Acute Coronary Events Research Articles

Acute Coronary Syndrome: Disparities of Pathophysiology and Mortality with and without Peripheral Artery Disease.

There are a number of devastating complications associated with peripheral artery disease, including limb amputations and acute limb ischemia. Despite the overlap, atherosclerotic diseases have distinct causes that need to be differentiated and managed appropriately. In coronary atherosclerosis, thrombosis is often precipitated by rupture or erosion of fibrous caps around atheromatous plaques, which leads to acute coronary syndrome. Regardless of the extent of atherosclerosis, peripheral artery disease manifests itself as thrombosis. Two-thirds of patients with acute limb ischemia have thrombi associated with insignificant atherosclerosis. A local thrombogenic or remotely embolic basis of critical limb ischemia may be explained by obliterative thrombi in peripheral arteries of patients without coronary artery-like lesions. Studies showed that thrombosis of the above-knee arteries was more commonly due to calcified nodules, which are the least common cause of luminal thrombosis associated with acute coronary events in patients with acute coronary syndrome. Cardiovascular mortality was higher in peripheral artery disease without myocardial infarction/stroke than in myocardial infarction/stroke without peripheral artery disease. The aim of this paper is to gather published data regarding the disparities of acute coronary syndrome with and without peripheral artery disease in terms of pathophysiology and mortality.

Patient Experience of Inpatient Education After an Acute Coronary Syndrome Event

This study sought to explore the patient’s experience of inpatient health education after leaving hospital from an acute coronary syndrome (ACS) event, to understand areas of strength and opportunities for improvement. This study is a pilot using a qualitative descriptive design, drawing on phenomenological methods. Thirteen adult patients (aged ≥18 years) with a diagnosis of ACS participated in semi-structured telephone interviews held 2 weeks after hospital discharge. Almost half of the participants identified as being New Zealand Māori (46%), Pacific Islander (15%), New Zealand European (15%), Indian (15%), and other European (8%). Research findings were grouped, using thematic analysis, into three key themes: “making sense of my cardiac event”, “moving towards health”, and “building personal connections aids learning”. Multiple personal and system factors were identified that influence patients’ psychological recovery and their level of engagement with health information. The quality of relationships with health professionals encountered shaped patient uptake and investment in the education provided. When patients transitioned home, family and friends aided their return to normal and encouraged motivation towards healthy lifestyle change. This study provides important insights into the impact of an ACS event and identifies areas where health professionals can actively support health literacy and self-care during the transition from hospital to home.

Comparison of in hospital outcome of patients with and without distorted terminal portion of QRS complex on initial electrocardiogram in ST segment elevation myocardial infarction with GRACE scoring assessment

Distorted terminal portion of QRS complex on initial electrocardiogram in ST segment elevation myocardial infarction is a strong predictor of in hospital adverse outcome This observational prospective study was carried out in the department of cardiology, BSMMU, Dhaka from July 2014 to June 2015 to analyse admission ECG in patients of STEMI based on terminal portion of QRS complex and find out inhospital death, heart failure, cardiogenic shock and recurrent myocardial infarction, with GRACE scoring assessment. Total 60 patients with STEMI (age 54.33±10.37, 55M/5/F) were included in this study after analysing the selection criteria. We defined two ECG groups according to absence of distortion of terminal QRS (Group-I) and presence of distorted terminal QRS (Group-II) in two or more adjacent leads. Group-II further divided into pattern-A – J point originating at ³50% of height of R wave in leads with qR configuration and pattern B- S wave is absent in leads with RS configuration. Global Registry of Acute Coronary Events (GRACE) risk score was evaluated and compared in between two groups. Out of 60 patients of STEMI, 30 patients had distortion of QRS complex. There were 7 deaths, 16 heart failure, 3 cardigenic shock and no recurrent myocardial infarction. Hospital mortality and heart failure were found to be significantly higher in distorted QRS group (1 vs. 6 patients p=0.04; 4 vs. 12 patients p=0.02; respectively), cardiogenic shock of both groups did not show significant difference (0 vs. 3 patients p=0.075). Multiple logistic regression analysis using hospital mortality as dependable variable and all studied risk factors were independent variables, QRS distortion on admission ECG and Killip class were only variable found to be statistically significant (OR=7.25, p value < 0.05 ; OR=16.25, p value< 0.05 respectively). GRACE risk score was significantly high in distorted QRS group and low in without QRS distorted group (6 vs 15 patients p=0.014; 6 vs 16 patients p=0.007; respectively). Intermediate GRACE score did not show any statistically significant difference between two groups (p=0.77). Careful analysis of ECG which is simple, cheap, universally available bed side investigation may offer important prognostic information in patients with STEMI and would help in deciding which patients should go urgent myocardial revascularization procedure. Assessment of GRACE risk scoring is strongly encourage in everyday clinical practice as it provides reliable identification of STEMI patients who are at high risk of death. Bangladesh Medical Res Counc Bull 2022; 48(3): 211-218

Exercise Adherence in Older and Middle-Aged Adults With Coronary Artery Disease Before and During COVID-19.

Regular exercise is advised for individuals given a diagnosis of cardiovascular disease. COVID-19 presented challenges to exercise adherence. The objective of this study was to determine long-term exercise adherence and whether individuals with cardiovascular disease adhered to American Heart Association/American College of Cardiology Foundation guidelines before and during the COVID-19 pandemic. This is an observational cross-sectional study in which men (73%) and women discharged from a multiwide hospital system after an acute coronary event were enrolled. Participants completed 3 questionnaires, including the Exercise Adherence Rating Scale. Five hundred eighty-two individuals (mean [SD] age, 67 [9.8] years) completed the survey. Fifty-three percent of participants met minimum exercise guidelines during COVID-19. Exercise days per week decreased significantly during COVID-19 in women ( P = .013) but not significant for men ( P = .301). Categorized by age, the decrease was significant for middle-aged women ( P = .002), not older women ( P = .336). Men exercised more minutes per session ( P = .034), and had greater exercise adherence ( P = .003) and greater exercise intensity ( P < .001). Overall, women participated less in cardiac rehabilitation ( P = .046) and reported the greatest disparity in exercise adherence and intensity. Exercise after an acute event is beneficial, and the percentage of individuals meeting recommended guidelines should be higher considering the relationship between exercise and the possibility of future cardiac events. On the basis of the many physical and mental benefits of maintaining exercise, healthcare practitioners are encouraged to screen all patients for exercise adherence with a major emphasis on educating women and older adults.

Gender disparities in Cardiac Rehabilitation - Are we concealing apples from Eve?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Cardiovascular disease is a leading cause of death in both men and women and cardiac rehabilitation (CR) is recommended as part of secondary prevention for these patients. Despite this, there are still important asymmetries when it comes to enrolment of women in CR programs. Purpose To determine differences between referral and outcomes of cardiac rehabilitation programs among women. Methods Prospective cohort study which included consecutive pts who were participating in a centre-based CR program lasting 8 weeks from 2019 to 2021. We analyzed prevalence of risk factors, lab echocardiographic and CPET data in women who were enrolled in the program. Statistical analysis was performed with Mann-Whitney and Wilcoxon tests Results: From a total of 349 patients, 60 women completed a CR program – 17,8% of pts – representing a far smaller percentage when accounting to acute coronary syndrome events in our center in those 2 years (31% women). Mean age of female participants was 60 ± 11,8 years; 74% had hypertension, 64% dyslipidemia, 19% diabetes and only 40% had never smoked. There were no significant differences when compared to male, except for thyroid disease which was more frequent among women (p&amp;lt;0.01). Regarding lab data we noticed an improvement of LDL-c, total cholesterol, HDL-c, although only NTproBNP showed a statistically significant reduction (p=0.001). There was also an improvement of LVEF, once again without statistical significance (in contrast to the male population). After completion of the program, there was an improvement regarding CPET duration and workload (p&amp;lt;0.001 and p=0.019). Interestingly there was no difference in terms of peak VO2/kg, a data that goes in line with some reports of less impact of exercise based CR in this parameter in women. Moreover, there were no differences between genders in terms of outcome, namely admissions or cardiovascular death. Conclusion Women still have a lower rate of enrolment in CR programs, despite results showing a similar benefit to men. CR effectiveness by CPET should include other parameters besides VO2 peak. Strategies should be developed to improve women participation in CR.

Type I Kounis syndrome induced by COVID-19 vaccination in China: a case report

BackgroundKounis syndrome is a rare clinical condition characterized by the occurrence of an acute coronary event induced by an acute allergic episode. The ongoing pandemic of coronavirus disease 2019 (COVID-19) has contributed to an increase in the incidence of allergic reactions to a certain extent, thereby increasing the incidence of Kounis syndrome. Timely diagnosis and effective management of this disease are important in clinical practice.Case presentationWe report a 43-year-old woman who developed generalized pruritus, breathlessness, paroxysmal precordial crushing pain, and dyspnea after receiving the third dose of the COVID-19 vaccine. After anti-allergic treatment and therapy for acute myocardial ischemia, her symptoms resolved with improvement in cardiac function and resolution of ST-segment changes. The prognosis was satisfactory, and the final diagnosis was type I Kounis syndrome.ConclusionThis patient with type I Kounis syndrome rapidly developed acute coronary syndrome (ACS) after an acute allergic reaction to the COVID-19 vaccine. ​Timely diagnosis of acute allergic reaction and ACS, and targeted treatment based on the relevant guidelines are the key to successful treatment of the syndrome.​

Adding value of the Charlson comorbidity index to the Grace score for mortality risk prediction in patients with acute coronary syndrome

Abstract Funding Acknowledgements Type of funding sources: None. Background The Global Registry of Acute Coronary Events (GRACE) risk score is widely recommended for risk assessment in patients with acute coronary syndrome (ACS). The Charlson Comorbidity Index (CCI) is a recognized measure of comorbid burden, and a useful tool for estimating prognosis in patients with multiple coexisting illnesses. Despite it has been validated in the context of ACS-related mortality, scarce and conflicting data still exist about the role of the CCI when added to the traditional GRACE risk score for outcome prediction in patients with acute coronary syndrome (ACS). Purpose The assessment of the potential predictive value of the CCI both for short, and long term all-cause mortality, in a contemporary ACS population, and its potential adding value beyond the GRACE risk score. Methods All consecutive admission due to ST-elevation myocardial infarction-STEMI, non ST elevated myocardial infarction-NSTEMI, and unstable angina-UA, from 01/01/2018 to 31/12/2020 were retrospectively reviewed from an internal database of a tertiary cardiac center in Italy. Logistic and Cox proportional regression analysis were performed in order to assess the contribution of the CCI on short and long term mortality. In order to specify the CCI adding value to the GRACE score, several measures of improvement in discrimination (increase in the area under the receiver-operating characteristic curve-AUC, the integrated discrimination improvement-IDI, and the continuous net reclassification improvement-cNRI&amp;gt;0) , were implemented. Robustness of the results were assessed through an internal validation procedure with bootstrapping. Results A total of 1310 patients (646 STEMI, 588 NSTEMI, and 76 UA) were identified. Almost 28% were female, and the median age was 68 (58-78). 97 (7,4%) and 136 (11,2%) deaths occurred, respectively, in hospital and during long term follow-up (median follow-up time: 12 months; IQR: 8-23). After multivariate logistic regression analysis the CCI was not associated with in-hospital death, while it was significantly and independently associated with the long-term mortality along with GRACE score (HR: 1,33, 95% CI: 1,22-1,43; p&amp;lt;0,001, Fig.1). An additive effect of CCI with the GRACE risk score was observed in predicting long-term mortality with an AUC from 0,762 to 0.821 (p &amp;lt; 0,001). The incremental predictive value of combining CCI and the GRACE risk score for the long term mortality was significantly improved, as shown by the net reclassification improvement (cNRI&amp;gt;0: 0.678, p &amp;lt; 0.001, Table 1) and integrated discrimination improvement (IDI: 0.08, p &amp;lt; 0.001). Conclusion The CCI is a predictor of long-term mortality and improves risk stratification of patients with ACS over the GRACE risk score.

The prediction of angiographic coronary thrombus burden using the admission GRACE 2.0 score in ST-elevation myocardial infarction patients

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Heavy coronary thrombus burden is associated with increased periprocedural complications in ST-elevation myocardial infarction (STEMI) patients undergoing primary PCI (PPCI)[1]. The prediction of such a burden can help in planning the PPCI procedure in the best way. The Global Registry of Acute Coronary Events (GRACE) 2.0 score is a useful non-invasive tool to predict major adverse events in STEMI patients [2]. Purpose to assess the difference in coronary thrombus burden in STEMI patients with low and high risk GRACE 2.0 score on admission. Methods We retrospectively studied 210 STEMI patients who presented to a single PPCI centre over a period of 6 months. We consecutively included all the patients who were eligible for PPCI according to the European Society of Cardiology (ESC) guidelines [2]. We excluded the patients who received fibrinolysis, who had a previous PCI and presented with in-stent thrombosis and those who presented more than 24 hours from the onset of chest pain. All procedures were done according to the Helsinki declaration of research on human beings. The study protocol was approved by the local research ethics committee. The GRACE 2.0 score was calculated at the time of presentation to the emergency department using the online calculator [3]. We divided the patients according to their GRACE 2.0 score into a high-risk score (more than 140) and a non-high-risk score(up to 140) groups according to the ESC guidance.2 We compared the two groups regarding various cardiovascular risk factors and the angiographic thrombus burden during the PPCI procedure. Two experienced interventional cardiologists (blinded to the allocation group) assessed the thrombus burden using the TIMI thrombus grades [4]. A heavy thrombus burden was defined as a thrombus grade of 4 or 5. A professional statistician carried out the statistical analysis using IBM SPSS 21.0 software. Results The baseline characteristics of the studied groups are shown in figure 1. Multivariate regression analysis did not show an influence of the different cardiovascular risk factors on the thrombus burden in the studied groups. The percentage of patients with a heavy thrombus burden was higher in the high-risk score group; however, the difference between the two groups was not statistically significant (44.6% vs 35.3%, P=0.46) (figure 2). This study is the first to assess the ability of the GRACE 2.0 score to predict the coronary thrombus burden in STEMI patients undergoing PPCI. The study is limited by the small number of patients included and the small geographical scale. Conclusion Although the GRACE 2.0 is a well-validated tool to predict the clinical prognosis in STEMI patients, it could not identify those patients with a high coronary thrombus burden in our small study. Further larger-scale studies are required to find other non-invasive tools to identify this high-risk cohort.

Potential utility of B-type natriuretic peptides in secondary prevention following percutaneous coronary intervention in remote communities of Western Australia

Introduction A third of all acute coronary events that present in the Australian population occur in patients with established coronary heart disease. This study assessed the prognostic value of combined B-type natriuretic peptides (BNP) measurement and quantitative myocardial perfusion scan (MPS) data for cardiac events (CE). Material and methods This retrospective cohort study involved 133 patients from rural Western Australia. The cut-off for normality was 6.0 for qualitative summed difference scores (SDS) of MPS and 400 pg/mL for BNP. Results Patients with no CE had a mean SDS and BNP (1.52 with a 95% CI of 0.34 to 2.69), (175.9 with a 95% CI of 112.7-239.1) that was lower than patients with CE (6.54 with 95% CI 4.18-9.89) (P = 0.0003), (669.1 with 95% CI 543.9-794.3) (P < 0.0001). The sensitivity and specificity of combined testing for predicting CE respectively were 79.6% and 86.3% for SDS, 84.6% and 94.1% for BNP, and 100% and 92.7% for SDS and BNP combined. Discussion and conclusion Elevated BNP is marginally superior to MPS in predicting CEs in patients who have previously undergone percutaneous coronary intervention (PCI); however, MPS can identify the region of myocardium most at risk. Routine BNP monitoring in this subgroup may serve as secondary prevention by identifying subclinical disease.

Alexithymia for cardiologists: a clinical approach to the patient.

Alexithymia literally meaning 'no words for emotions' is a term used in mental health settings to describe people who have difficulties in identifying and verbalizing their emotional states. There is evidence in the literature that this personality trait may influence negatively the illness behavior when an acute coronary event occurs. In fact, people with high alexithymia are more likely to experience wrong appraisal and interpretation of symptoms, and because of their difficulty in describing feelings to others, they can be poor in reporting symptoms at the first consultation with a physician. This behavioral pattern (alexithymic) may put patients with acute myocardial infarction at higher risk for delayed medical care. Here, we aim to present an overview of alexithymia from the perspective of the clinical cardiologist, with a focus on the definition, clinical recognition, and potential impact on cardiovascular health.

Acute coronary events in SARS-CoV-2 - causal or incidental?

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus can damage respiratory, cardiovascular system by various mechanism which can lead to increased morbidity and mortality. Aims and Objectives: The aim of the study was to assess incidence of acute coronary syndrome (ACS) in moderate to severe cases of infection with SARS-CoV-2. Materials and Methods: This was an observational cross-sectional study including 60 patients of age ≥18 years of either gender presenting to GTB Hospital diagnosed as positive for SARS-CoV-2 by RT-PCR and/or Rapid Antigen Test and belonging to moderate and severe category without any prior history of respiratory, cardiac, gastrointestinal, renal illness, long-term corticosteroid, or immunomodulator use. The cardiac involvement was assessed by history, clinical examinations, and investigations. Results: Cardiovascular involvement was present in 25% patients. Cardiac involvement included ACS including ST elevation myocardial infarction (STEMI) (3.3%), non-STEMI (10%), unstable angina (1.67%), left ventricular hypertrophy (8.3%), bundle branch block (3.3%), atrial fibrillation (1.67%), and bradycardia (1.67%). Raised cardiac enzyme levels positively correlated with ECG abnormalities. Respiratory involvement was seen in 85% of patients. among which 56.7% patients in severe category, 41.67% patients in moderate category, and 1.67% patients in mild category as per CTSI scoring. There was lung parenchymal involvement with ground glass opacities in bilateral lungs (68.3%), lobar consolidation (6.7%), cavitatory lesion (5%), pulmonary edema (5%), pneumothorax (3.3%), emphysematous changes (3.3%), and bilateral pleural effusion (3.3%). Conclusion: ACS occurs frequently in patients with SARS-CoV-2 and it is associated with complications such as congestive heart failure, bundle branch block, atrial fibrillation, bradycardia, and heart block.

Lipid-Lowering Therapy Utilization and Dosage Among Patients with Acute Coronary Syndrome Events: A Retrospective Cohort from 12 Community Hospitals.

Clinical practice guidelines recommend initiating a high-intensity LLT and continued monitoring of low-density lipoprotein cholesterol (LDL-C) following acute coronary syndrome (ACS). We used real-world data to describe LLT utilization after discharge and 1-year adherence. The reduction in LDL-C was also evaluated. Data were extracted from electronic health records (EHRs) from 12 hospitals in a large community healthcare system in midwestern United States between 2013 and 2019. Data on eligible patients recently discharged with an ACS event were linked to pharmacy claims data to describe LLT fill rates and 1-year post-discharge adherence. Adherence was reported as the proportion of days covered ≥80%. Of the 10,589 eligible patients, 49% filled a high-intensity statin at discharge and only 36% were adherent at 1 year. The mean (SD) age was 66.1±13.3, 39.3% were females, 58.8% were Caucasian, and 53.0% had Medicare. There was a clear trend for greater fill rates at discharge among patients with higher LDL-C values than those with lower values (p<0.01). Key predictors of high-intensity (versus medium-intensity) LLT use within 21 days after an ACS event included ACS type (odds ratio [OR] 0.59; 95% confidence interval [CI] 0.52-0.67 for NSTEMI versus STEMI), age group (OR: 0.59; 95% CI: 0.48-0.72 for >75 years versus <65years), and statin use before index ACS event (OR: 1.56; 95% CI: 1.23-1.88). This real-world study found that despite recommendations in clinical practice guidelines, high-intensity LLT fill rates at discharge and 1-year adherence to LLT remain suboptimal. Clinical characteristics, including ACS type and LDL-C values, were strong predictors of filling and adherence to guideline-recommended therapy. Age, sex, and race/ethnicity disparities were observed in discharge fill rates and 1-year adherence. These results highlight the need for continued efforts at the patient and provider levels to improve LLT adherence among ACS patients.

PO-04-202 RESUSCITATED OUT OF HOSPITAL CARDIAC ARREST AS THE INITIAL PRESENTATION OF HYPERTROPHIC CARDIOMYOPATHY

Hypertrophic cardiomyopathy (HCM) is the most common heritable cardiomyopathy, and it is associated with ventricular arrhythmias and sudden death. Out-of-hospital cardiac arrest (OHCA) may be the first presentation of HCM in some patients. To determine the frequency of resuscitated OHCA as the initial presentation of HCM, as well as the characteristics, initial management, and outcomes of these patients. Patients with HCM were identified with a comprehensive phenotyping approach, including natural language processing of electronic medical records, cardiac imaging reports, and diagnosis codes. HCM diagnoses were validated by trained reviewers. Among these, we focused on patients who had resuscitated OHCA as the initial presentation leading to the HCM diagnosis. Baseline characteristics, HCM treatments and outcomes were obtained from the electronic medical record. Of 6,276 patients diagnosed with HCM at our institution between 2001-2019, we identified 29 (0.5%) patients with resuscitated OHCA as their initial HCM presentation (17% female; mean age at the time of OHCA 34 ± 17 years). Ventricular tachyarrhythmia was the confirmed cause of OHCA in 24 patients. No patients had a primary acute coronary event as the etiology of OHCA. The median of the thickest wall segment was 30.5 mm and 8 (28%) patients had obstructive HCM. An apical pouch was present in 5 (17%) patients. All patients underwent ICD implantation following OHCA and survived hospital discharge. The mean follow-up post-OHCA was 9 ± 6.6 years. During follow-up, 13 (45%) patients underwent septal reduction therapy. 8 (28%) patients had at least one appropriate ICD shock or antitachycardia pacing event for VT/VF. Two (7%) patients died during follow-up, one from a cardiac non-arrhythmic cause and one from an unknown cause. Resuscitated OHCA is an infrequent initial presentation of HCM. These patients remain at risk for recurrent VT/VF, but overall long-term survival is favorable with secondary prevention ICDs and other HCM-directed therapies.

Prognostic significance of serial N-terminal pro-B-type natriuretic peptide levels in patients with acute myocardial infarction: A prospective study

This study aimed to investigate the association between N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels at different sampling times and prognosis in patients with acute myocardial infarction (AMI) undergoing emergency percutaneous coronary intervention (PCI). Between March 2017 and January 2020, 1,105 patients with AMI who underwent emergency PCI were included. NT-proBNP levels were measured on days 0, 1, 2, 3, and 7. A composite of all-cause death, MI recurrence (reMI), and rehospitalization due to heart failure, known as major adverse cardiovascular events (MACE), was recorded. During the 36.8-month follow-up, 175 patients (15.8%) experienced MACEs. When patients were grouped based on quartiles of NT-proBNP levels on days 0 and 7, the results demonstrated that patients in quartile 4 showed a substantially increased MACE risk compared to those in quartile 1 (hazard ratio [HR] 2.27, 95% confidence interval [CI]:1.27-4.08, P=.006; HR 2.20, 95%CI:1.23-3.94, P=.008). There were U-shaped relationships between the HR for MACE and NT-proBNP levels on days 2, 3, and 7, as well as peak NT-proBNP (P for nonlinearity=.007, .006, .004, and .009, respectively). A similar relationship was observed in the HR for reMI and NT-proBNP levels on days 2 and 3. For MACE at 3 years, serial NT-proBNP levels improved the predictive accuracy of the Global Registry of Acute Coronary Events (GRACE) risk score (concordance index [C-index]: 0.711; continuous net reclassification improvement [NRI]: 0.192, 95% CI: 0.022-0.445; integrated discrimination improvement [IDI]: 0.034, 95% CI: 0.016-0.064). For all-cause death at 3 years, the combination of NT-proBNP and GRACE score showed excellent performance, with C-index, continuous NRI, and IDI values of 0.801, 0.373 (95%CI: 0.072-0.853), and 0.051 (95%CI: 0.025-0.091), respectively. Early and sequential measurement of NT-proBNP levels could assist in predicting MACE risk. Moreover, the relationship between MACE risk and NT-proBNP levels was U-shaped. clinicaltrials.gov NCT: 03593928.

Social Determinants of Health and Mortality After Premature and Non-premature Acute Coronary Syndrome

ObjectiveTo describe and compare the determinants of 1-year mortality after premature vs non-premature acute coronary syndrome (ACS). Patients and MethodsParticipants presenting with ACS were enrolled in a prospective registry of 29 hospitals in 4 countries, from January 22, 2012 to January 22, 2013, with 1-year of follow-up data. The primary outcome was all-cause 1-year mortality after premature ACS (men aged <55 years and women aged <65 years) and non-premature ACS (men aged ≥55 years and women aged ≥65 years). The associations between the baseline patient characteristics and 1-year mortality were analyzed in models adjusting for the Global Registry of Acute Coronary Events (GRACE) score and reported as adjusted odds ratio (aOR) (95% CI). ResultsOf the 3868 patients, 43.3% presented with premature ACS that was associated with lower 1-year mortality (5.7%) than those with non-premature ACS. In adjusted models, women experienced higher mortality than men after premature (aOR, 2.14 [1.37-3.41]) vs non-premature ACS (aOR, 1.28 [0.99-1.65]) (Pinteraction=.047). Patients lacking formal education vs any education had higher mortality after both premature (aOR, 2.92 [1.87-4.61]) and non-premature ACS (aOR, 1.78 [1.36-2.34]) (Pinteraction=.06). Lack of employment vs any employment was associated with approximately 3-fold higher mortality after premature and non-premature ACS (Pinteraction=.72). Using stepwise logistic regression to predict 1-year mortality, a model with GRACE risk score and 4 characteristics (education, employment, body mass index [kg/m2], and statin use within 24 hours after admission) had higher discrimination than the GRACE risk score alone (area under the curve, 0.800 vs 0.773; Pcomparison=.003). ConclusionIn this study, women, compared with men, had higher 1-year mortality after premature ACS. The social determinants of health (no formal education or employment) were strongly associated with higher 1-year mortality after premature and non-premature ACS, improved mortality prediction, and should be routinely considered in risk assessment after ACS.

Timing of invasive coronary angiography in non-ST-elevation acute coronary syndrome-an updated individual patient data meta-analysis.

The optimal timing of invasive coronary angiography in non-ST-elevation acute coronary syndrome (NSTE-ACS) was subject of several randomized controlled trials (RCTs) since more than 20 years. American and European guidelines recommend an early invasive strategy <24 h for high-risk NSTE-ACS patients with a global registry of acute coronary events (GRACE) risk score >140 but without evidence for ongoing ischaemia or haemodynamic instability.1,2 However, scientific evidence supporting this recommendation is sparse. Butt et al.3 analysed the effect of the GRACE risk score on all-cause mortality in a post-hoc analysis of the very early versus deferred invasive evaluation using computerized tomography (VERDICT) trial. We combined the published VERDICT data with an existing database of our previous meta-analysis (Supplementary material online for further details, Table S1, Table S2, and Figure S1r).4 Consecutively, we updated our previous GRACE risk score subgroup analysis to synthetize up-to-date scientific evidence from the currently available data. The methodology is described in the Supplementary material online in detail. In short, we performed one-stage as well as two-stage meta-analyses. Both approaches led to the same result that an early invasive strategy does reduce the risk of all-cause mortality in patients with a GRACE risk score >140 but not in patients with a GRACE risk score ≤140 or the unselected population of NSTE-ACS patients (Figure 1). While some heterogeneity is present in the total population (I2 = 30%), it is absent in each subgroup stratum (I2 = 0%; Supplementary material online, Figure S2). The reported finding is driven by the addition of data from the VERDICT trial. Exclusion of this trial leads to a similar finding as reported in our previous meta-analysis (see Supplementary material online, Table S3 and Supplementary material online, Figure S3).4

Prognostic implications of the 4S-AF scheme to characterize new-onset atrial fibrillation after myocardial infarction

AimsThe 4S-AF scheme (Stroke risk [St], Symptom severity [Sy], Severity of atrial fibrillation burden [Sb], Substrate [Su]) is a novel approach for the holistic characterization of AF. We aimed to investigate the prognostic implications of the 4S-AF scheme score in acute myocardial infarction (AMI) patients with new-onset atrial fibrillation (NOAF). MethodsWe included 262 patients with post-MI NOAF who had complete data for the 4S-AF scheme evaluation between February 2014 and March 2018. The 4S-AF scheme score was calculated as a sum of each domain with a maximum of 9. The primary outcome was all-cause death. ResultsOf 262 patients (66.0% males, mean age 74.5 ± 10.4 years) were analyzed. The mean 4S-AF scheme score was 5.0 ± 1.6. There were 62 (27.3%) all-cause deaths within a median follow-up of 2.6 years. According to multivariable Cox regression models, each 1-point increase in the 4S-AF scheme score was significantly associated with 39% increased all-cause mortality (HR: 1.39, 95% CI: 1.16–1.67, P<0.001), which was mainly driven by the Sb (HR: 1.43, 95%CI: 1.05–1.95, P = 0.025) and Su (HR: 1.53, 95%CI: 1.17–2.02, P = 0.002) domains. Adding the 4S-AF scheme score on top of the Global Registry of Acute Coronary Events score could significantly improve its discriminative capability (C-index from 0.713 to 0.761, P = 0.039) and reclassification performance (continuous net reclassification improvement: 41.0% [95%CI: 12.5–69.6]; integrated discrimination improvement: 5.1% [95%CI: 2.2–8.1]) for all-cause mortality. ConclusionsCharacterization of NOAF using the 4S-AF scheme aids in the risk stratification of AMI patients with NOAF.

Acute coronary event (ACE) prediction following breast radiotherapy by features extracted from 3D CT, dose, and cardiac structures.

Heart toxicity, such as major acute coronary events (ACE), following breast radiation therapy (RT) is of utmost concern. Thus, many studies have been investigating the effect of mean heart dose (MHD) and dose received in heart sub-structures on toxicity. Most studies focused on the dose thresholds in the heart and its sub-structures, while few studies adopted such computational methods as deep neural networks (DNN) and radiomics. This work aims to construct a feature-driven predictive model for ACE after breast RT. A recently proposed two-step predictive model that extracts a number of features from a deep auto-segmentation network and processes the selected features for prediction was adopted. This work refined the auto-segmenting network and feature processing algorithms to enhance performance in cardiac toxicity prediction. In the predictive model, the deep convolutional neural network (CNN) extracted features from 3D computed tomography (CT) images and dose distributions in three automatically segmented heart sub-structures, including the left anterior descending artery (LAD), right coronary artery (RCA), and left ventricle (LV). The optimal feature processing workflow for the extracted features was explored to enhance the prediction accuracy. The regions associated with toxicity were visualized using a class activation map (CAM)-based technique. Our proposed model was validated against a conventional DNN (convolutional and fully connected layers) and radiomics with a patient cohort of 84 cases, including 29 and 55 patient cases with and without ACE. Of the entire 84 cases, 12 randomly chosen cases (5 toxicity and 7 non-toxicity cases) were set aside for independent test, and the remaining 72 cases were applied to 4-fold stratified cross-validation. Our predictive model outperformed the conventional DNN by 38% and 10% and radiomics-based predictive models by 9% and 10% in AUC for 4-fold cross-validations and independent test, respectively. The degree of enhancement was greater when incorporating dose information and heart sub-structures into feature extraction. The model whose inputs were CT, dose, and three sub-structures (LV, LAD, and RCA) reached 96% prediction accuracy on average and 0.94 area under the curve (AUC) on average in the cross-validation, and also achieved prediction accuracy of 83% and AUC of 0.83 in the independent test. On 10 correctly predicted cases out of 12 for the independent test, the activation maps implied that for cases of ACE toxicity, the higher intensity was more likely to be observed inside the LV. The proposed model characterized by modifications in model input with dose distributions and cardiac sub-structures, and serial processing of feature extraction and feature selection techniques can improve the predictive performance in ACE following breast RT.

Predictors of Readmission after the First Acute Coronary Syndrome and the Risk of Recurrent Cardiovascular Events-Seven Years of Patient Follow-Up.

Recurrent hospitalization after acute coronary syndromes (ACS) is common. Identifying risk factors associated with subsequent cardiovascular events and hospitalization is essential for the management of these patients. Our research consisted in observing the outcomes of subjects after they suffered an acute coronary event and identifying the factors that can predict rehospitalization in the first 12 months and the recurrence of another acute coronary episode. Data from 362 patients admitted with ACS during 2013 were studied. Recurrent hospitalizations were retrospectively reviewed from medical charts and electronic hospital archives over a period of seven years. The mean age of the studied population was 64.57 ± 11.79 years, 64.36% of them being males. The diagnosis of ACS without ST elevation was registered in 53.87% of the patients at index hospitalization. More than half had recurrent hospitalization in the first year after the first ACS episode. Patients with lower ejection fraction (39.20 ± 6.85 vs. 42.24 ± 6.26, p < 0.001), acute pulmonary edema during the first hospitalization (6.47% vs. 1.24%, p = 0.022), coexistent valvular heart disease (69.15% vs. 55.90%, p = 0.017), and three-vessel disease (18.90% vs. 7.45%, p = 0.002) were more frequently readmitted in the following twelve months after their first acute coronary event, while those with complete revascularization were less frequently admitted (24.87% vs. 34.78%, p = 0.005). In multiple regression, complete revascularization during the index event (HR = 0.58, 95% CI 0.35-0.95, p = 0.03) and a higher LVEF (left ventricular ejection fraction) (HR = 0.95, 95% CI 0.92-0.988, p = 0.009) remained independent predictors of fewer early readmissions. Complete revascularization of the coronary lesions at the time of the first event and a preserved LVEF were found to be the predictors of reduced hospitalizations in the first year after an acute coronary event.

Cardiovascular risk factors associated with coronary ectasia and acute myocardial infarction.

Coronary ectasia has a low prevalence in the general population. Its risk factors may differ from those of coronary artery disease. To identify the prevalence of coronary ectasia in patients with acute myocardial infarction (AMI) and cardiovascular risk factors (CVRFs). Retrospective, cross-sectional study. Out of 3,254 cardiac catheterizations for AMI during one year, 2,975 had no coronary ectasia. We included 558 patients with coronary ectasia on coronary angiography and, as controls, subjects with similar characteristics except for coronary ectasia, and CVRFs were recorded. Descriptive statistics, bivariate and multivariate analysis were used; odds ratio (OR) was calculated. 279 patients with and without coronary ectasia were studied. The prevalence of coronary ectasia was 8.5 %. The platelet/lymphocyte ratio (PLR) was higher in patients with ectasia than in those without ectasia (p = 0.003). In the bivariate analysis, associated CVRFs were overweight, obesity and diabetes, and in the multivariate analysis, hypercholesterolemia (OR: 3.90; p = 0.0001) and exposure to herbicides (OR: 6.82; p = 0.020). A high prevalence of coronary ectasia was found, with the main risk factors being a history of herbicide use and hypercholesterolemia. PLR was found to be elevated in these patients. Early detection is important due to its association with acute coronary events.