6-month Major Adverse Cardiovascular Events Research Articles

Effectiveness and safety of a novel intravascular lithotripsy system for severe coronary calcification: CALCI-CRACK trial.

Intravascular lithotripsy is effective and safe for managing coronary calcification; however, available devices are limited, and complex lesions have been excluded in previous studies. This study aimed to investigate the effectiveness and safety of a novel intravascular lithotripsy system for severe calcification in a population with complex lesions. CALCI-CRACK (ChiCTR2100052058) is a prospective, single-arm, multicenter study. The primary endpoint was the procedural success rate. Major safety endpoints included major adverse cardiovascular events (MACE) and target lesion failure (TLF) at 30 days and 6 months, and severe angiographic complications. Calcification morphology was assessed in the optical coherence tomography (OCT) subgroup. In total, 242 patients from 15 high-volume Chinese centers were enrolled, including 26.45% of patients with true bifurcation lesions, 3.31% with severely tortuous vessels, and 2.48% with chronic total occlusion, respectively. The procedural success rate was 95.04% (95% confidence interval 91.50-97.41%), exceeding the pre-specified performance goal of 83.4% (p<0.001). The 30-day and 6-month MACE rates were 4.13% and 4.55%, respectively. TLF rates at these time-points were 1.24% and 1.65%, respectively. Severe angiographic complications occurred in 0.42% of patients. In the OCT subgroup (n=93), 93.55% of calcified lesions were fractured, and minimal lumen area increased from 1.55 ± 0.55 mm2 to 4.91 ± 1.22 mm2 after stent implantation, with acute gain rate of 245 ± 102%. The novel intravascular lithotripsy system is effective and safe for managing severely calcified coronary lesions in a cohort that included true bifurcation lesions, severely tortuous vessels, and chronic total occlusion. (ChiCTR2100052058).

Takotsubo cardiomyopathy in India and its electrocardiography (ECG) comparison to myocardial infarction

BackgroundOwing to the limited research on Takotsubo Cardiomyopathy (TCM) in Asia, we aim to evaluate in detail the clinical profiles, lab parameters, investigations, and major adverse cardiovascular events (MACE) seen in patients with TCM in the Indian subcontinent. Additionally, we have compared the electrocardiographic findings of patients with TCM to those of patients with myocardial infarction (MI).ResultsThe average age of the patients affected was found to be 60 ± 11 years. Women (87.5%) and patients with hypertension (40%) were found to be at an increased risk of developing the syndrome. The most common presenting symptom was dyspnea (48%) following a trigger most commonly emotional (45%). ST elevation and significant T wave inversions were observed in 40% of patients with TCM. Echocardiography revealed a low left ventricular ejection fraction of 43 ± 9%. Coronary angiography was normal in 60%, the rest had mild/subcritical stenoses. The 6-month MACE was 20% and the mortality rate was 7.5%. Follow-up echocardiography of patients with TCM showed improvement in EF in 75% patients.ConclusionsTCM was majorly seen in postmenopausal women following an emotional trigger, but a variety of other triggers were noted. T-wave inversions in TCM follow a diffuse pattern in contrast to specific leads seen in MI. Normal or subcritical stenosis in coronaries at presentation, along with a low EF which improves on follow up provide greater evidence for the diagnosis of TCM.

Abstract 18968: Safety and Efficacy of Shockwave Intravascular Lithotripsy in the Management of Calcified Coronary Arteries: A Systematic Review and Meta-Analysis

Introduction: Shockwave intravascular lithotripsy (SWL) aims to facilitate optimal stent delivery and expansion for improved blood flow in treating calcified coronary artery disease. We sought to assess the safety and efficacy of SWL in managing de novo calcified lesions, lesions after failed/sub-optimal pre-dilatation with conventional balloon-based devices, under-expanded stents, and in-stent restenosis. Methods: A comprehensive literature search (Medline, Embase, Web of Science, Cochrane, and Google Scholar) was performed for studies that evaluated SWL in managing calcified coronary lesions. Efficacy outcomes included residual stenosis &lt;30% and successful stent delivery with a low incidence of device delivery failure. Safety outcomes included procedural complications and major adverse cardiovascular events (MACE). MACE is a composite outcome of all-cause mortality, cardiac mortality, myocardial infarction, target vessel/lesion revascularization, and stent thrombosis. Event rates across the included studies were pooled in a meta-analysis using the random effects model. An overall estimate and 95% confidence interval were reported for each outcome. Heterogeneity was estimated using the I-squared statistic. Results: Out of the 1446 identified studies, 40 were included, with a total of 2718 patients. Residual stenosis &lt;30% was achieved in 91.3% of patients (95% confidence interval 89.7% to 92.6%). Device delivery failure occurred in 6.7% of patients (95% CI 5% to 9%). In-hospital MACE occurred in 6.1% of patients (95% CI 5% to 7.4%), 30-day MACE in 7.4% (95% CI 6.2% to 8.8%), 6-month MACE in 8.3% (95% CI 7.1% to 9.6%), and 1-year MACE in 10% (95% CI 8.7% to 11.4%). Conclusions: SWL is a safe and efficient calcium modification intervention with high clinical success, minimal angiographic complications, and a low adverse event rate. Direct comparisons with the standard of care are needed in larger studies to establish clinical utility and superiority.

Feasibility and clinical outcomes of 48 mm drug eluting stents in management of patients with coronary artery disease

Abstract Background Long Coronary lesions represent a formidable challenge during percutaneous coronary intervention (PCI). Implantation of multiple contiguous stents may result in sections of overlapping stents or gaps of unstented segments and is an independent predictor of restenosis and major adverse cardiovascular events (MACEs). Objectives To assess the feasibility, and short-term clinical outcomes of implanting 48mm drug eluting stents (DES) in treatment of long lesions in patients with coronary artery disease (CAD). Methods A prospective study enrolling 300 patients, with a single CAD planned to undergo PCI with 48mm DES. Clinical data, procedural outcomes and follow-up to 6 months were obtained. MACEs were considered the combined study end point defined as cardiac death, non-fatal myocardial infarction, unstable angina and the need for target lesion revascularization (TLR). Results Among the 300 subjects enrolled, 80% were males, mean age was 60.8±8.6 years. Procedural success rate was 97.3%. Failure of crossing was encountered in 4 patients due to severe tortuosity. Six-month clinical outcome was compared between diabetic (DM) (n=90) and non-DM patients; 6-month cumulative MACEs were significantly lower in the non-DM than in DM group (2.9% in non-DM vs. 13.3% in DM, p=0.013). Clinically driven TLR was 4% and two cardiac deaths were reported. The independent predictors of repeat revascularization were insulin treated type 2 DM, and reference vessel diameter (RVD) ≤2.75 mm. Conclusion The use of 48mm DES is feasible, safe and cost effective in treatment of long coronary lesions. Independent predictors of repeat revascularization are type 2 diabetes mellitus, and RVD ≤2.75mm. Funding Acknowledgement Type of funding sources: None.

Mid-term outcome of de novo lesions vs. in stent restenosis treated by intravascular lithotripsy procedures: Insights from the French Shock Initiative

BackgroundIntravascular lithotripsy (IVL) is a promising new technology for disrupting de-novo calcified coronary lesions (DNL) before percutaneous coronary intervention (PCI). We assessed 12-month outcomes of IVL in patients undergoing PCI for DNL or intra stent restenosis (ISR) lesions related to device underexpansion. MethodsProspective analysis of patients in the multicentre all-comers French Shock Initiative IVL registry. The primary safety endpoints in this analysis were in-hospital and 12-month major adverse cardiovascular events (MACE: cardiac death, myocardial infarction or target vessel revascularization). The primary effectiveness endpoint was procedural success, defined as <30% residual stenosis without severe angiographic complications. Event rates were analysed for the cohort and for DNL and ISR procedures separately. ResultsA total of 220 lesions were treated (76.7% DNL and 23.3% ISR) in 202 patients. Procedural success was achieved in 95.5% of patients (DNL group: 96.5%; ISR group: 92.0%). In-hospital MACE occurred in 6.4% of cases, mainly driven by periprocedural infarctions. The rate of MACE-free survival at 1 year was 86.6% in the overall cohort. Rates of target vessel (TVR) and lesion (TLR) revascularisation were 6.4% and 2.5%, respectively. The 1-year MACE rate was 91.5% in DNL group and 83.8% in ISR group. ConclusionsIn this large all-comers IVL cohort, rates of in-hospital and 1-year MACE were moderate. The safety and efficiency of IVL was comparable in DNL and ISR lesions. A comparative study of the impact of IVL on outcomes appears warranted.

Biomarker-based risk model to predict cardiovascular events in patients with acute coronary syndromes – Results from BIPass registry

SummaryBackgroundRisk models integrating new biomarkers to predict cardiovascular events in acute coronary syndromes (ACS) are lacking. Therefore, we evaluated the prognostic value of biomarkers in addition to clinical predictors and developed a biomarker-based risk model for major adverse cardiovascular events (MACE) within 12 months after hospital admission with ACS.MethodsPatients (n = 4407) consecutively enrolled from November, 2017 to October, 2019 in three hospitals of a prospective Chinese registry (BIomarker-based Prognostic Assessment for Patients with Stable Angina and Acute Coronary Syndromes, BIPass) were designated as the risk model development cohort. Validation was performed in 1409 patients enrolled in two independent hospitals. Cox proportional hazards regression analysis was used to generate a risk prediction model and evaluate the incremental prognostic value of each biomarker.FindingsOver 12 months, 196 patients experienced MACE (5.1%/year). Among twelve candidate biomarkers, N-terminal pro-B-type natriuretic peptide (NT-proBNP) measured at baseline showed the most prognostic capability independent of clinical predictors. The developed BIPass risk model included age, hypertension, previous myocardial infarction, stroke, Killip class, heart rate, and NT-proBNP. It displayed improved discrimination (C-statistic 0.79, 95% CI 0.73-0.85), calibration (GOF = 9.82, p = 0.28) and clinical decision curve in the validation cohort, outperforming the GRACE and TIMI risk scores. Cumulative rates for MACE demonstrated good separation in the BIPass predicted low, intermediate, and high-risk groups.InterpretationThe BIPass risk model, integrating clinical variables and NT-proBNP, is useful for predicting 12-month MACE in ACS. It effectively identifies a gradient risk of cardiovascular events to aid personalized care.FundingNational Key R&D Program of China (2017YFC0908700, 2020YFC0846600), National S&T Fundamental Resources Investigation Project (2018FY100600, 2018FY100602), Taishan Pandeng Scholar Program of Shandong Province (tspd20181220), Taishan Young Scholar Program of Shandong Province (tsqn20161065, tsqn201812129), Youth Top-Talent Project of National Ten Thousand Talents Plan and Qilu Young Scholar Program.

Sex differences in treatment and outcomes of patients with in-hospital ST-elevation myocardial infarction.

Background and HypothesisTwo cohorts face high mortality after ST‐elevation myocardial infarction (STEMI): females and patients with in‐hospital STEMI. The aim of this study was to evaluate sex differences in ischemic times and outcomes of in‐hospital STEMI patients.MethodsConsecutive STEMI patients treated with percutaneous coronary intervention (PCI) were prospectively recruited from 30 hospitals into the Victorian Cardiac Outcomes Registry (2013−2018). Sex discrepancies within in‐hospital STEMIs were compared with out‐of‐hospital STEMIs. The primary endpoint was 12‐month all‐cause mortality. Secondary endpoints included symptom‐to‐device (STD) time and 30‐day major adverse cardiovascular events (MACE). To investigate the relationship between sex and 12‐month mortality for in‐hospital versus out‐of‐hospital STEMIs, an interaction analysis was included in the multivariable models.ResultsA total of 7493 STEMI patients underwent PCI of which 494 (6.6%) occurred in‐hospital. In‐hospital versus out‐of‐hospital STEMIs comprised 31.9% and 19.9% females, respectively. Female in‐hospital STEMIs were older (69.5 vs. 65.9 years, p = .003) with longer adjusted geometric mean STD times (104.6 vs. 94.3 min, p < .001) than men. Female versus male in‐hospital STEMIs had no difference in 12‐month mortality (27.1% vs. 20.3%, p = .92) and MACE (22.8% vs. 19.3%, p = .87). Female sex was not independently associated with 12‐month mortality for in‐hospital STEMIs which was consistent across the STEMI cohort (OR: 1.26, 95% CI: 0.94–1.70, p = .13).ConclusionsIn‐hospital STEMIs are more frequent in females relative to out‐of‐hospital STEMIs. Despite already being under medical care, females with in‐hospital STEMIs experienced a 10‐min mean excess in STD time compared with males, after adjustment for confounders. Adjusted 12‐month mortality and MACE were similar to males.

Antiplatelet therapy in patients with conservatively managed spontaneous coronary artery dissection from the multicentre DISCO registry.

The role of antiplatelet therapy in patients with spontaneous coronary artery dissection (SCAD) undergoing initial conservative management is still a matter of debate, with theoretical arguments in favour and against its use. The aims of this article are to assess the use of antiplatelet drugs in medically treated SCAD patients and to investigate the relationship between single (SAPT) and dual (DAPT) antiplatelet regimens and 1-year patient outcomes. We investigated the 1-year outcome of patients with SCAD managed with initial conservative treatment included in the DIssezioni Spontanee COronariche (DISCO) multicentre international registry. Patients were divided into two groups according to SAPT or DAPT prescription. Primary endpoint was 12-month incidence of major adverse cardiovascular events (MACE) defined as the composite of all-cause death, non-fatal myocardial infarction (MI), and any unplanned percutaneous coronary intervention (PCI). Out of 314 patients included in the DISCO registry, we investigated 199 patients in whom SCAD was managed conservatively. Most patients were female (89%), presented with acute coronary syndrome (92%) and mean age was 52.3 ± 9.3 years. Sixty-seven (33.7%) were given SAPT whereas 132 (66.3%) with DAPT. Aspirin plus either clopidogrel or ticagrelor were prescribed in 62.9% and 36.4% of DAPT patients, respectively. Overall, a 14.6% MACE rate was observed at 12 months of follow-up. Patients treated with DAPT had a significantly higher MACE rate than those with SAPT [18.9% vs. 6.0% hazard ratios (HR) 2.62; 95% confidence intervals (CI) 1.22-5.61; P = 0.013], driven by an early excess of non-fatal MI or unplanned PCI. At multiple regression analysis, type 2a SCAD (OR: 3.69; 95% CI 1.41-9.61; P = 0.007) and DAPT regimen (OR: 4.54; 95% CI 1.31-14.28; P = 0.016) resulted independently associated with a higher risk of 12-month MACE. In this European registry, most patients with SCAD undergoing initial conservative management received DAPT. Yet, at 1-year follow-up, DAPT, as compared with SAPT, was independently associated with a higher rate of adverse cardiovascular events (ClinicalTrial.gov id: NCT04415762).

A prognostic nomogram for long-term major adverse cardiovascular events in patients with acute coronary syndrome after percutaneous coronary intervention

BackgroundAccurate prediction of major adverse cardiovascular events (MACEs) is very important for the management of acute coronary syndrome (ACS) patients. We aimed to construct an effective prognostic nomogram for individualized risk estimates of MACEs for patients with ACS after percutaneous coronary intervention (PCI).MethodsThis was a prospective study of patients with ACS after PCI from January 2013 to July 2019 (n = 2465). After removing patients with incomplete clinical information, a total of 1986 patients were randomly divided into evaluation (n = 1324) and validation (n = 662) groups. Predictors included in the nomogram were determined by a multivariate Cox proportional hazards regression model based on the training set. Receiver operating characteristic (ROC) curves and calibration curves were used to assess the discrimination and predictive accuracy of the nomogram, which were then compared with those of the classic models. The clinical utility of the nomogram was assessed by X-tile analysis and Kaplan–Meier curve analysis.ResultsIndependent prognostic factors, including lactate level, age, left anterior descending branch stenosis, right coronary artery stenosis, brain natriuretic peptide level, and left ventricular ejection fraction, were determined and contained in the nomogram. The nomogram achieved good areas under the ROC curve of 0.712–0.762 in the training set and 0.724–0.818 in the validation set and well-fitted calibration curves. In addition, participants could be divided into two risk groups (low and high) according to this model.ConclusionsA simple-to-use nomogram incorporating lactate level effectively predicted 6-month, 1-year, and 4-year MACE incidence among patients with ACS after PCI.

Six-Month Outcomes for COVID-19 Negative Patients with Acute Myocardial Infarction Before Versus During the COVID-19 Pandemic

The Coronavirus disease 2019 (COVID-19) pandemic has changed the way patients seek medical attention and how medical services are provided. We sought to compare characteristics, clinical course, and outcomes of patients presenting with acute myocardial infarction (AMI) during the pandemic compared with before it. This is a multicenter, retrospective cohort study of consecutive COVID-19 negative patients with AMI in Lithuania from March 11, 2020 to April 20, 2020 compared with patients admitted with the same diagnosis during the same period in 2019. All patients underwent angiography. Six-month follow-up was obtained for all patients. A total of 269 patients were included in this study, 107 (40.8%) of whom presented during the pandemic. Median pain-to-door times were significantly longer (858 [quartile 1=360, quartile 3 = 2,600] vs 385.5 [200, 745] minutes, p <0.0001) and post-revascularization ejection fractions were significantly lower (35 [30, 45] vs 45 [40, 50], p <0.0001) for patients presenting during vs. prior to the pandemic. While the in-hospital mortality rate did not differ, we observed a higher rate of six-month major adverse cardiovascular events for patients who presented during versus prior to the pandemic (30.8% vs 13.6%, p = 0.0006). In conclusion, 34% fewer patients with AMI presented to the hospital during the COVID-19 pandemic, and those who did waited longer to present and experienced more 6-month major adverse cardiovascular events compared with patients admitted before the pandemic.

Outcome of left main stem percutaneous coronary intervention in a UK nonsurgical center: A 5‐year clinical experience

To evaluate the outcome of unprotected left main stem (LMS) percutaneous coronary intervention (PCI) in a large UK nonsurgical center. PCI on unprotected LMS is increasingly regarded as a viable alternative to coronary artery bypass grafting (CABG) with comparable outcome and safety profile in select groups. The safety and efficacy of unprotected LMS PCI without on-site surgical back up has not been reported. Data on all unprotected LMS PCI performed between January 2011 and December 2015, was collected from the local PCI database and electronic patient records. In hospital and 1-year major adverse cardiovascular events (MACE) (all-cause mortality, myocardial infarction [MI], stroke, and target vessel revascularization [TVR]) was recorded. 249 patients had unprotected LMS intervention during the study period. 77% of patients (n = 192) were male and mean age was 70 ± 12 years. 31% (n = 78) of cases were elective, 44% (n = 109) NSTEMI, and 25% (n = 62) STEMI. Anatomical distribution: 19% (n = 47) ostial left main, 31% (n = 77) shaft, and 50% (n = 125) bifurcation. The mean SYNTAX score was 24.4 ± 10.6. 22% (n = 55) of patients had severe LV impairment preprocedure and 13% (n = 33) were in cardiogenic shock at presentation. 35% (14%) required IABP support. The vast majority (98.4%) of procedures were successful. No patients required emergency transfer for CABG surgery. There were 25 (10%) in-hospital deaths. 68% of in-hospital deaths occurred in patients undergoing primary PCI for STEMI. 72% of patients who died were in cardiogenic shock at presentation. The 12-month MACE rate was 17.2%. Death occurred in 11.6%, MI in 2.4%, TVR in 2.4%, and stroke in 0.8% of patients. These results highlight the safety and efficacy of unprotected LMS PCI in a high volume non-surgical center.

Short-Term Clinical Outcomes of Single Versus Dual Antiplatelet Therapy after Infrainguinal Endovascular Treatment for Peripheral Arterial Disease

After infrainguinal endovascular treatment for peripheral arterial disease (PAD), it is uncertain whether single antiplatelet therapy (SAPT) or dual antiplatelet therapy (DAPT) should be preferred. This study investigated major adverse limb events (MALE) and major adverse cardiovascular events (MACE) between patients receiving SAPT and DAPT. Patient data from three centers in the Netherlands were retrospectively collected and analyzed. All patients treated for PAD by endovascular revascularization of the superficial femoral, popliteal, or below-the-knee (BTK) arteries and who were prescribed acetylsalicylic acid or clopidogrel, were included. End points were 1-, 3-, and 12-month MALE and MACE, and bleeding complications. In total, 237 patients (258 limbs treated) were included, with 149 patients receiving SAPT (63%) and 88 DAPT (37%). No significant differences were found after univariate and multivariate analyses between SAPT and DAPT on 1-, 3-, and 12-month MALE and MACE, or bleeding outcomes. Subgroup analyses of patients with BTK treatment showed a significantly lower 12-month MALE rate when treated with DAPT (hazard ratio 0.33; 95% confidence interval 0.12–0.95; p = 0.04). In conclusion, although patient numbers were small, no differences were found between SAPT and DAPT regarding MALE, MACE, or bleeding complications. DAPT should, however, be considered over SAPT for the subgroup of patients with below-the-knee endovascular treatment.

Association of PC and AT levels in the early phase of STEMI treated with pPCI with LV systolic function and 6-month MACE

ABSTRACT Objectives: To examine a relationship between protein C (PC) and antithrombin III (AT III) activities with ejection fraction of left ventricle (EFLV), in the early phase of acute ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (pPCI), and to investigate whether PC and AT III are associated with major adverse cardiovascular events (MACE) within 6 months following from pPCI. Patients and methods: The research had a prospective character and included 357 patients who had, following the diagnosis of the STEMI, undergone pPCI at the Clinic of Cardiology and Emergency Internal Medicine, Military Medical Academy, Belgrade, Serbia, from January 2010 until April 2019. Results: The EFLV positively correlated with PC values (rho = 0.229). There was a statistically significant increase in the PC values between patients with MACE compared with those without MACE at 6 months’ follow-up evaluation (p < 0.0001). Also, significant difference in PC values between patients who died in hospital and those who were alive at 6 months’ follow-up (p < 0.01) was observed. PC values were different across different EFLV groups (p < 0.001), increasing from the 1st to the 4th EFLV quartiles: the median and the interquartile values for the 1st, 2nd, 3rd and 4th quartiles were 1.0400IU/l ± 0.15, 1.1400IU/l ± 0.15, 1.1350IU/l ± 0.16 and 1.2200IU/l ± 0.14, respectively. Conclusion: Increased PC activity in the early phase of STEMI is associated with higher EFLV 5 days after the pPCI as well as with MACE at 6 months after the pPCI.

The sex difference in 6-month MACEs and its explaining variables in acute myocardial infarction survivors: Data from CPACS-3 study

BackgroundWe aimed to assess sex difference in developing major adverse cardiovascular events (MACEs) after discharge and factors associated with the gender disparity among AMI survivors. MethodsWe selected the patients hospitalized with either NSTEMI or STEMI from 101 Chinese centers in the CPACS 3 study. We compared sex differences in MACEs and mortality in 6 months after discharge using a Cox proportional hazards model, following sequential adjustment for covariates. Results8958 patients with AMI were included and 30.3% were women. Overall, the crude rate of MACEs at 6 month for women were significantly higher than men (6.5% vs 4.5%; hazard ratio (HR) =1.47; 95% CI, 1.21–1.77). Women also had significantly higher total mortality compared to men (4.4% vs 2.7%; HR = 1.65; 95% CI, 1.30–2.09). Among possible explanatory factors, patients' cardiovascular risk profile might explain 53%, age 38%, low level of education and socioeconomic status 32%. Interestingly, medications at discharge did not contribute to the sex disparity in 6-month risk of MACEs. These factors could explain a similar proportion of the gender disparity in total death. All together, these factors could explain all the disparity in the risk of both MACEs (HR = 1.05,95% CI, 0.85–1.31) and total death (HR = 1.00,95% CI,0.76–1.30). ConclusionsThe gender disparity in MACEs and total death among AMI patients continues at 6 months after discharged surviving. Multiple factors could explain the higher risk for women, including poorer cardiovascular risk factor profile, older age and lower socioeconomic status. Trial RegistrationCPACS-3 was registered on www.clinicaltrails.gov, and the registration number is NCT01398228.

One-Year Outcomes of Patients With Established Coronary Artery Disease Presenting With Acute Coronary Syndromes

The risk of major adverse cardiovascular events (MACE) remains high in patients with established coronary artery disease (CAD). The aim of this study was to assess the prognostic significance of established CAD in patients who present with acute coronary syndromes (ACS) using a large established multicenter registry. Consecutive patients from the Melbourne Interventional Group registry who presented with ACS and underwent percutaneous coronary intervention from 2005 to 2015 were included. Patients with a history of myocardial infarction, percutaneous coronary intervention, or coronary artery bypass graft surgery were included in the established CAD cohort. The primary end points were 12-month mortality and 12-month MACE. Of the 12,878 ACS patients included in our study, 3,542 (28%) patients had established CAD. Over the 10-year study period, the proportion of patients presenting with established CAD decreased (30.7% to 25.2%; p-for-overall-trend <0.001). Non-ST elevation myocardial infarction was the most prominent presentation in the established CAD cohort (45.1%) whereas ST-elevation myocardial infarction was the most prominent in the de novo CAD cohort (51%; p< 0.001). The patients in the established CAD cohort were older, had more co-morbidities and were more likely to present with high-risk features such as atrial fibrillation, left main disease, multivessel CAD and left ventricular dysfunction (all p < 0.001). Regarding revascularization in ST-elevation myocardial infarction presentations, symptom-to-door time was shorter, whereas door-to-balloon-time was longer in those with established CAD (p < 0.001). On multivariate analysis, established CAD was an independent risk factor for 12-month MACE (odds ratio 1.40, 95% confidence intervals 1.23 to 1.58, p < 0.001), but not for 12-month mortality (odds ratio 1.08, 95% confidence intervals 0.77 to 1.52, p = 0.66). In conclusion, patients with a history of myocardial infarction or previous revascularization have a higher rate of MACE at 12 months. Despite this they do not appear to suffer from higher mortality.

A 6-Month Follow-Up Study of the Relation between Apolipoprotein E Gene Polymorphism and Major Adverse Cardiovascular Events in Patients with Acute Coronary Syndrome

Objectives: This study aimed to investigate the relation between ApoE gene polymorphisms and major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS) during a 6-month follow-up. Methods: From October 2016 to July 2017, 211 patients were admitted to a cardiology clinic with a diagnosis of ACS. Blood samples were obtained from all patients on the first day. The primary end point was a 6-month incidence of MACE. ApoE gene polymorphism was genotyped by real-time PCR using TaqMan® SNP Genotyping Assay. Results: The patients with the E4 allele were associated with higher low-density lipoprotein (LDL) cholesterol and total cholesterol (TC) levels compared with the patients without the E4 allele (p = 0001 and p = 0.001). The patients with the E4 allele were associated with a higher rate of MACE compared with the patients without the E4 allele (ApoE4 allele(+) 23.1% vs. ApoE4 allele(−) 9.3%; p = 0.03). Multivariable analysis suggested that E4 allele carriers showed an 85% risk increment of 6-month MACE (odds ratio 2.48, 95% confidence interval 2.37–5.95; p = 0.01). Conclusions: The trial shows that E4 allele carriers were correlated with not only higher LDL cholesterol and TC levels, but also with a higher incidence of MACE during a 6-month follow-up.

Clinical outcomes following primary percutaneous coronary intervention for ST-elevation myocardial infarction according to sex and race.

Female sex and South Asian race have been associated with poor clinical outcomes following primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) but remain understudied in large real-world series. We therefore investigated the association of sex and race with clinical outcomes following PPCI. We conducted a prospective study of all patients undergoing PPCI for STEMI between January 2009 and December 2011 at a large UK cardiac centre. Clinical characteristics and outcomes were compared according to sex and race using Chi-square test, independent samples Student's t-test and Mann-Whitney U-test. Primary and secondary outcomes were 12-month major adverse cardiovascular events (MACEs) - defined as all-cause mortality, myocardial infarction and unplanned revascularization, analysed using Cox proportional hazard models adjusting for cardiovascular risk factors. Three thousand and forty-nine patients were included. Women ( n=826) were older than men ( n=2223) (median age 69 vs. 60 years, p <0.01). Mortality (hazard ratio 1.48 (1.15-1.90)) and MACE (hazard ratio 1.40 (1.14-1.72)) were higher in women in univariable analysis. However, there were no significant sex-differences in mortality or MACE after age-stratification alone. Multivariable analysis also showed no significant differences in outcomes between sexes. South Asians ( n=297) were younger but had a higher prevalence of most risk factors than White patients ( n=2570). Mortality and MACE did not differ significantly between South Asian and White patients in univariable or multivariable analysis. MACE and mortality was not greater in women, or in South Asian patients following PPCI after adjustment for cardiovascular risk factors including age, which was most strongly associated with both outcomes.

Pretreatment with dual antiplatelet therapy in patients with ST-elevation myocardial infarction.

The optimal time to administer P2Y12 inhibitors in patients with ST-elevation myocardial infarction (STEMI) remains to be defined. We sought to assess whether a pretreatment strategy was associated with improved coronary reperfusion and clinical outcomes. Consecutive patients from the Melbourne Interventional Group registry (2005-2014) who presented with STEMI and underwent primary PCI were included. Those who received any P2Y12 inhibitor prior to arrival in the cardiac catheterisation laboratory were included in the pretreatment group. The primary endpoints were the proportion of patients with initial TIMI flow grade <3 and in-hospital bleeding. The secondary endpoints were 12-month mortality and major adverse cardiovascular events (MACE). Of the 2,807 patients included, 892(31.8%) received pretreatment. Clopidogrel was the most common P2Y12 inhibitor used (79.6%). Pretreatment was associated with less thromboaspiration and GPIIb/IIIa inhibitor use (both P < 0.01). Pretreatment was not associated with lower rates of TIMI flow <3 on initial angiogram (78.0% vs. 80.7%, P = 0.18) nor with increased in-hospital bleeding (3.6% vs. 3.9%, P = 0.67). Pretreatment was associated with lower 12-month mortality (4.7% vs. 7.0%, P = 0.02) but similar MACE rate (13.0% vs. 14.1%, P = 0.43). Multivariate analysis revealed pretreatment was not an independent predictor of 12-month mortality (OR 0.79; 95% CI 0.5-1.3, P = 0.32). Pretreatment with a P2Y12 inhibitor in patients with STEMI was not routine practice in our Australian cohort and was not associated with improved coronary reperfusion or clinical outcomes. Larger studies are required to definitively ascertain the risk/benefit ratio of dual antiplatelet therapy pretreatment in STEMI.

Trends and Impact of Door-to-Balloon Time on Clinical Outcomes in Patients Aged

Guidelines strongly recommend patients with ST-elevation myocardial infarction (STEMI) receive timely mechanical reperfusion, defined as door-to-balloon time (DTBT) ≤90 minutes. The impact of timely reperfusion on clinical outcomes in patients aged 75-84 and ≥85 years is uncertain. We analysed 2,972 consecutive STEMI patients who underwent primary percutaneous coronary intervention from the Melbourne Interventional Group Registry (2005-2014). Patients aged <75 years were included in the younger group, those aged 75-84 years were in the elderly group and those ≥85 years were in the very elderly group. The primary endpoints were 12-month mortality and major adverse cardiovascular events (MACE). 2,307 (77.6%) patients were <75 years (mean age 59 ± 9 years), 495 (16.7%) were 75-84 years and 170 (5.7%) were ≥85 years. There has been a significant decrease in DTBT over 10 years in younger and elderly patients (p-for-trend <0.01 and 0.03) with a trend in the very elderly (p-for-trend 0.08). Compared to younger and elderly patients, the very elderly had higher 12-month mortality (3.6% vs 10.7% vs. 29.4%; p = 0.001) and MACE (10.8% vs 20.6% vs 33.5%; p = 0.001). DTBT ≤90 minutes was associated with improved outcomes on univariate analysis but was not an independent predictor of improved 12-month mortality (OR 0.84, 95% CI 0.54-1.31) or MACE (OR 0.89, 95% CI 0.67-1.16). In conclusion, over a 10-year period, there was an improvement in DTBT in patients aged <75 years and 75-84 years however DTBT ≤90 minutes was not an independent predictor of 12-month outcomes. Thus assessing whether patients aged ≥85 years are suitable for invasive management does not necessarily translate to worse clinical outcomes.

The Predictive Role of Serum Triglyceride to High-Density Lipoprotein Cholesterol Ratio According to Renal Function in Patients with Acute Myocardial Infarction.

ObjectiveA high serum triglyceride to high-density lipoprotein cholesterol (TG/HDL-C) ratio has been reported as an independent predictor for cardiovascular events in the general population. However, the prognostic value of this ratio in patients with renal dysfunction is unclear. We examined the association of the TG/HDL-C ratio with major adverse cardiovascular events (MACEs) according to renal function in patients with acute myocardial infarction (AMI).MethodThis study was based on the Korea Acute Myocardial Infarction Registry database. Of 13,897 patients who were diagnosed with AMI, the study population included the 7,016 patients with available TG/HDL-C ratio data. Patients were stratified into three groups according to their estimated glomerular filtration rate (eGFR), and the TG/HDL-C ratio was categorized into tertiles. We investigated 12-month MACEs, which included cardiac death, myocardial infarction, and repeated percutaneous coronary intervention or coronary artery bypass grafting.ResultsDuring the 12-month follow up period, 593 patients experienced MACEs. There was a significant association between the TG/HDL-C ratio and MACEs (p<0.001) in the entire study cohort. Having a TG/HDL-C ratio value in the highest tertile of TG/HDL-C ratio was an independent factor associated with increased risk of MACEs (hazard ratio [HR], 1.56; 95% confidence interval [CI], 1.26–1.93; p<0.001). Then we performed subgroup analyses according to renal function. In patients with normal renal function (eGFR ≥ 90 ml/min/1.73m2) and mild renal dysfunction (eGFR ≥ 60 to < 90ml/min/1.73m2), a higher TG/HDL-C ratio was significantly associated with increased risk of MACEs (HR, 1.64; 95% CI, 1.04–2.60; p = 0.035; and HR, 1.56; 95% CI, 1.14–2.12; p = 0.005, respectively). However, in patients with moderate renal dysfunction (eGFR < 60 ml/min/1.73m2), TG/HDL-C ratio lost its predictive value on the risk of MACEs (HR, 1.23; 95% CI, 0.82–1.83; p = 0.317).ConclusionsIn patients with AMI, TG/HDL-C ratio is a useful independent predictor of 12-month MACEs. However, this ratio does not have predictive power in patients with moderate renal dysfunction.