ACEF Score Research Articles

Development and validation of a model integrating clinical and coronary lesion-based functional assessment for long-term risk prediction in PCI patients.

To establish a scoring system combining the ACEF score and the quantitative blood flow ratio (QFR) to improve the long-term risk prediction of patients undergoing percutaneous coronary intervention (PCI). In this population-based cohort study, a total of 46 features, including patient clinical and coronary lesion characteristics, were assessed for analysis through machine learning models. The ACEF-QFR scoring system was developed using 1263 consecutive cases of CAD patients after PCI in PANDA III trial database. The newly developed score was then validated on the other remaining 542 patients in the cohort. In both the Random Forest Model and the DeepSurv Model, age, renal function (creatinine), cardiac function (LVEF) and post-PCI coronary physiological index (QFR) were identified and confirmed to be significant predictive factors for 2-year adverse cardiac events. The ACEF-QFR score was constructed based on the developmental dataset and computed as age (years)/EF (%) + 1 (if creatinine ≥ 2.0 mg/dL) + 1 (if post-PCI QFR ≤ 0.92). The performance of the ACEF-QFR scoring system was preliminarily evaluated in the developmental dataset, and then further explored in the validation dataset. The ACEF-QFR score showed superior discrimination (C-statistic = 0.651; 95% CI: 0.611-0.691, P < 0.05 versus post-PCI physiological index and other commonly used risk scores) and excellent calibration (Hosmer-Lemeshow χ2 = 7.070; P = 0.529) for predicting 2-year patient-oriented composite endpoint (POCE). The good prognostic value of the ACEF-QFR score was further validated by multivariable Cox regression and Kaplan-Meier analysis (adjusted HR = 1.89; 95% CI: 1.18-3.04; log-rank P < 0.01) after stratified the patients into high-risk group and low-risk group. An improved scoring system combining clinical and coronary lesion-based functional variables (ACEF-QFR) was developed, and its ability for prognostic prediction in patients with PCI was further validated to be significantly better than the post-PCI physiological index and other commonly used risk scores.

Very long-term prognostic value of clinical SYNTAX score in patients undergoing percutaneous coronary intervention for left main coronary artery disease

Abstract Background Recently, long-term prognostic value of SYNTAX score (SS) has been validated in patients with left main coronary artery disease (LMCA). However, the ability of clinical SYNTAX score (CSS) to predict very long-term outcomes in patients undergoing percutaneous coronary intervention (PCI) for LMCA has not been fully investigated yet. Purpose We aimed to validate the impact of CSS on very long-term outcomes in patients undergoing PCI for LMCA. Methods Between June 2006 and December 2012, 279 patients underwent unprotected LMCA PCI were analyzed. The SS for each patient was calculated by scoring all coronary lesions using SS algorithm. CSS was calculated by multiplying the SS to an ACEF score (age/left ventricular ejection fraction + 1 if serum creatinine&amp;gt;2mg/dL). Major adverse cardiac events (MACEs) were defined as death, non-fatal myocardial infarction, and revascularizations. Mean follow-up duration was 2,529±1664 days. Results The CSS (26.8±11.9 versus 39.9±26.1, p&amp;lt;0.001) as well as SS (23.2±6.9 versus 25.8±7.9, p=0.003) was significantly higher in patients with MACEs. Area under the curve for MACEs (0.672 versus 0.599, p=0.0023) and mortality (0.744 versus 0.626, p&amp;lt;0.0001) of CSS was significantly higher compared with those of SS (Figure 1). The CSS significantly improved the reclassification and the integrated discrimination of patients compared to SS. Log CSS was an independent predictor for MACEs (hazard ratio [HR] 5.37, 95% confidence interval [CI] 1.98 – 14.61; p = 0.006) and mortality (HR 11.69, 95% CI 3.30 – 41.31; p &amp;lt; 0.001). When patients were categorized into 3 groups according to tertiles of CSS (Low CSS ≤ 22, 22 &amp;lt; Mid CSS ≤ 34, High CSS &amp;gt; 34), patients in the highest CSS tertile had significantly higher rates of MACEs (log-rank p&amp;lt;0.001) and mortality (log-rank p&amp;lt;0.001) compared with those in the lower 2 tertiles (Figure 2). The highest CSS tertile was an independent predictor for MACEs (HR 2.33, 95% CI 1.42 – 3.82; p = 0.001) and mortality (HR 5.66, 95% CI 2.20 – 14.57; p &amp;lt; 0.001). Conclusions The CSS is useful to predict very long-term clinical outcome in patients underwent unprotected LMCA PCI.

Performance of Prognostic Scoring Systems in MINOCA: A Comparison among GRACE, TIMI, HEART, and ACEF Scores.

Background: the prognosis of patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) is not benign; thus, prompting the need to validate prognostic scoring systems for this population. Aim: to evaluate and compare the prognostic performance of GRACE, TIMI, HEART, and ACEF scores in MINOCA patients. Methods: A total of 250 MINOCA patients from January 2017 to September 2021 were included. For each patient, the four scores at admission were retrospectively calculated. The primary outcome was a composite of all-cause death and acute myocardial infarction (AMI) at 1-year follow-up. The ability to predict 1-year all-cause death was also tested. Results: Overall, the tested scores presented a sub-optimal performance in predicting the composite major adverse event in MINOCA patients, showing an AUC ranging between 0.7 and 0.8. Among them, the GRACE score appeared to be the best in predicting all-cause death, reaching high specificity with low sensitivity. The best cut-off identified for the GRACE score was 171, higher compared to the cut-off of 140 generally applied to identify high-risk patients with obstructive AMI. When the scores were tested for prediction of 1-year all-cause death, the GRACE and the ACEF score showed very good accuracy (AUC = 0.932 and 0.828, respectively). Conclusion: the prognostic scoring tools, validated in AMI cohorts, could be useful even in MINOCA patients, although their performance appeared sub-optimal, prompting the need for risk assessment tools specific to MINOCA patients.

The value of the ACEF II score in Chinese patients with elective and non-elective cardiac surgery

ObjectiveTo evaluate the value of the ACEF II score in predicting postoperative hospital death and acute kidney injury requiring dialysis (AKI-D) in Chinese patients.MethodsThis retrospective study included adult patients who underwent cardiopulmonary bypass open heart surgery between January 2010 and December 2015 at Guangdong Provincial People’s Hospital. ACEF II was evaluated to predict in-hospital death and AKI-D using the Hosmer–Lemeshow goodness of fit test for calibration and area under the receiver operating characteristic (ROC) curve for discrimination in non-elective and elective cardiac surgery.ResultsA total of 9748 patients were included. Among them, 1080 underwent non-elective surgery, and 8615 underwent elective surgery. Mortality was 1.8% (177/9748). In elective surgery, the area under the ROC (AUC) of the ACEF II score was 0.704 (95% CI: 0.648–0.759), similar to the ACEF score of 0.709 (95% CI: 0.654–0.763). In non-elective surgery, the AUC of the ACEF II score was 0.725 (95% CI: 0.663–0.787), higher than the ACEF score (AUC = 0.625, 95% CI: 0.553–0.697). The incidence of AKI-D was 3.5% (345/9748). The AUC of the ACEF II score was 0.718 (95% CI: 0.687–0.749), higher than the ACEF score (AUC = 0.626, 95% CI: 0.594–0.658).ConclusionACEF and ACEF II have poor discrimination ability in predicting AKI-D in non-elective surgery. The ACEF II and ACEF scores have the same ability to predict in-hospital death in elective cardiac surgery, and the ACEF II score is better in non-elective surgery. The ACEF II score can be used to assess the risk of AKI-D in elective surgery in Chinese adults.

A PROSPECTIVE STUDY TO IDENTIFY THE BEST PREDICTOR OF IN-HOSPITAL MORTALITY IN PATIENTS UNDERGOING EMERGENT PERCUTANEOUS CORONARY REVASCULRIZATION; COMPARATIVE ANALYSIS OF FOUR WELL ESTABLISHED RISK SCORES

Objectives: This study was conducted to compare the predictive power of Shock Index (SI), TIMI Risk Index (TRI), LASH Score, and ACEF Score for the prediction of in-hospital mortality in a contemporary cohort of ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) at a tertiary care cardiac center of a developing country.&#x0D; Methodology: Consecutive patients diagnosed with STEMI and undergoing primary PCI were included in this study. SI, TRI, LASH, and ACEF were computed and their predictive power was assessed as the area under the curve (AUC) on the receiver operating characteristics (ROC) curve analysis for in-hospital mortality.&#x0D; Results: A total of 977 patients were included in this study, 780 (79.8%) of which were male, and the mean age was 55.6 ± 11.5 years with 149 (15.3%) under 45 years of age. At presentation, 101 (11.4%) patients were in Killip class III/IV, 121 (12.4%) had arrhythmias, 59 (6%) were in cardiac arrest, and 130 (13.3%) were intubated. The in-hospital mortality rate was 4.3% (42). AUC for TRI was 0.669 (cut-off: ≥17.5, sensitivity: 76.2%, specificity: 45.6%). AUC for SI was 0.595 (cut-off: ≥0.9, sensitivity: 21.4%, specificity: 89.8%). AUC for LASH score was 0.745 (cut-off: ≥0, sensitivity: 76.2%, specificity: 66.9%). AUC for the ACEF score was 0.786 (cut-off: ≥1.66, sensitivity: 71.4%, specificity: 73.5%).&#x0D; Conclusion: In conclusion, ACEF showed sufficiently high predictive power with good sensitivity and specificity compared to other three scores. These simplified indices based on readily available hemodynamic parameters can be reliable alternatives to the computational complex scoring systems for the risk stratification of STEMI patients.

Predicting value on short-term outcome of various established risk prediction models in extracorporeal membrane oxygenation treated cardiogenic shock patients due to ST-segment elevation myocardial infarction

Objective: To investigate the predicting value of different risk prediction models for short-term death in patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock and treated with extracorporeal membrane oxygenation (ECMO). Methods: This study was a retrospective case-control study. Forty patients with STEMI complicated by cardiogenic shock who hospitalized in the First Affiliated Hospital of Zhengzhou University from April 2017 to August 2021 and treated with percutaneous coronary intervention (PCI) and ECMO, were enrolled in this study. Patients were divided into survival group and death group according to their clinical outcomes at 30 days after ECMO implantation, and clinical data of the two groups were collected and analyzed. Receiver operating characteristic (ROC) curve and decision curve analysis (DCA) were used to compare the predictive value of ACEF, AMI-ECMO, Encourage and SAVE risk scores for mortality at 30 days after ECMO implantation. According to the evaluation results of DCA, the optimal risk score was selected. Kaplan-Meier curve estimating the 30-day survival after ECMO implantation was plotted by grouping risk scores with reference to previous literatures. Results: A total of 40 patients with STEMI combined with cardiogenic shock were included, age was (57.4±16.7) years, 31 (77.5%) patients were male, there were 21 (52.5%) patients in the death group and 19 (47.5%) in the survival group. Compared with the survival group, patients in the death group had higher lactic acid values, higher proportion of anterior descending artery or left main artery lesions, and a higher proportion of acute renal failure and continuous renal replacement therapy during hospitalization (all P<0.05). Compared with survival group, ACEF, AMI-ECMO and Encourage scores were higher in death group, SAVE score was lower in death group (all P<0.05). The ROC curve analysis showed that the area under the curve (AUC) of ACEF, AMI-ECMO, Encourage and SAVE scores in predicting mortality were 0.707, 0.816, 0.757, and 0.677 respectively (P>0.05). ACEF score demonstrated the highest sensitivity (90.5%) and Encourage score exhibited the highest specificity (89.5%). DCA indicated that the AMI-ECMO and Encourage scores had the best performance in predicting the 30-day mortality after ECMO therapy. Kaplan-Meier survival curve analysis showed that the 30-day mortality after ECMO implantation increased with the increase of AMI-ECMO and Encourage scores (log-rank P≤0.001). Conclusions: The 4 scoring systems are all suitable for predicting 30-day mortality after VA-ECMO therapy in patients with ST-segment elevation myocardial infarction complicated by cardiogenic shock. Among them, AMI-ECMO and Encourage scores have better predicting performance.

Analysis of Influencing Factors of Unplanned Readmission in Patients With Acute Coronary Syndrome Within 30 Days After PCI.

The purpose of this study is to identify the influencing factors of unplanned readmission in patients with the acute coronary syndrome (ACS) within 30 days after percutaneous coronary intervention (PCI). From November 1, 2018, to October 31, 2019, the clinical data of 1277 patients with acute coronary syndrome and percutaneous coronary intervention retrospectively were collected. After screening by exclusion and rejection criteria, a total of 936 patients finally entered the study. Patients were divided into the readmission group (57 cases) and the non-readmission group (879 cases), according to whether unplanned readmission occurred within 30 days after PCI. To analyze the influence of patients' age, past disease history, medication history, laboratory data, vascular diseases, and other factors on readmission and the clinical characteristics of readmission patients. Fifty-seven patients had unplanned readmission within 30 days, and the readmission rate was 6.09%. The clinical features of readmission patients are older age, longer hospitalization days, more emergency percutaneous coronary intervention, more patients with diabetes history, and more patients diagnosed with ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction. Logistic regression analysis revealed that smoking index, number of diseased vessels, ACEF score, diabetes, and PCI status were the influencing factors of unplanned readmission of ACS patients within 30 days after PCI. Smoking index, number of diseased vessels, ACEF score, diabetes, and PCI status are the influencing factors of unplanned readmission within 30 days after percutaneous coronary intervention for patients with acute coronary syndrome.

PROGNOSTIC VALUE OF RESIDUAL SYNTAX SCORE COMBINED WITH ACEF SCORE IN ACUTE CORONARY SYNDROME PATIENT AFTER PERCUTANEUS CORONARY INTERVENTION IN SAIFUL ANWAR HOSPITAL, MALANG

Background : Percutaneous coronary intervention (PCI) is one of the revascularization options in patients with clinical acute coronary syndrome (ACS) who often have multiple and complex vascular lesions. So, the decision to complete revascularization is still a topic that is widely explored to reduce the rate of rehospitalization and reinfarction. This study aims to determine the predictor value of rehospitalization and reinfarction events that can be used in ACS patients undergoing IKP using coronary angiography parameters with residual SYNTAX scores and clinical parameters using ACEF scores. Method : The study was cohort prospective with the inclusion criteria being all ACS patients who underwent PCI in RSUD Dr. Saiful Anwar Malang from January 2017 to July 2021. All patients underwent IKP and underwent coronary angiography evaluation after IKP with a residual SYNTAX score (rSS) and divided into categories into rSS≤8 and rSS&gt;8. All patients underwent laboratory examination of serum creatinine and post-PCI echocardiography, and an ACEF score was obtained (ACEF score = age/left ventricular ejection fraction + 1 [if serum creatinine &gt;2 mg/dl]). Research subjects will be followed up for at least 1 year related to the incidence of post-PCI rehospitalization and reinfarction. Results : From a total sample of 209 patients, it was found that the residual SYNTAX score data had the most significant predictive factor for the occurrence of rehospitalization at 1 year after PCI (OR 6.14 [95% CI, 1.92-1967]). At the value of rSS &gt; 8, (AUC 0.750 [95% CI, 0.682-0.818], p 0.001) has a good predictive value for the occurrence of rehospitalization. However, combining with clinical parameters using the ACEF score provides a better predictive value. This study shows that the combination of rSS&gt;8 and ACEF score&gt;1.2 provides a better predictive value (AUC 0.884 [95%CI, 0.832-0.936) for the incidence of rehospitalization in post-PCI ACS patients. Conclusion : Acute coronary syndrome patients with residual SYNTAX scores &gt; 8 and ACEF scores &gt; 1.2 had a strong predictive value for rehospitalization events 1 year after PCI. The use of the combination of these two scores is expected to be a clinical guide to obtain the degree of completeness of revascularization in ACS patients.

Usefulness of the SYNTAX Score II to Predict In-Hospital and Long-Term Mortality in ST-Segment Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention.

ObjectivesThe prognostic significance of SYNTAX Score II (SS-II) is well-known in patients with chronic coronary syndromes. However, its predictive ability for mortality in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (p-PCI) remains unclear. Therefore, we aimed to investigate the prognostic accuracy of SS-II in STEMI patients who underwent p-PCI.MethodsA total of 743 STEMI patients treated with p-PCI were retrospectively analyzed. Study population was divided into three groups according to SS-II and defined as SS-IILOW ≤22.5 (n=245), 22.5 <SS-II MID ≤31 (n=243) and SS-II HIGH >31 (n=255). In-hospital and long-term mortality at long-term follow-up were defined as clinical endpoints of the study.ResultsThe incidence of in-hospital (15% vs. 0.4% vs. 0.8%, p<0.001) and all-cause mortality (32.2% vs. 6.6% vs. 2.9%, p<0.001) were significantly higher in SS-IIHIGH group compared with the other two groups. In addition, Kaplan–Meier analysis showed statistically significantly increased incidence of death in SS-II > 31 group (P [log-rank] <0.001). SS-II >31 was defined as an independent predictor of all-cause mortality (hazard ratio 5.22 95% confidence interval 2.11–12.87 p<0.001). Area under the curve values derived from ROC analysis to evaluate the predictive accuracy of SS-II, anatomical and clinical SS, modified ACEF score, and Global Registry of Acute Coronary Events risk scores for all-cause mortality were 0.82, 0.71, 0.81, 0.82, and 0.82, respectively (p<0.001).ConclusionSS-II has an increased predictive ability for in-hospital and long-term mortality in STEMI patients undergoing p-PCI.

OR60. The acef (age, creatinine, ejection fraction) score predicts major adverse cardiac events in patients hospitalized for acute coronary syndrome

Abstract Background and Aims Age, Creatine, and Ejection Fraction (ACEF) score is a simple model for predicting mortality in patients undergoing elective cardiac surgery. However, the ability of ACEF score to predict other outcomes, such as major adverse cardiac events (MACE) in patients hospitalized with ACS, is less established. Method and Result In this study, 71 patients who were admitted with ACS to Kediri General Hospital between January and June 2020 with echocardiography data were included. The follow-up period to observe MACE was 6 months. The ACEF score was calculated using the following formula: age (years)/left ventricular ejection fraction (%) + 1 (if baseline serum creatinine was &amp;gt; 2 mg/dl). The median ACEF score was 1.15 (0.6-5.08). A higher ACEF score was linked with higher SGOT, the presence of diabetes mellitus, anaemia, and left bundle branch block (LBBB) on admission. ACEF score's predictive performance was then evaluated. Receiver-operating characteristic (ROC) curve analysis was used to assess the ability of ACEF score to predict MACE. The observed AUC was 0.8 (95% CI 0.6-0.98). Using ACEF score cut-off of 1.79, the sensitivity was 85.7% and the specificity was 82.8% to predict future MACE. The AUC in this study was higher than that in previous studies. Kristic et al (2021) found AUC of 0.63 (0.55-0.7) for ACEF score in predicting MACE in NSTE-ACS. Conclusion ACEF score may serve a simple way to predict risk of future MACE in patients hospitalized for ACS.

CatLet score and Clinical CatLet score as predictors of long-term outcomes for patients with acute myocardial infarction undergoing delayed percutaneous coronary intervention

Abstract Background We have recently developed a Coronary Artery Tree description and Lesion EvaluaTion (CatLet) angiographic scoring system based on the 17 myocardial segment model, law of competitive blood supply, and law of flow conservation. This novel angiographic scoring system can be utilized to account for the variable coronary anatomy, the severity and complexity of coronary artery lesions, and to standardize the collection of angiographic data. Our preliminary study demonstrated that the CatLet score better predicted clinical outcomes than the SYNTAX score for patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI). The current study aimed at assessing whether the CatLet score (CS) and the Clinical CatLet score (CCS) predicted clinical outcomes for AMI patients undergoing delayed PCI. Methods The CS was calculated in 1018 consecutively prospectively enrolled AMI patients. Primary end point was major adverse cardiac events (MACEs), a composite of myocardial infarction, cardiac death, and ischemia-driven revascularization. CCS was calculated multiplying the CS by the ACEF score constructed using age, creatinine, and LVEF. Tertile partitioning of CS and CCS were as follows: CSlow ≤12, CSmid 13–18, and CStop ≥19; CCSlow ≤13, CCSmid 14–24, and CCStop ≥25, respectively. Cox regression analysis was employed to identify the associations between predictors and clinical outcomes. Results Four-year MACE rates were significantly higher with CStop compared with CSlow [4.82 (3.39–6.85), P&amp;lt;0.001], which was also the case for all-cause death, cardiac death, myocardial infarction, and ischemia-driven revascularization; for all these endpoints, there were a significant trend (P&amp;lt;0.001) for higher event rates with the increasing CS tertiles as shown in Figure 1. Stratifying outcomes across CCS tertiles resulted in similar results for the comparisons between CCStop and CCSlow. For MACEs, CCS had a significantly increased C-index [(C-index (95% CI), 0.725 (0.692–0.759) vs. 0.693 (0.659–0.727), P=0.001] compared with CS, which was also the case for all-cause death, cardiac death, and myocardial infarction. However, for ischemia-driven revascularization, CCS had a slightly decreased C-index [0.655 (0.609–0.701) vs. 0.670 (0.625–0.716), P=0.235] compared with CS, without a significant difference. In terms of calibration, CCS was comparable to CS for MACEs, all-cause death, cardiac death, and myocardial infarction. However, calibration for ischemia-driven revascularization worsened for CCS compared with CS (χ2=22.07, P=0.004 vs. χ2=7.79, P=0.454). Both scores remained to be independent predictors of clinical outcomes (in separate models) after adjustment for a broad spectrum of risk factors. Conclusions CS and to a greater extent CCS were able to risk-stratify long-term outcomes in AMI patients undergoing delayed PCI. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): 2020YFC2004705 &amp; SYS2019040 Figure 1. Kaplan-Meier curves for endpoints

The Incremental Prognostic Value of the Clinical Residual SYNTAX Score for Patients With Chronic Renal Insufficiency Undergoing Percutaneous Coronary Intervention.

Background: The residual SYNTAX score (RSS) is considered a powerful prognostic indicator for determining a reasonable revascularization strategy in patients undergoing percutaneous coronary intervention (PCI), but the absence of clinical parameters is one of the limitations of RSS, especially in the chronic renal insufficiency (CRI) comorbidity setting. The present work aimed to investigate the incremental prognostic value of clinical residual SYNTAX score (CRSS) compared with RSS in CRI cases after PCI.Methods: Totally 2,468 consecutive CRI cases who underwent PCI from January 2014 to September 2017 were included in this retrospective analysis. CRSS was obtained by multiplying RSS by the modified ACEF score. Individuals with CRSS >0 were considered to have incomplete revascularization and stratified by CRSS tertiles, the remaining cases constituted the complete revascularization (CR) group. The outcomes between these groups were compared.Results: At a median follow-up of 3 years, compared with CR group, individuals with CRSS >12 showed elevated rates of all clinical outcomes, and those with CRSS ≤ 12 showed similar all-cause and cardiac mortality rates. In multivariable analysis, CRSS was a powerful independent predictive factor of all clinical outcomes. The net reclassification improvement levels of CRSS over RSS for all-cause and cardiac mortality rates were 10.3% (p = 0.007) and 16.4% (p < 0.001), respectively. Compared with RSS, CRSS markedly ameliorated all-cause and cardiac mortality risk stratification.Conclusions: Compared with RSS, CRSS has incremental predictability for long-term all-cause and cardiac mortality in CRI cases following PCI.

ACEF performed better than other risk scores in non-ST-elevation acute coronary syndrome during long term follow-up

BackgroundRisk stratification of patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) is an important clinical method, but long-term studies on patients subjected to all-treatment strategies are lacking. Therefore, the aim was to compare several established risk scores in the all-treatment NSTE-ACS cohort during long-term follow-up.MethodsConsecutive patients (n = 276) with NSTE-ACS undergoing coronary angiography were recruited between September 2012 and May 2015. Six risk scores for all patients were calculated, namely GRACE 2.0, ACEF, SYNTAX, Clinical SYNTAX, SYNTAX II PCI and SYNTAX II CABG. The primary end-point was Major Adverse Cardiovascular Events (MACE) which was a composite of cardiac death, nonfatal myocardial infarction, ischemic stroke or urgent coronary revascularization.ResultsDuring a median follow-up of 33 months, 64 MACE outcomes were recorded (23.2%). There was no difference between risk score categories, except in the highest risk group of ACEF and SYNTAX II PCI scores which exhibited significantly more MACE (51.6%, N = 33 and 45.3%, N = 29, P = 0.024, respectively). In the multivariate Cox regression analysis of individual variables, only age and atrial fibrillation were significant predictors for MACE (HR 1.03, 95% CI 1.00–1.05, P = 0.023 and HR 2.02, 95% CI 1.04–3.89, P = 0.037, respectively). Furthermore, multivariate analysis of the risk scores showed significant prediction of MACE only with ACEF score (HR 2.16, 95% CI 1.36–3.44, P = 0.001). The overall performance of GRACE, SYNTAX, Clinical SYNTAX and SYNTAX II CABG was poor with AUC values of 0.596, 0.507, 0.530 and 0.582, respectively, while ACEF and SYNTAX II PCI showed the best absolute AUC values for MACE (0.630 and 0.626, respectively).ConclusionsACEF risk score showed better discrimination than other risk scores in NSTE-ACS patients undergoing all-treatment strategies over long-term follow-up and it could represent a fast and user-friendly tool to stratify NSTE-ACS patients.

Hyperhomocysteinemia and inflammatory biomarkers are associated with higher clinical SYNTAX score in patients with stable coronary artery disease

Background/Aim. Previous studies have confirmed a positive correlation between homocysteine levels and a greater risk for acute coronary syndrome and stroke, but there are no available data to support an association between homo-cysteine and inflammatory markers and the severity of coronary artery disease according to the clinical SYNTAX score in patients with stable angina. The aim was to determine the association between homocysteine and inflammatory biomarker levels: interleukin (IL)-6, high sensitive C-reactive protein (hs-CRP), fibrinogen, erythrocyte sedimentation rate (ESR) and the severity of coronary artery disease according to clinical SYNTAX score. Methods. Eighty-two patients with stable angina pectoris (average age 65 ? 8 years, 28.9% females) underwent coronary angiography and were divided into three groups according to the clinical SYNTAX score: the group I &lt; 22 (39 patients), the group II 23?32 (16 patients), the group III &gt; 33 (27 patients). The severity and complexity of coronary artery disease were calculated by clinical SYNTAX score, multiplying the SYN-TAX score with the modified ACEF score, based on the patients? left ventricular ejection fraction, age and creatinine clearance (derived with Cockcroft?Gault equation). Results. Homocysteine levels were significantly higher in patients with high clinical SYNTAX score [the group I: median (interquartile range ? IQR): 10.20 (3.97), the group II: 10.45 (5.77), the group III: 14.70 (7.50), p = 0.005]. Patients in the group III had significantly higher homocysteine levels compared to the group I (p = 0.001). We also found a posi-tive association between inflammatory biomarkers (IL-6, hsCRP, fibrinogen, ESR) and the severity of coronary artery disease according to the clinical SYNTAX score (p = 0.017, 0.001, 0.032, 0.049 respectively). We detected significantly lower plasma levels of vitamin B12 in the group III and group II in comparison with the group I (the group I: median (IQR): 238 (160), the group II: 171 (160), the group III: 172 (102), p = 0.022), which indicates its important role in homocysteine metabolism. Conclusion. The elevated plasma levels of homocysteine, IL-6, hsCRP, fibrinogen, ESR were detected in patients with high clinical SYNTAX score (&gt; 33). Our results showed that hyperhomocysteinemia and some inflammatory biomarkers can predict more severe and extensive coronary artery disease in stable angina patients.

Predictive Capacity of ACEF Score to Detect All-Cause Mortality and Post Contrast Acute Kidney Injury Among PCI Patients

Background and Aims: ACEF score is simple risk score which uses only three parameters for predicting mortality and postcontrast acute kidney injury (PC-AKI). This study was designed to look into various risk factors and ACEF score for patients undergoing Percutaneous Coronary Intervention (PCI).&#x0D; Methods: This is single-centre, observational, cross-sectional study. The patients were divided into tertiles.Bivariate analysis of various risk factors and ACEF score was done for PC-AKI as well as In-hospital and 30-day mortality.&#x0D; Results: Total 257 patients were included.The total mortality among PCI patients were low: In-hospital (0.8%) and 30-day (1.9%). The risk factor for increased mortality were higher Killip class and reduced Ejection Fraction (EF). PCAKI occurred in one-fifth. The risk factors for PC-AKI were increasing age, higher Killip class, diabetes, reduced EF, emergency PCI procedure and higher contrast volume. Hydration with NS was protective against PC-AKI. Mean ACEF score was higher among those who died within 30 days (p=0.35) and who developed PC-AKI (p&lt;0.001). ACEF-low had trend toward better outcome with no mortality (p=0.17) and had low risk of PC-AKI (p=0.026). ACEF-moderate had reduced risk of PC-AKI (p=0.029), however was not associated with increased odds of 30-day mortality (p=0.66). ACEF-high showed significantly increased odds of mortality (p=0.04) and PC-AKI (p&lt;0.001). Discriminatory capacity of ACEF score to detect 30-day mortality was good (AUC 0.82, p= 0.016) and goodness of fit=0.70. Discriminatory capacity of ACEF score to detect PC-AKI was fair (AUC 0.7, p&lt;0.001) and goodness of fit=0.62.&#x0D; Conclusions: ACEF score fairly predicts the short-term mortality and PC-AKI in patients undergoing PCI.

Chronic total occlusion management in female patients: gender gap?

Abstract Background A gender gap has been known to exist in the clinical presentation, management and outcomes of coronary artery disease. Nevertheless, it is not well described how these differences pertain to the management of chronic total occlusion (CTO) of coronary arteries. The aim of this study was to compare sex-based differences in CTO management and long-term outcomes. Methods We included all consecutive patients with CTO diagnosed in an academic center between 2010 to 2014. There were no exclusion criteria. We collected demographic, clinical, and management data. All-cause and cardiac mortality were assessed during a median follow-up of 4.03 years (IQR 2.6–4.8). Results A total of 1248 consecutive patients (mean age 67.3±10.9 years; 23,5% females) with at least one CTO receiving either revascularization or optimal medical treatment (MT) were identified. The female group included 198 patients (23.5%). Women were older, had a higher prevalence of type 2 DM and a lower ventricle ejection fraction compared to their male counterparts (p&amp;lt;0.05). There were no differences in the number of CTOs depending on gender, but women had a higher Global SYNTAX II score (50±12 vs 44±22; p&amp;lt;0.001) compared to men. The female group had a higher positive result for ischemia or viability (90% vs. 77%; P=0.04) compared to the male group. Nevertheless, women were more often treated with MT alone compared to male patients (57% vs 49%; P=0.04), who were more likely to undergo PCI or surgery. There were no significant differences in CTO revascularization success between both groups (30% vs. 24%; P=0.40). During a median follow-up of 4.03 years (IQR 2.6–4.8), a total of 386 (31%) patients died. Women presented a higher rate of all-cause mortality in both MT and revascularization groups (52% vs. 39% and 17% vs 16%, respectively; p&amp;lt;0.001) compared to men. Although cardiac mortality was lower in the revascularized patients, it was significantly higher in women compared to men, regardless of CTO treatment strategy (37% vs. 23% and 11% vs 8%; p&amp;lt;0.001 for both). Multivariable analysis identified that female gender was associated with higher rates of cardiac mortality [OR 1.67, 95% confidence interval (CI) (1.10–2.57), P&amp;lt;0.001, but not with all-cause mortality [OR 1.37, 95% confidence interval (CI) (0.92–2.02), P=0.1]. Age, peripheral vascular disease, chronic kidney disease, the ACEF score, the Global SYNTAX I score, and MT of the CTO were also independent predictors for all-cause and cardiac mortality. Conclusions In our cohort, female patients with a CTO were significantly older and presented more prevalence of diabetes mellitus. Women with CTO were more often treated with MT alone, compared to their male counterparts, who were more likely to undergo invasive strategies - PCI or surgery. Female gender was associated with higher cardiac mortality on our cohort regardless of CTO treatment in a long-term follow-up. Figure 1 Cardiac Survival Rates Funding Acknowledgement Type of funding source: None

HbA1C modified Clinical SYNTAX score as a prognostic tool in patients with diabetes mellitus and multi-vessel coronary artery disease treated with primary percutaneous coronary intervention

Abstract Introduction Patients with acute coronary syndrome (ACS) and diabetes mellitus (DM) have an increased risk of major adverse cardiovascular events (MACE) after percutaneous coronary intervention (PCI), which is not estimated sufficiently-multidimensionally in terms of type and severity of the ACS and/or DM and angiographic findings. Aim The study was intended to estimate and compare the predictive clinical value of the modified SYNTAX score versus the predictive clinical value of the SYNTAX score to the one-year appearance of MACE after conducted PCI in patients with DM (with diagnosis longer than one year and multivessel disease) and acute coronary syndrome (ACS). Material and methods A prospective cross-section study was performed in patients with DM and ACS. In the PCI period the following risk factors where were recorded: 1) age and metabolic variables – glycosylated hemoglobin (HbA1c), total cholesterol, triglyceridemia; 2) endocrinological variables – DM therapy, tip of DM; 3) ACS modality; 4) radiological / anatomical variable – SYNTAX score and 5) clinical variables in modified ACEF score and clinical SYNTAX score. One-year MACE were recorded. Results From a total of 136 consecutive patients, 55 of them developed at least one MACE in one-year follow-up. Two highly predictable MACE risk indexes (MACERI) were constructed. The first risk index – MACERI (c statistic = 0.879) was defined by: SYNTAX score &amp;gt;21, modified ACEF &amp;gt;1.38, HbA1c ≥8 (%), triglyceridemia ≥2.3 (mmol / L) in patients on insulin therapy and ACS modality – unstable angina pectoris. MACERI has better predictive characteristics than SYNTAX score (c statistic = 0.798) as well as ACF score, but not in relation to clinical SYNTAX score (c statistic = 0.820). The second risk index – MACERI II (c statistic = 0.923), defined the same risk factors as MACERI, except HbA1c ≥8 (%),which additionally contains a risk factor – the presence of three-vessel disease. MACERI II had significantly better predictive characteristics than all mentioned scores, but also in relation to MACERI. Conclusions MACERI and MACERI II can potentially have great application in future risk factors studies for one-year MACE in patients with DM and ACS who underwent PCI, because with them the effects of these factors measure multidimensionally at valid and accurate manner. Funding Acknowledgement Type of funding source: None

A comparison of existing risk prediction models in patients undergoing venoarterial extracorporeal membrane oxygenation

BackgroundPatients undergoing consideration for venoarterial extracorporeal membrane oxygenation (VA-ECMO) require an immediate risk profile assessment in the setting of incomplete information. A number of survival prediction models for critically ill patients and patients undergoing elective cardiac surgery or institution of VA-ECMO support have been designed. We assess the ability of these models to predict outcomes in a cohort of patients undergoing institution of VA-ECMO for cardiogenic shock or cardiac arrest. MethodsFifty-one patients undergoing institution of VA-ECMO support were retrospectively analyzed. APACHE II, SOFA, SAPS II, Encourage, SAVE, and ACEF scores were calculated. Their ability to predict outcomes were assessed. ResultsIndications for ECMO support included postcardiotomy shock (25%), ischemic etiologies (39%), and other etiologies (36%). Pre-ECMO arrest occurred in 73% and 41% of patients underwent cannulation during arrest. Survival to discharge was 39%. Three survival prediction model scores were significantly higher in nonsurvivors to discharge than surivors; the Encourage score (25.4 vs 20; p = .04), the APACHE II score (23.6 vs 19.2; p = .05), and the ACEF score (3.1 vs 1.8; p = .03). In ROC analysis, the ACEF score demonstrated the greatest predictive ability with an AUC of 0.7. ConclusionsA variety of survival prediction model scores designed for critically ill ICU and VA-ECMO patients demonstrated modest discriminatory ability in the current cohort of patients. The ACEF score, while not designed to predict survival in critically ill patients, demonstrated the best discriminatory ability. Furthermore, it is the simplest to calculate, an advantage in the emergent setting.

Case-mix affects calibration of cardiosurgical severity scores.

Prognostic models are often used to assess the quality of healthcare. Several scores were developed to predict mortality after cardiac surgery, but none has reached optimal performance in subsequent validations. We validate the most used scores (EUROSCORE I and II, STS, and ACEF) on a cohort of cardiac-surgery patients, assessing their robustness against case-mix changes. The scores were validated on 14,559 patients admitted to 16 Italian cardiosurgical ICUs participating to Margherita-Prosafe project in 2014 and 2015. Calibration was assessed through Hosmer-Lemeshow Test, standardized mortality ratio, and GiViTI calibration test and belt. Discrimination was measured by the area under the ROC curve. The study included 10,317 patients who were eligible to the calculation of the STS Score (4156 isolated valve, 4681 isolated CABG and 1480 single valve and CABG) which calibrated well in these subgroups. The ACEF Score and EUROSCORE I and II were available for 14,139, and 14,071 patients, respectively. EUROSCORE I significantly overestimated mortality; EUROSCORE II calibrated well overall, but underestimated mortality of patients undergoing complex surgery and non-elective ones. The ACEF Score calibrated poorly in elective and non-elective patients. Discrimination was acceptable for all models (AUC>0.70), but not for the ACEF Score. Cardiac surgery scores calibrate poorly when the case-mix of validation and development samples differs. To grant reliability for benchmarking, they should be validated in the clinical settings on which they are applied and updated periodically. Advanced statistical tools are essential for the correct interpretation and application of severity scores.

Survival benefit of revascularization versus optimal medical therapy alone for chronic total occlusion management in patients with diabetes.

Chronic total occlusion (CTO) is common in patients with diabetes mellitus. Data on the long-term outcomes after treatment of CTOs in this high-risk population are scarce. To compare the long-term clinical outcomes of CTO revascularization either by coronary artery bypass graft (CABG) or successful percutaneous coronary intervention (PCI) versus optimal medical treatment (MT) alone in patients with diabetes. A total of 538 consecutive patients with diabetes and at least one CTO were identified from 2010 to 2014 in our center. In the present analysis, patients were stratified according to the CTO treatment strategy that was selected. MT was selected in 61% of patients whereas revascularization in the remaining 39%. Patients undergoing revascularization were younger, had higher left ventricular ejection fraction (LVEF), lower ACEF score, and more positive myocardial ischemia detection results compared to the MT group (p < .001).Patients referred for CABG had higher rates of left main disease compared to the PCI and MT groups (32% vs. 3% and 11%, respectively; p < .001). Complete revascularization was more often achieved in the CABG group, compared to the PCI group (62% vs. 32% p < .001). Multivariable analysis showed that revascularization with CABG was associated with lower rates of all-cause and cardiac mortality rates compared to MT, [hazard ratio (HR) 0.41, 95% confidence interval (CI) 0.25-0.70, p < .001 and HR 0.40, 95% CI 0.20-81, p = .011, respectively]. Successful CTO-PCI showed a trend towards benefit in all-cause mortality (HR 0.58, 95% CI 0.33-1.04, p = .06). In our registry, CTO revascularization in diabetic patients, especially with CABG, was associated with lower long-term mortality rates as compared to MT alone.