groups according to the admission BUNLVEFr cut-off value determined by Youden index. The primary endpoint was 30-day all-cause mortality and the secondary endpoint was the composite events of major adverse cardiovascular events (MACEs). Cox proportional hazard models were performed to analyze the association of BUNLVEFr with the outcome. Results: The optimal cut-off value of BUNLVEFr is 16.63. The 30-day all-cause mortality and MACEs in patients with BUNLVEFr≥16.63 was significantly higher than in patients with BUNLVEFr<16.63 (30-day all-cause mortality: 66.2% vs. 17.1%, p < 0.001; 30-day MACEs: 80.0% vs. 48.0%, p < 0.001). After multivariable adjustment, BUNLVEFr≥16.63 remained an independent predictor for higher risk of 30-day all-cause mortality (HR = 3.553, 95% CI: 2.125–5.941, p < 0.001) and MACEs (HR = 2.026, 95% CI: 1.456–2.820, p < 0.001). Subgroup analyses found that the effect of BUNLVEFr was consistent in different subgroups (all p-interaction>0.05). Conclusion: The admission BUNLVEFr provided important prognostic information for AMI-CS patients.

Gender differences in the management and outcomes of acute coronary syndrome in indians: A systematic review and meta-analysis

BackgroundGender differences in acute coronary syndrome (ACS) outcomes have been noted in global data, which however did not analyse Indian data. No prior systematic review and meta-analysis (SRM) has addressed this important aspect of gender bias in Indian women with ACS. Hence this SRM aimed to address this knowledge gap. MethodsElectronic databases were searched for studies in ACS comparing cardiovascular disease presentation, treatment received and outcomes in women and men from India. Primary outcomes were to evaluate gender-differences in 30-day death and major adverse cardiovascular events (MACE). Secondary outcomes were to evaluate gender-differences in presentation, management and mortality. The SRM is registered with PROSPERO (CRD42023477286). ResultsFrom initially screened 3753 articles, data from 9 studies (61,185 patients) were analysed. Women with ACS had higher prevalence of diabetes [Odds ratio (OR) 1.65(95%CI:1.33–2.04); p < 0.001; I2 = 95 %] and hypertension [OR2.06(95%CI:1.88–2.25); p < 0.001; I2 = 42 %]. Smoking was significantly lower in women [OR 0.05(95%CI:0.03–0.07); p < 0.001; I2 = 87 %]. Non-ST elevation myocardial infarction (NSTEMI) was significantly higher in women [OR 1.92(95%CI:1.66–2.21); p < 0.001; I2 = 0 %]. Diagnostic angiography [OR 0.64(95%CI:0.56–0.74); p < 0.001; I2 = 46 %] and percutaneous coronary interventions [OR0.71(95%CI:0.55–0.92); p = 0.01; I2 = 92 %] were significantly lower in women. Women had significantly higher 30-day mortality [Hazard ratio (HR)2.26(95%CI:2.01–2.55); p < 0.001; I2 = 6 %], 1-year mortality [HR2.41(95%CI:1.89–3.07); p < 0.001; I2 = 53 %], in-hospital death [HR1.88(95%CI:1.19–2.96); p = 0.007; I2 = 92 %], stroke [HR 1.84 (95%CI:1.34–2.52); p < 0.001; I2 = 0 %] and MACE outcomes [OR 2.05 (95%CI:1.78–2.35); p < 0.001]. Use of aspirin, clopidogrel, beta-blockers and nitrates were significantly lower in women. ConclusionOur study highlights worse outcomes in Indian women with ACS. Higher burden of diabetes and hypertension, decreased used of PCI and lesser aggressive pharmacotherapy may be some of the contributing factors.

Emergency Department Blood Pressure Treatment and Outcomes in Adults Presenting with Severe Hypertension.

Patients who present to the emergency department (ED) with severe hypertension defined as a systolic blood pressure (SBP) ≥180 millimeters of mercury (mm Hg) or diastolic (DBP) ≥120 (mm Hg) without evidence of acute end-organ damage are often deemed high risk and treated acutely in the ED. However, there is a dearth of evidence from large studies with long-term follow-up for the assessment of major adverse cardiovascular events (MACE). We conducted the largest study to date of patients presenting with severe hypertension to identify predictors of MACE and examine whether blood pressure at discharge is associated with heightened risk. We enrolled ED patients with a SBP of 180-220mm Hg but without signs of end-organ damage and followed them for one year. The primary outcome was MACE within one year of discharge. Secondarily, we performed a propensity-matched analysis to test whether SBP ≤160mm Hg at discharge was associated with reduced MACE at 30 days. A total of 12,044 patients were enrolled. The prevalence of MACE within one year was 1,865 (15.5%). Older age, male gender, history of cardiovascular disease, cerebrovascular disease, diabetes, smoking, presentation with chest pain, altered mental status, dyspnea, treatment with intravenous and oral hydralazine, and oral metoprolol were independent predictors for one-year MACE. Additionally, discharge with an SBP ≤160mm Hg was not associated with 30-day MACE-free survival after propensity matching (hazard ratio 0.99, 95% confidence interval 0.78-1.25, P = 0.92). One-year MACE was relatively common in our cohort of ED patients with severe hypertension without acute end-organ damage. However, discharge blood pressure was not associated with 30-day or one-year MACE, suggesting that BP reduction in and of itself is not beneficial in such patients.

P2Y12 adenosine receptor inhibitors preloading among patients with non-ST-elevation acute coronary syndromes; insights from a nationwide multicenter registry.

The safety and efficacy of treatment with P2Y12 adenosine-diphosphate receptor inhibitors (P2Y12-RI) before coronary angiography among patients with non-ST-segment elevation acute coronary syndromes (NSTEACS) are questionable. To assess the pretreatment rate with P2Y12-RI and its association with ischemic and bleeding risks among patients with NSTEACS. The study comprised patients with NSTEACS referred for coronary angiography and included in the Acute Coronary Syndrome Israeli Surveys between 2013 and 2021. Patients were divided into two groups according to the timing of P2Y12-RI loading concerning coronary angiography: pretreatment and posttreatment. The primary endpoints were 30-day major adverse cardiovascular events (MACE; composite of cardiovascular mortality, myocardial infarction, stroke, stent thrombosis, and urgent revascularization) and 1-year all-cause mortality. Of 3076 patients, 2423 (78.8%) received pretreatment with a P2Y12-RI, and 653 (21.2%) received P2Y12-RI posttreatment. Prasugrel and ticagrelor were used more in the posttreatment group compared to the pretreatment group (16% vs. 6% and 38% vs. 25%, respectively, p < 0.001 for both). No difference was observed in the rate of 30-day MACE comparing pretreatment and posttreatment (5.3% vs. 2.2%, respectively, p = 0.62). A sensitivity analysis of 30-day MACE among patients from the 2021 survey demonstrated similar results (2.5% in the posttreatment group vs. 8.0% in the pretreatment group, p = 0.13). There were no differences in 1-year all-cause mortality rates between the pretreatment and posttreatment groups (4.8% vs. 3.8%, p = 0.31). Among patients with NSTEACS referred for an invasive strategy, the P2Y12-RI posttreatment strategy was associated with similar 30-day and 1-year MACE as the pretreatment strategy. These large-scale, multicenter, real-world data provide reassurance on the safety and efficacy of delaying P2Y12-IR until after coronary stratification to improve clinical decision-making.

Cracking the Code of Coronary Calcium: One-year Clinical Outcomes of Intravascular Lithotripsy in All-comers and Two Complex Cohorts

Background: Severe coronary calcifications are commonly encountered in real-world populations and in left main (LM) disease, heightening complication risks including stent underexpansion. Although intravascular lithotripsy (IVL) appears safe, longer-term data in high-risk populations are lacking. The aim of this study was therefore to examine 1-year IVL outcomes for severely calcified lesions in two complex cohorts: LM stenosis and underexpanded stents (UES) during stent implantation. Methods: A registry study was carried out to examine major adverse cardiovascular events (MACEs) (MI, target vessel revascularisation [TVR], cardiac mortality). The LM and UES subgroups were compared with their counterparts in the non-LM and de novo lesion subgroups, respectively. Results: The study involved 102 participants (median age, 70 years, 68% male), and the cardiovascular burden was high (diabetes, 72%; dialysis, 18%; prior MI, 43%, median left ventricular ejection fraction, 45%). Many participants presented acutely (acute coronary syndrome, 36%; decompensated heart failure, 13%) and had complex anatomies (triple-vessel disease, 77%). The cardiovascular burden was higher in the LM and UES subgroups than in the non-LM and de novo lesion subgroups, but the rates of procedural complications and 30-day MACEs were low and were not significantly different. The 1-year MACE rate was higher in the LM group than in non-LM (29% versus 10%, p=0.042), but was non-significant after adjusting for baseline variables (OR 3.08; 95% CI [0.87–10.9]); the rates of 1-year MI, TVR and mortality did not differ from non-LM. In the UES group, 1-year MACE rate (17% versus 13%, p=0.500) was similar to that for de novo lesions. Conclusion: The preliminary data suggest that the use of IVL is reasonable when encountering stent underexpansion due to severe coronary calcifications during stent implantation. The 1-year MACE rate was higher in calcific LM stenosis, probably due to greater comorbidity burden and acute presentations.

Prognostic Value of the Advanced Lung Cancer Inflammation Index Ratio in Patients with Acute Myocardial Infarction Complicated by Cardiogenic Shock: A Cohort Study.

Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) carries a high mortality risk. Inflammation and nutrition are involved in the pathogenesis and prognosis of both AMI and CS. The advanced lung cancer inflammation index ratio (ALI) combines the inflammatory and nutritional status. Our present study aimed to explore the prognostic value of ALI in patients with CS following AMI. In total, 217 consecutive patients with AMI complicated by CS were divided into two groups based on the ALI admissions cut-off: 12.69 and 12.69. The primary endpoint of this study was 30-day all-cause mortality. The secondary endpoints were gastrointestinal hemorrhage and major adverse cardiovascular events (MACEs), including 30-day all-cause mortality, atrioventricular block, ventricular tachycardia/ventricular fibrillation, and nonfatal stroke. The association of ALI with the study endpoints was analyzed by Cox regression analysis. During the 30-day follow-up period after admission, 104 (47.9%) patients died and 150 (69.1%) suffered MACEs. The Kaplan-Meier analysis revealed significantly higher cumulative mortality and lower MACE rates in the low-ALI group compared to the high-ALI group (both log-rank p 0.001). The 30-day mortality rate was significantly higher in patients with ALI 12.69 compared to ALI 12.69 (72.1% vs. 22.6%; p 0.001). Furthermore, the incidence of MACEs was higher in patients with ALI 12.69 (85.6% vs. 51.9%; p 0.001). The receiver operating curve showed that ALI had a modest predictive value (area under the curve [AUC]: 0.789, 95% confidence interval [CI]: 0.729, 0.850). After multivariable adjustment, ALI 12.69 was an independent predictor for both 30-day all-cause mortality (hazard ratio [HR]: 3.327; 95% CI: 2.053, 5.389; p 0.001) and 30-day MACEs (HR: 2.250; 95% CI 1.553, 3.260; p 0.001). Furthermore, the addition of ALI to a base model containing clinical and laboratory data statistically improved the predictive value. Assessing ALI levels upon admission can provide important information for the short-term prognostic assessment of patients with AMI complicated by CS. A lower ALI may serve as an independent predictor of increased 30-day all-cause mortality and MACEs.

Cardiac arrest and cardiogenic shock complicating ST-segment elevation myocardial infarction in China: A retrospective multicenter study

BackgroundData on the effect of cardiac arrest (CA), cardiogenic shock (CS), and their combination on the prognosis of Chinese patients with ST-segment elevation myocardial infarction (STEMI) are limited. The present study sought to evaluate the clinical outcomes of STEMI complicated by CA and CS, and to identify the risk factors for CA or CS. MethodsThis study included 7468 consecutive patients with STEMI in China. The patients were divided into 4 groups (CA + CS, CA only, CS only, and No CA or CS). The endpoints were 30-day all-cause death and major adverse cardiovascular events. A Cox proportional hazards regression analysis was performed. ResultsCA, CS, and their combination were noted in 332 (4.4 %), 377 (5.0 %), and 117 (1.6 %) among all patients. During the 30-day follow-up, 817 (10.9 %) all-cause deaths and 964 (12.9 %) major adverse cardiovascular events occurred, and the incidence of all-cause mortality (3.6 %, 62.3 %, 74.1 %, 83.3 %) and major adverse cardiovascular events (5.4 %, 67.1 %, 75.0 %, and 87.2 %) significantly increased in the No CA or CS, CS only, CA only, and CA + CS groups, respectively. In the multivariate Cox regression models, compared with the No CA or CS group, the CA + CS, CA, and CS-only groups were associated with an increased risk of all-cause death and major adverse cardiovascular events. Patients with CA + CS had the highest risk of all-cause death (hazard ratio [HR], 25.259 [95 % confidence interval (CI) 19.221–33.195]) and major adverse cardiovascular events (HR 19.098, 95%CI 14.797–24.648). ConclusionsCA, CS, and their combination were observed in approximately 11 % of Chinese patients with STEMI, and were associated with increased risk for 30-day mortality and major adverse cardiovascular events in Chinese patients with STEMI.

Sex-Specific Troponin and Creatine Kinase Thresholds After Coronary Bypass Surgery

BackgroundThe impact of sex-differences on the release of cardiac biomarkers after coronary artery bypass grafting (CABG) remains unknown. The aim of our study was to (1) investigate the impact of sex-differences in cardiac biomarker release after CABG and (2) determine sex-specific thresholds for high-sensitivity cardiac troponin (hs-cTn) and creatine kinase-myocardial band (CK-MB) associated with 30-day major adverse cardiovascular events (MACE) and mortality. MethodsA consecutive cohort of 3687 patients, comprising 643 women (17.4%) and 3044 men (82.6%), undergoing CABG from 2008 to 2021 in 2 tertiary university centers with serial postoperative cTn and CK-MB measurement was analyzed. The composite primary outcome was MACE at 30 days. Secondary end points were 30-day mortality and 5-year mortality and MACE. Sex-specific thresholds for cTn and CK-MB were determined. ResultsLower levels of cTn were found in women after CABG (69.18 vs 77.57 times the upper reference limit [URL]; P < .001). The optimal threshold value for cTn was calculated at 94.36 times the URL for female patients and 206.07 times the URL for male patients to predict 30-day MACE. Female patients missed by a general threshold had increased risk for MACE or death within 30 days (cTn: MACE: odds ratio [OR], 3.78; 95% CI, 1.03-13.08; P = .035; death: OR, 4.98; 95% CI, 1.20-20.61; P = .027; CK-MB: MACE: OR, 10.04; 95% CI, 2.07-48.75; P < .001; death: OR 13.59; 95% CI, 2.66-69.47; P = .002). ConclusionsWe provide evidence for sex-specific differences in the outcome and biomarker release after CABG. Sex-specific cutoffs are necessary for the diagnosis of perioperative myocardial injury to improve outcomes of women after CABG.

Effect of COVID-19 Pandemic Lockdown on Emergency Medical Service Utilisation, and Percutaneous Coronary Intervention Volume—An Australian Perspective

Acute coronary syndrome (ACS) admissions and percutaneous coronary intervention (PCI) volume declined during periods of COVID-19 lockdown internationally in 2020. The effect of lockdown on emergency medical service (EMS) utilisation, and PCI volume during the initial phase of the pandemic in Australia has not been well described. We analysed data from the Victorian Cardiac Outcomes Registry (VCOR), a state-wide PCI registry, linked with the Ambulance Victoria EMS registry. PCI volume, 30-day major adverse cardiovascular and cerebrovascular events (MACCE; composite of mortality, myocardial infarction, stent thrombosis, unplanned revascularisation, and stroke), and EMS utilisation were compared over four time periods: lockdown (26 Mar 2020-12 May 2020); pre-lockdown (26 Feb 2020-25 Mar 2020); post-lockdown (13 May 2020-10 Jul 2020); and the year prior (26 Mar 2019-12 May 2019). Interrupted time series analysis was performed to assess PCI trends within and between consecutive periods. The EMS utilisation for ACS during lockdown was higher compared with other periods: lockdown 39.4% vs pre-lockdown 29.7%; vs post-lockdown 33.6%; vs year prior 27.1%; all p<0.01. Median daily PCI cases were similar: 31 (IQR 10, 38) during lockdown; 39 (15, 49) pre-lockdown; 39.5 (11, 44) post-lockdown; and, 42 (10, 49) the year prior; all p>0.05. Median door-to-procedure time for ACS indication during lockdown was shorter at 3 hours (1.2, 20.6) vs pre-lockdown 3.9 (1.7, 21); vs post-lockdown 3.5 (1.5, 21.26); and, the year prior 3.5 (1.5, 23.7); all p<0.05. Lockdown period was associated with lower odds for 30-day MACCE compared to pre-lockdown (odds ratio [OR] 0.55 [0.33-0.93]; p=0.026); post-lockdown (OR 0.66; [0.40-1.06]; p=0.087); and the year prior (OR 0.55 [0.33-0.93]; p=0.026). Contrary to international trends, EMS utilisation for ACS increased during lockdown but PCI volumes remained similar throughout the initial stages of the pandemic in Victoria, with no observed adverse effect on 30-day MACCE during lockdown. These data suggest that the public health response in Victoria was not associated with poorer quality cardiovascular care in patients receiving PCI.

Post-Procedure Monocyte Count Levels Predict Major Adverse Cardiovascular Events (MACE) Following Transcatheter Aortic Valve Implantation (TAVI) for Aortic Stenosis

Aortic stenosis has recently been characterised as having an inflammatory aetiology, beyond the traditional degenerative model. Recruitment of monocytes has been associated with inflammation contributing to progression of calcific aortic-valve disease. Prior research has demonstrated that pre-procedure inflammatory biomarkers do not consistently discriminate poorer outcomes in those with aortic stenosis. It remains, however, unclear if postprocedure inflammatory biomarkers, which are influenced by intraprocedural pro-inflammatory insults, can predict major adverse cardiovascular events (MACE) post transcatheter aortic valve implantation (TAVI). All patients with postprocedure monocyte levels undergoing transcatheter aortic valve implantation at The Alfred Hospital, Melbourne, Australia (2008-2019) were included. The highest monocyte count from postprocedure days 1 to 3 was used. Patients were divided into "high" or "low" postprocedure monocyte count groups using the Youden Index. The incidence of 30-day MACE a composite of stroke, acute myocardial infarction, and death) was then compared. In total, 472 patients were included (54% men, median age 84 years). Fourteen (14) patients (3%) suffered a 30-day MACE. Those with high postprocedure monocyte count were more likely to: be hypertensive (p=0.049); have a higher Society of Thoracic Surgeons risk score (p=0.032); and, undergo non-transfemoral access (p=0.018). A high (≥0.975) postprocedure monocyte count was significantly associated with 30-day MACE (odds ratio [OR] 1.16 for each 0.1 increase in monocyte, p=0.025). This association remained present on multivariable analysis adjusted for age, sex, Society of Thoracic Surgeons risk score, and self-expanding valve prosthesis type (OR 1.17, p=0.028). The association between postprocedure monocytosis and 30-day MACE suggests that minimising peri-procedural inflammatory insults may improve outcomes. This inexpensive and readily available biomarker may also aid in tailored risk stratification for patients.

Percutaneous coronary intervention outcomes based on American College of Cardiology/American Heart Association coronary lesion classification over 14 years – Melbourne interventional group (MIG) registry

BackgroundThe American College of Cardiology / American Heart Association (ACC/AHA) introduced a coronary lesion classification in 1988 to stratify coronary lesions for probability of procedural success and complications after coronary angioplasty. Our aim is to assess the validity of the ACC/AHA lesion classification in predicting outcomes of percutaneous coronary intervention (PCI) in a contemporary cohort of patients. MethodsConsecutive PCI procedures performed between 2005 and 2018, were divided into three periods. At each period, the ACC/AHA lesion classification (A, B1, B2, C) was analysed with respect to procedural characteristics, in-hospital and 30-day outcomes, as well as long-term mortality by linkage to the National Death Index (NDI). ResultsIn total, 21,437 lesions were included with 7399 lesions (2005–2009), 6917 lesions (2010–2014) and 7121 lesions (2015–2018). There was a progressive increase in the number of complex lesions treated over time with ACC/AHA type C (15 %, 21 % and 26 %, p < 0.01). The rate of PCI procedural success decreased with increase in the complexity of lesions treated across all three periods (p < 0.01). Further, in-hospital and 30-day major adverse cardiovascular events (MACE), major adverse cardiac and cerebrovascular events (MACCE) increased across all three time periods (all p < 0.05). ConclusionsOur study validates the ACC/AHA lesion classification as a meaningful tool for prediction of PCI outcomes. Despite advances in PCI techniques and technology, complex lesion PCI defined by this classification continues to be associated with adverse outcomes.

Surgery or endovascular therapy for patients with chronic limb-threatening ischemia requiring infrapopliteal interventions

ObjectiveThe recent publication of randomized trials comparing open bypass surgery to endovascular therapy in patients with chronic limb-threatening ischemia, namely, Best Endovascular vs Best Surgical Therapy in Patients with Critical Limb Ischemia (BEST-CLI) and Bypass versus Angioplasty in Severe Ischaemia of the Leg-2 (BASIL-2), has resulted in potentially contradictory findings. The trials differed significantly with respect to anatomical disease patterns and primary end points. We performed an analysis of patients in BEST-CLI with significant infrapopliteal disease undergoing open tibial bypass or endovascular tibial interventions to formulate a relevant comparator with the outcomes reported from BASIL-2. MethodsThe study population consisted of patients in BEST-CLI with adequate single segment saphenous vein conduit randomized to open bypass or endovascular intervention (cohort 1) who additionally had significant infrapopliteal disease and underwent tibial level intervention. The primary outcome was major adverse limb event (MALE) or all-cause death. MALE included any major limb amputation or major reintervention. Outcomes were evaluated using Cox proportional regression models. ResultsThe analyzed subgroup included a total of 665 patients with 326 in the open tibial bypass group and 339 in the tibial endovascular intervention group. The primary outcome of MALE or all-cause death at 3 years was significantly lower in the surgical group at 48.5% compared with 56.7% in the endovascular group (P = .0018). Mortality was similar between groups (35.5% open vs 35.8% endovascular; P = .94), whereas MALE events were lower in the surgical group (23.3% vs 35.0%; P<.0001). This difference included a lower rate of major reinterventions in the surgical group (10.9%) compared with the endovascular group (20.2%; P = .0006). Freedom from above ankle amputation or all-cause death was similar between treatment arms at 43.6% in the surgical group compared with 45.3% the endovascular group (P = .30); however, there were fewer above ankle amputations in the surgical group (13.5%) compared with the endovascular group (19.3%; P = .0205). Perioperative (30-day) death rates were similar between treatment groups (2.5% open vs 2.4% endovascular; P = .93), as was 30-day major adverse cardiovascular events (5.3% open vs 2.7% endovascular; P = .12). ConclusionsAmong patients with suitable single segment great saphenous vein who underwent infrapopliteal revascularization for chronic limb-threatening ischemia, open bypass surgery was associated with a lower incidence of MALE or death and fewer major amputation compared with endovascular intervention. Amputation-free survival was similar between the groups. Further investigations into differences in comorbidities, anatomical extent, and lesion complexity are needed to explain differences between the BEST-CLI and BASIL-2 reported outcomes.