Acute Percutaneous Coronary Intervention Research Articles

Clinical Outcomes After Acute Coronary Syndromes or Revascularization Among People Living With HIV

Clinical outcomes after acute coronary syndromes (ACS) or percutaneous coronary interventions (PCIs) in people living with HIV have not been characterized in sufficient detail, and extant data have not been synthesized adequately. To better characterize clinical outcomes and postdischarge treatment of patients living with HIV after ACS or PCIs compared with patients in an HIV-negative control group. Ovid MEDLINE, Embase, and Web of Science were searched for all available longitudinal studies of patients living with HIV after ACS or PCIs from inception until August 2023. Included studies met the following criteria: patients living with HIV and HIV-negative comparator group included, patients presenting with ACS or undergoing PCI included, and longitudinal follow-up data collected after the initial event. Data extraction was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Clinical outcome data were pooled using a random-effects model meta-analysis. The following clinical outcomes were studied: all-cause mortality, major adverse cardiovascular events, cardiovascular death, recurrent ACS, stroke, new heart failure, total lesion revascularization, and total vessel revascularization. The maximally adjusted relative risk (RR) of clinical outcomes on follow-up comparing patients living with HIV with patients in control groups was taken as the main outcome measure. A total of 15 studies including 9499 patients living with HIV (pooled proportion [range], 76.4% [64.3%-100%] male; pooled mean [range] age, 56.2 [47.0-63.0] years) and 1 531 117 patients without HIV in a control group (pooled proportion [range], 61.7% [59.7%-100%] male; pooled mean [range] age, 67.7 [42.0-69.4] years) were included; both populations were predominantly male, but patients living with HIV were younger by approximately 11 years. Patients living with HIV were also significantly more likely to be current smokers (pooled proportion [range], 59.1% [24.0%-75.0%] smokers vs 42.8% [26.0%-64.1%] smokers) and engage in illicit drug use (pooled proportion [range], 31.2% [2.0%-33.7%] drug use vs 6.8% [0%-11.5%] drug use) and had higher triglyceride (pooled mean [range], 233 [167-268] vs 171 [148-220] mg/dL) and lower high-density lipoprotein-cholesterol (pooled mean [range], 40 [26-43] vs 46 [29-46] mg/dL) levels. Populations with and without HIV were followed up for a pooled mean (range) of 16.2 (3.0-60.8) months and 11.9 (3.0-60.8) months, respectively. On postdischarge follow-up, patients living with HIV had lower prevalence of statin (pooled proportion [range], 53.3% [45.8%-96.1%] vs 59.9% [58.4%-99.0%]) and β-blocker (pooled proportion [range], 54.0% [51.3%-90.0%] vs 60.6% [59.6%-93.6%]) prescriptions compared with those in the control group, but these differences were not statistically significant. There was a significantly increased risk among patients living with HIV vs those without HIV for all-cause mortality (RR, 1.64; 95% CI, 1.32-2.04), major adverse cardiovascular events (RR, 1.11; 95% CI, 1.01-1.22), recurrent ACS (RR, 1.83; 95% CI, 1.12-2.97), and admissions for new heart failure (RR, 3.39; 95% CI, 1.73-6.62). These findings suggest the need for attention toward secondary prevention strategies to address poor outcomes of cardiovascular disease among patients living with HIV.

The Relationship Between CHA2DS2-VASc Scores and The Degree of TIMI Flow in Patients with Acute ST-Segment Elevation Myocardial Infarction Who Underwent Primary Percutaneous Coronary Intervention at Dr. Saiful Anwar Malang

Background: Suboptimal reperfusion of the compromised myocardium in the area of the culprit coronary arteries is one of the main problems associated with primary PCI that need reliable risk stratification methods to accurately predict the occurrence of decreased TIMI flow given its complex pathophysiology. Some parameters are included CHA2DS2-VASc score. Objective: To understand the relationship between CHA2DS2-VASc and the decreased TIMI flow in STE-ACS patients who had underwent primary PCI at RSUD dr. Saiful Anwar Malang. Material and Methods: The study was cohort retrospective with the inclusion criteria being all STE-ACS patients who underwent primary PCI in RSUD Dr. Saiful Anwar Malang from January 2018 – August 2023. Patients were assigned to TIMI flow grade <3 group (N =169) and TIMI flow grade 3 (N = 677) according to TIMI Flow degree after primary PCI. All the patient’s angiogram were evaluated for TIMI score and CHA2DS2-VASc score is based on a guideline. We concluded data in SPSS program and used the Spearman test and p value of .05 was considered as significant. Result: From a total sample of 846 patients, the correlation between STE-ACS onset and TIMI flow indicates that a higher number of patients with STE-ACS onset <12 hours was found in the TIMI flow <3 and 3 groups (p=0.000). The cutoff CHA2DS2 VASC score's sensitivity and specificity values were ascertained using ROC analysis with cut off value 2.5. The incidence of decreased TIMI flow rate was more significant in the CHA2DS2-VASc ≥3 group with DM (+) and age ≥64 (OR value 0.156, p=0.000) than in the CHA2DS2-VASc ≥3 group without DM and age < 64. With an OR value of 2.94 (p=0.000), Killip class > 2 is another powerful predictor of lower TIMI flow. Conclusion: The only variables in the CHA2DS2-VASc score component that are most strongly associated with the risk of reducing the degree of TIMI flow are DM, age, and Killip class. Keyword: Acute Coronary Syndrome, CHA2DS2-VASc Score, Intervention, Percutaneous Coronary Slow Flow- No Reflow Phenomena, TIMI Flow Degree.

The role of microvascular obstruction and intramyocardial hemorrhage in reperfusion injury to the heart

Microvascular obstruction (MVO) of coronary arteries promotes an increase in mortality and major adverse cardiac events in patients with acute myocardial infarction (AMI) and percutaneous coronary intervention (PCI). Intramyocardial hemorrhage (IMH) is observed in 41–50 % of patients with ST-segment elevation myocardial infarction and PCI and is accompanied by inflammation. There is evidence that microthrombi are not involved in the development of MVO, which is associated with infarct size, the duration of ischemia, and myocardial edema. However, there is no conclusive evidence that the latter plays an important role in the development of MVO. There is evidence that platelets, inflammation, Ca2+ overload, neuropeptide Y, and endothelin-1 could be involved in the pathogenesis of MVO. The role of endothelial cell dysfunction in MVO formation in patients with AMI and PCI remains under question. It is unclear whether nitric oxide production is decreased in patients with MVO. It was obtained only indirect evidence on the involvement of inflammation in the development of MVO. The role of reactive oxygen species, necroptosis and pyroptosis in the pathogenesis of MVO is also not studied. The participation of thromboxane A2, vasopressin, and prostacyclin in the formation of MVO is unknown. It was not obtained conclusive evidence on the involvement of coronary artery spasm in the development of MVO. Dual antiplatelet therapy improves the efficacy of PCI in prevention of MVO. It is unknown whether epinephrine or L-type Ca2+-channel blockers improves coronary blood flow in patients with MVO.

Feasibility and Safety of Bridging Antiplatelet Therapy with Cangrelor in Neuro-Oncology: A Preliminary Experience.

Antiplatelet therapy is mandatory for prevention of thrombotic events in patients with a recent history of acute coronary syndromes and/or percutaneous coronary interventions. However, if an urgent surgery is required during antiplatelet therapy, a compromise between the ischemic/thrombotic and hemorrhagic risk has to be reached. Different bridging schemes are reported in the literature, but there is no clear consensus on the optimal treatment strategy in terms of efficacy and safety. Although some indications about the perioperative management of antiplatelet therapy regarding specific surgical specializations are available, balancing the thrombotic and hemorrhagic risk on an individual basis, no evidence referring to neurosurgical or neuro-oncologic procedures is reported. Herein, we present our preliminary experience in the perioperative management of a patient who underwent a neurosurgical procedure for the resection of a primary malignant brain tumor using an intravenous P2Y12 inhibitor (cangrelor) as bridging therapy after a recent acute myocardial infarction treated with primary percutaneous coronary intervention and stenting. The oral P2Y12 inhibitor (clopidogrel) was withdrawn 5 days prior to the surgical procedure and continuous infusion of cangrelor was started 3 days before the surgery at a dose of 0.75 μg/kg/min. Cangrelor was discontinued 2 hours before surgery and resumed 72 hours after tumor resection for further 60 hours. Neither cangrelor-related bleeding nor cardiac ischemic events were observed in the perioperative period and the following 90 days, supporting data regarding the feasibility and safety of this bridging scheme. Further studies are needed to confirm our promising results.

Association of Increased Inter-arm Blood Pressure Difference with Long-term Clinical Outcomes in Patients with Acute Myocardial Infarction Who Underwent Percutaneous Coronary Intervention.

Objective Patients with acute myocardial infarction (AMI) often have peripheral artery disease (PAD). It is well known that the long-term clinical outcomes of AMI are worse in patients with a low ankle-brachial index (ABI) than in patients with a preserved ABI. Unlike ABI, the association between the inter-arm blood pressure difference (IABPD) and clinical outcomes in patients with AMI has not yet been established. This retrospective study examined whether or not the IABPD is associated with long-term clinical outcomes in patients with AMI. Methods We included 979 patients with AMI and divided them into a high-IABPD group (IABPD ≥10 mmHg, n=31) and a low-IABPD group (IABPD <10 mmHg, n=948) according to the IABPD measured during hospitalization for AMI. The primary endpoint was the all-cause mortality rate. Results During a median follow-up duration of 694 days (Q1, 296 days; Q3, 1,281 days), 82 all-cause deaths were observed. Kaplan-Meier curves showed that all-cause death was more frequently observed in the high-IABPD group than in the low-IABPD group (p<0.001). A multivariate Cox hazard analysis revealed that a high IABPD was significantly associated with all-cause death (hazard ratio 2.061, 95% confidence interval 1.012-4.197, p=0.046) after controlling for multiple confounding factors. Conclusion A high IABPD was significantly associated with long-term all-cause mortality in patients with AMI. Our results suggest the usefulness of the IABPD as a prognostic marker for patients with AMI.

Cohort Profile: the European Unified Registries On Heart care Evaluation and Randomised Trials (EuroHeart) - Acute Coronary Syndrome and Percutaneous Coronary Intervention.

The European Unified Registries On Heart care Evaluation And Randomized Trials (EuroHeart) aims to improve the quality of care and clinical outcomes for patients with cardiovascular disease. The collaboration of acute coronary syndrome/percutaneous coronary intervention (ACS/PCI) registries is operational in seven vanguard European Society of Cardiology member countries. Adults admitted to hospitals with ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) are included, and individual patient-level data collected and aligned according to the internationally agreed EuroHeart data standards for ACS/PCI. The registries provide up to 155 variables spanning patient demographics and clinical characteristics, in-hospital care, in-hospital outcomes, and discharge medications. After performing statistical analyses on patient data, participating countries transfer aggregated data to EuroHeart for international reporting.Between 1st January 2022 and 31st December 2022, 40021 admissions (STEMI 46.7%, NSTEMI 53.3%) were recorded from 192 hospitals in the seven vanguard countries: Estonia, Hungary, Iceland, Portugal, Romania, Singapore, and Sweden. The mean age for the cohort was 67.9 (standard deviation 12.6) years, and it included 12628 (31.6%) women. The EuroHeart collaboration of ACS/PCI registries prospectively collects and analyses individual data for ACS and PCI at a national level, after which aggregated results are transferred to the EuroHeart Data Science Centre. The collaboration will expand to other countries and provide continuous insights into the provision of clinical care and outcomes for patients with ACS and undergoing PCI. It will serve as a unique international platform for quality improvement, observational research, and registry-based clinical trials.

No-Reflow Prediction in Acute Coronary Syndrome During Percutaneous Coronary Intervention: The NORPACS Risk Score.

Suboptimal coronary reperfusion (no reflow) is common in acute coronary syndrome percutaneous coronary intervention (PCI) and is associated with poor outcomes. We aimed to develop and externally validate a clinical risk score for angiographic no reflow for use following angiography and before PCI. We developed and externally validated a logistic regression model for prediction of no reflow among adult patients undergoing PCI for acute coronary syndrome using data from the Melbourne Interventional Group PCI registry (2005-2020; development cohort) and the British Cardiovascular Interventional Society PCI registry (2006-2020; external validation cohort). A total of 30 561 patients (mean age, 64.1 years; 24% women) were included in the Melbourne Interventional Group development cohort and 440 256 patients (mean age, 64.9 years; 27% women) in the British Cardiovascular Interventional Society external validation cohort. The primary outcome (no reflow) occurred in 4.1% (1249 patients) and 9.4% (41 222 patients) of the development and validation cohorts, respectively. From 33 candidate predictor variables, 6 final variables were selected by an adaptive least absolute shrinkage and selection operator regression model for inclusion (cardiogenic shock, ST-segment-elevation myocardial infarction with symptom onset >195 minutes pre-PCI, estimated stent length ≥20 mm, vessel diameter <2.5 mm, pre-PCI Thrombolysis in Myocardial Infarction flow <3, and lesion location). Model discrimination was very good (development C statistic, 0.808; validation C statistic, 0.741) with excellent calibration. Patients with a score of ≥8 points had a 22% and 27% risk of no reflow in the development and validation cohorts, respectively. The no-reflow prediction in acute coronary syndrome risk score is a simple count-based scoring system based on 6 parameters available before PCI to predict the risk of no reflow. This score could be useful in guiding preventative treatment and future trials.

Effect of modified Buyang huanwu decoction on hemorheology, myocardial remodeling, serum soluble CD40 ligand and serum soluble P-selectin in patients with acute myocardial infarctionafter percutaneous coronary intervention

Purpose: To investigate the effect of modified Buyang Huanwu decoction on hemorheology and myocardial remodeling in patients with acute myocardial infarction (AMI) after conventional percutaneous coronary intervention (PCI), and its relationship with serum levels of soluble CD40 ligand (sCD40L) and soluble P-selectin (sP-sel). &#x0D; Methods: After PCI, 80 patients seen from February 2021 to February 2022 in Shijiazhuang Fourth Hospital, China with AMI were enrolled in the study. Subjects were assigned to study and control groups. Control group received standard conventional medical treatments, while study group received modified Buyang Huanwu decoction, in addition to the same standard treatment, orally twice a day (morning and night) for 3 months). The effect of modified Buyang Huanwu decoction was determined by comparing the post-treatment clinical outcomes and levels of hemorheology indices and myocardial remodeling-associated indices (myocardial injury markers) in both groups of patients. &#x0D; Results: The clinical outcome in study group was significantly better, and the hemorheology indices were significantly improved when compared to control subjects (p &lt; 0.05). Serum levels of myocardial injury markers (cardiac troponin (cTnI), cardiac markers (CRP), and brain natriuretic peptide (BNP)), and inflammatory markers (sCD40L and sP-sel) in study group were significantly decreased to varying degrees, relative to control group (p &lt; 0.05). &#x0D; Conclusion: Modified Buyang Huanwu decoction reduces inflammatory marker levels, cardiac inflammatory response and myocardial remodeling, and improves the prognosis of AMI in patients after PCI. Therefore, it may be beneficial to develop other methods for treating acute myocardial infarction after percutaneous coronary intervention.

Disruption of hospital care during the first year of the COVID-19 pandemic impacted socioeconomic groups differently: population based study using routine registration data

BackgroundDuring the COVID-19 pandemic, provision of non-COVID healthcare was recurrently severely disrupted. The objective was to determine whether disruption of non-COVID hospital use, either due to cancelled, postponed, or forgone care, during the first pandemic year of COVID-19 impacted socioeconomic groups differently compared with pre-pandemic use.MethodsNational population registry data, individually linked with data of non-COVID hospital use in the Netherlands (2017–2020). in non-institutionalised population of 25–79 years, in standardised household income deciles (1 = low, 10 = high) as proxy for socioeconomic status. Generic outcome measures included patients who received hospital care (dichotomous): outpatient contact, day treatment, inpatient clinic, and surgery. Specific procedures were included as examples of frequently performed elective and acute procedures, e.g.: elective knee/hip replacement and cataract surgery, and acute percutaneous coronary interventions (PCI). Relative risks (RR) for hospital use were reported as outcomes from generalised linear regression models (binomial) with log-link. An interaction term was included to assess whether income differences in hospital use during the pandemic deviated from pre-pandemic use.ResultsHospital use rates declined in 2020 across all income groups. With baseline (2019) higher hospital use rates among lower than higher income groups, relatively stronger declines were found for lower income groups. The lowest income groups experienced a 10% larger decline in surgery received than the highest income group (RR 0.90, 95% CI 0.87 – 0.93). Patterns were similar for inpatient clinic, elective knee/hip replacement and cataract surgery. We found small or no significant income differences for outpatient clinic, day treatment, and acute PCI.ConclusionsDisruption of non-COVID hospital use in 2020 was substantial across all income groups during the acute phases of the pandemic, but relatively stronger for lower income groups than could be expected compared with pre-pandemic hospital use. Although the pandemic’s impact on the health system was unprecedented, healthcare service shortages are here to stay. It is therefore pivotal to realise that lower income groups may be at risk for underuse in times of scarcity.

Acute coronary occlusion and percutaneous coronary intervention after out-of-hospital cardiac arrest.

Early coronary angiography (CAG) has been recommended in selected patients following out-of-hospital-cardiac-arrest (OHCA). We aimed to identify clinical features associated with acute coronary occlusion (ACO) and evaluate the associations between ACO, successful percutaneous coronary intervention (PCI) and outcomes in this population. We included comatose OHCA patients treated with targeted temperature management (TTM) between December 2005 and September 2016 who underwent early CAG within 24 hours. The co-primary outcomes were all-cause 30-day mortality and good neurological outcome (modified Rankin Score [mRS] ≤2) at hospital discharge. Among 155 patients (93% shockable arrest rhythm, 55% with ST elevation), 133 (86%) had coronary artery stenosis ≥50% and 65 (42%) had ACO. ST elevation (sensitivity 74%, specificity 59%, OR 4.0, 95% CI 2.0-8.1) and elevated first troponin (sensitivity 88%, specificity 26%, OR 2.5, 95% CI 1.1-6.1) had limited sensitivity and specificity for ACO. Unadjusted 30-day mortality did not differ significantly by coronary disease severity or ACO. Successful PCI was associated with a lower risk of 30-day mortality (adjusted HR 0.5, 95% CI 0.2-0.9, P=.03), especially among patients with ACO (adjusted HR 0.4, 95% CI 0.1-0.9, P=0.03). After adjustment, ACO and PCI were not associated with the probability of good neurological outcome. In this select cohort of resuscitated OHCA patients undergoing CAG, unstable coronary disease is highly prevalent and successful PCI was associated with a higher probability of 30-day survival, especially among those with ACO. Neither ACO nor successful PCI were independently associated with good neurological outcome.

Colchicine ameliorates myocardial injury induced by coronary microembolization through suppressing pyroptosis via the AMPK/SIRT1/NLRP3 signaling pathway

BackgroundCoronary microembolization(CME)is a common complication in acute coronary syndrome and percutaneous coronary intervention, which is closely related to poor prognosis. Pyroptosis, as an inflammatory programmed cell death, has been found to be associated with CME-induced myocardial injury. Colchicine (COL) has potential benefits in coronary artery disease due to its anti-inflammatory effect. However, the role of colchicine in pyroptosis-related CME-induced cardiomyocyte injury is unclear. This study was carried out to explore the effects and mechanisms of colchicine on myocardial pyroptosis induced by CME.MethodsThe CME animal model was constructed by injecting microspheres into the left ventricle with Sprague-Dawley rats, and colchicine (0.3 mg/kg) pretreatment seven days before and on the day of modeling or compound C(CC)co-treatment was given half an hour before modeling. The study was divided into 4 groups: Sham group, CME group, CME + COL group, and CME + COL + CC group (10 rats for each group). Cardiac function, serum myocardial injury markers, myocardial histopathology, and pyroptosis-related indicators were used to evaluate the effects of colchicine.ResultsColchicine pretreatment improved cardiac dysfunction and reduced myocardial injury induced by CME. The main manifestations were the improvement of left ventricular systolic function, the decrease of microinfarction area, and the decrease of mRNA and protein indexes related to pyroptosis. Mechanistically, colchicine increased the phosphorylation level of adenosine monophosphate-activated protein kinase (AMPK), promoted the expression of silent information regulation T1 (SIRT1), and inhibited the expression of NOD-like receptor pyrin containing 3 (NLRP3) to reduce myocardial pyroptosis. However, after CC co-treatment with COL, the effect of colchicine was partially reversed.ConclusionColchicine improves CME-induced cardiac dysfunction and myocardial injury by inhibiting cardiomyocyte pyroptosis through the AMPK/SIRT1/NLRP3 signaling pathway.

Retracted: Development and Validation of a Nomogram for Predicting Mortality in Patients with Atrial Fibrillation and Acute Coronary Syndrome Who Underwent Percutaneous Coronary Intervention in a Chinese Multicenter Cohort

Retracted: Development and Validation of a Nomogram for Predicting Mortality in Patients with Atrial Fibrillation and Acute Coronary Syndrome Who Underwent Percutaneous Coronary Intervention in a Chinese Multicenter Cohort

Predictive significance of modern echocardiographic parameters, stress ultrasound of the lungs in patients with acute myocardial infarction and percutaneous coronary intervention

Abstract Introduction Improving the EF can reduce the risk of cardiovascular complications (CVC) in postinfarction period. Short-term periprocedural dynamics (PPD) of EF and its prognostic value in patients with first acute myocardial infarction (AMI) and percutaneous coronary intervention (PCI) have not been studied. Stress lung ultrasound (LUS) can be used as an initial step in heart failure (HF) risk stratification. Speckle tracking Echo with assessment of myocardial work (MW) is promising in relation to the prediction of CVC in patients with AMI. The predictive abilities of 3D Echo deformity and rotation in patients with AMI are not well studied. Purpose Determination of the value of PPD EF, subclinical pulmonary congestion (PC) in stress LUS, parameters of MW and 3D-Echo in the prognosis of the development of CVC in long-term period in patients with the first AMI and PCI. Methods In 131 patients (89 men, mean age: 61.7±11.45 years, Me EF admission: 48%, multivessel coronary artery disease 66.4%) with a first MI without a history of HF with successful PCI, EF was assessed before PCI and at discharge, MW parameters, 3D-Echo parameters were determined, and stress LUS with physical activity was performed. An increase in EF&amp;gt;5% and an achievement of 50% or more were taken as a criterion for a positive PPD. After 3 months, the dynamics of 2- and 3D-Echo were evaluated. The observation period was 550 days. Hospitalization with HF, CV death, and composite point were assessed. Results Upon admission baseline EF&amp;lt;50% was detected in 56.5% of cases. 47.3% of patients from the group with baseline EF &amp;lt;50% did not have PPD EF after PCI, which is associated with an increased risk of hospitalization with HF (HR=7.13 p=0.004). An increase in PPD by 1% reduces the risks of hospitalization with HF by 1.31 times (p=0.013). According to the stress LUS, subclinical PC was detected in 99.1% of patients. In patients with baseline EF &amp;lt;50%, the sum of B-lines ≥10 during exercise increases the risks of hospitalization with HF by 2.4 times, and its combination with the absence of PPD - by 7.45 times during 1.5 years. With GLS&amp;lt;13.7%, the risk of hospitalization with HF increases by 2.34 times (p=0.048), GWW&amp;gt;161.5 mmHg% - by 2.65 times (p=0.028). The model for calculating the risk of hospitalization with HF included GLS (OR 0.75; p=0.006), GCW (OR 0.85; p=0.036) and ΔEF (OR 0.88; p=0.040). Patients hospitalized with HF after AMI showed a significant increase in the LV sphericity index after 3 months. The predictors of hospitalization with HF according to 3D Echo were indicators of circumflexial strain (CS)(OR 0.76; p=0.026), areal strain (AS)(OR 0.60; p=0.012), radial strain (RS)(OR 0.91; p=0.039), area strain dynamics over 3 months (HR 0.702; р=0.025). Conclusion In patients with the first AMI, it is advisable to conduct a comprehensive Echo with an assessment of MW, stress LUS to identify high-risk patients for the development of HF in the postinfarction period.

Ticagrelor or clopidogrel in atrial fibrillation patients undergoing percutaneous coronary intervention for myocardial infarction

Abstract Background Contemporary guidelines recommend clopidogrel as the P2Y12 receptor inhibitor of choice in atrial fibrillation (AF) patients with acute coronary syndrome and/or percutaneous coronary intervention (PCI) who require concomitant oral anticoagulation (OAC). Conversely, the use of ticagrelor or prasugrel in these settings is discouraged. Purpose To examine the efficacy and safety of more potent P2Y12 inhibitors (ticagrelor or prasugrel) versus clopidogrel in patients with AF on OAC undergoing PCI for myocardial infarction. Methods We conducted a Danish, nationwide, registry-based cohort study of patients on an OAC for presumed AF who underwent PCI for myocardial infarction from 2011 through 2019. Only individuals discharged on a P2Y12 inhibitor and an OAC were included, while those receiving a P2Y12 inhibitor prior to hospitalization were excluded. The primary efficacy outcome was major adverse cardiovascular events, defined as a composite of death from any cause, recurrent myocardial infarction, repeat revascularization, or stroke, while the primary safety outcome was bleeding requiring hospitalization. Death from any cause was the main secondary outcome. Absolute and relative risks for outcomes at 1 year were calculated through multivariable logistic regression with average treatment effect modeling. Efficacy outcomes were standardized for the CHA2DS2-VASc score and aspirin use while bleeding outcomes were standardized for the HAS-BLED score and proton-pump inhibitor use. Results A total of 2259 patients were included of whom 1918 (84.9%) were discharged on clopidogrel and 341 (15.1%) on ticagrelor or prasugrel (the latter two were merged into one group because only 38 persons were discharged on prasugrel). Individuals who received the more potent P2Y12 inhibitors were younger (median age 70 vs. 74 years), more often men (76.0% vs. 70.8%), and less often had prior coronary artery disease (5.6% vs. 9.6%) than those who received clopidogrel. The standardized risk of major adverse cardiovascular events was significantly lower in patients discharged on ticagrelor or prasugrel compared with clopidogrel (standardized absolute risk, 15.8% vs. 19.6%; relative risk, 0.81, 95% confidence interval [CI], 0.68 to 0.93; P=0.003), while the risk of bleeding did not differ (standardized absolute risk, 5.2% vs. 5.2%; relative risk, 1.00, 95% confidence interval, 0.69 to 1.32; P=0.99) (Figure). The risk of death was significantly lower in the group of patients who were prescribed ticagrelor or prasugrel compared with clopidogrel (P&amp;lt;0.001). Conclusions In patients with AF on OAC who had undergone PCI for myocardial infarction, discharge on ticagrelor or prasugrel versus clopidogrel was associated with reduced ischemic risk, but not an increased bleeding risk. While these findings appear to support an individualized choice of P2Y12 inhibitor in this population, they should be interpreted with caution given the observational nature of the study.Figure

Left-ventricular unloading with Impella during refractory cardiac arrest treated with veno-arterial extracorporeal membrane oxygenation - A systematic review and meta-analysis

Abstract Background Extracorporeal cardio-pulmonary resuscitation (ECPR) is the implementation of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) during refractory cardiac arrest. The role of left-ventricular (LV) unloading with Impella in addition to VA-ECMO ("ECMELLA") during ECPR is unlear. Purpose This is the first systematic review and meta-analysis to characterise patients receiving LV unloading and to compare in-hospital mortality between ECMELLA and VA-ECMO treatment during ECPR. Methods A systematic review and meta-analysis was performed according to the PRISMA checklist on clinical studies with adult patients with refractory cardiac arrest treated with ECMELLA or VA-ECMO as part of ECPR. The meta-analysis was performed by using a random-effects model. Risk of bias was assessed with Cochrane ROBINS-I tool, heterogeneity with Cochrane Q test and publication bias with funnel plots. Results Altogether, 13 study records from 32 tertiary care centers with a total of 1,037 adult patients with ECPR were included, out of which 785 patients (75.7%) received VA-ECMO and 252 (24.3%) ECMELLA support. Compared to VA-ECMO, the ECMELLA group was comprised of more male patients (71.4% vs. 57.3%), more patients with initial shockable ECG rhythms (55.2% vs. 40.3%), lower pre-ECPR pH (7.07 vs. 7.11) and higher lactate levels (10.9 vs. 10.1 mmol/L), as well as higher rates of acute myocardial infarction (75.0% vs. 41.9%) and percutaneous coronary interventions (71.8% vs. 35.4%) (Table). Age, rate of out-of-hospital cardiac arrest and low-flow times were similar between both treatment groups. Compared to ECMELLA, VA-ECMO alone was more frequently used in pulmonary embolism (6.4% vs. 0.4%) and miscellaneous causes of cardiac arrest (19.0% vs. 4.4%). ECMELLA support was associated with a 47% reduced mortality risk [95% Confidence Interval 0.31-0.93] compared to VA-ECMO alone: 123 (48.8%) vs. 539 (68.7%) patients (P=0.026). Patients with ECMELLA had a longer hospital length of stay (18.7 days vs. 10.6 days). Results remained robust in sensitivity analyses after exclusion of smaller studies and gray literature. Conclusions ECMELLA support was predominantly utilised in patients with acute myocardial infarction and VA-ECMO for pulmonary embolism and miscellaneous causes of cardiac arrest across institutions. Indications and frequency of ECMELLA use varied strongly between institutions. ECMELLA support during ECPR was associated with improved survival across studies and might be considered in well selected patients with refractory cardiac arrest. Further scientific evidence is urgently required to elaborate standardised guidelines for the use of LV unloading during ECPR.

Routinely available inflammation biomarkers as predictors of adverse outcomes following coronary angiography

Abstract Background Inflammatory activation plays a pivotal role in the development and progression of atherosclerosis and subsequently in coronary artery disease (CAD). Several biomarkers of inflammation such as C-reactive protein (CRP), leucocytes, and neutrophile-to-lymphocyte ratio (NLR), are considerable predictors of adverse events in CAD patients. The presence of underlying inflammation may also affect net outcomes of patients undergoing coronary angiography and percutaneous coronary intervention (PCI). However, the association between inflammatory activation and patient outcomes after coronary angiography remain widely unclear. Purpose The study goal was to investigate the predictive value of routinely used inflammation biomarkers including CRP, leukocytes and NLR in a large all-comer patient population undergoing coronary angiography. We aimed to gain additional insights into the association of inflammatory markers with patient outcomes to take a step towards personalized risk stratification for CAD patients. Methods A total of 12 642 patients undergoing coronary angiography between 2010 and 2021 with full laboratory analysis were enrolled in this observational study. CRP, leucocytes and NLR were analysed for possible effects on all-cause and cardiovascular mortality. We further investigated target lesion revascularization (TLR) after PCI in the presence of underlying inflammation as an intervention-specific endpoint. Results 3300 (26%) patients presented with acute coronary syndromes (ACS) and 4145 (33%) patients were treated with PCI. All investigated inflammatory biomarkers (CRP, leukocytes, NLR) were significantly associated with all-cause mortality and especially with cardiovascular mortality in both acute and elective patients. This association remained highly significant after adjusting for demographic and clinical variables. While CRP was strongly related with cardiovascular mortality in STEMI patients (ad. HR per 1 SD: 1.35 [95%-CI: 1.14 – 1.59]), no significant association was observed in NSTEMI patients (ad. HR per 1 SD: 1.04 [95%-CI: 0.92 – 1.17]; p for interaction: 0.007; figure 1). Notably, CRP was not found to be associated with TLR in patients undergoing acute or elective PCI (ad. HR per 1 SD: 0.99 [95%-CI: 0.88 – 1.11]; p-value: 0.857). However, we found a highly significant association between NLR and TLR in both acute and elective patients (ad. HR per 1SD: 1.27 [95%-CI: 1.12 – 1.43]; p-value: &amp;lt;0.001). Conclusion Inflammatory activation is associated with increased mortality in patients undergoing coronary angiography. Although the impact of inflammation on interventional outcomes may be assumed, our study did not show significant associations between CRP and TLR. However, NLR emerged as a robust predictor of adverse events after PCI. Thus, while CRP does not impact the interventional outcome of PCI, a modulation of the cellular immune response does.Figure 1

Abstract 16290: Lipoprotein (a) as a Predictor of Recurrent Myocardial Infarction/Coronary Revascularization in Patients With Acute Coronary Syndrome Who Underwent PCI: A Meta-Analysis of Observational Studies

Introduction: Lipoprotein (a) [Lp(a)] has been recognized as an independent predictor of atherosclerotic cardiovascular disease (ASCVD). However, there is limited data on the association between Lp(a) levels and risk of recurrent myocardial infarction (MI)/coronary revascularization in patients with acute coronary syndrome (ACS) who underwent percutaneous coronary intervention (PCI). Methods: PubMed/Medline, EMBASE, and Scopus were searched for studies evaluating the association of Lp(a) with recurrent ischemic events from the year 2000-2023. Patients with coronary artery disease or ACS with baseline Lp(a) who underwent PCI or coronary stenting and had outcomes as recurrent MI/ coronary revascularization were included. Random effects models and I 2 statistics were used for pooled hazard ratios (HR), odds ratio (OR), and heterogeneity assessment. A leave-one-out sensitivity analysis was also performed. Results: The initial search resulted in 651 articles, of which nine studies with 27964 patients (mean age 58-66 years, 74.79% male) were included. Of the nine studies, six were retrospective and three prospective. Mean±SD/Median (IQ) follow-up duration was four years [range 2-7 years]. There was an increased risk of recurrent MI/coronary revascularization associated with Lp(a) ≥30 mg/dL (OR, 1.44, 95% CI: 1.09-1.89, I 2 = 79.24%, p=0.009) (Fig 1a) and Lp(a) ≥10-30 mg/dL (OR, 1.19, 95% CI: 1.009-1.416, I 2 = 0%, p=0.039) (Fig 1b), but failed to reach significance with Lp(a) as a continuous variable (OR, 1.004, 95% CI: 0.998-1.009, I 2 = 85.02%, p=0.221) (Fig 1c). Leave-one-out sensitivity analysis showed an equivalent result for various Lp(a) cutoffs (Fig 1a, 1b, and 1c). Conclusions: Our meta-analysis suggests an association of raised Lp(a) with increased risk of recurrent MI/coronary revascularization in ACS patients who underwent PCI.

Long-term effects of a home exercise program in patients with acute myocardial infarction and percutaneous coronary intervention: prospective observational study

OBJECTIVE: Our aim was to evaluate the effects of home physical training (HPT) in patients with acute myocardial infarction (AMI) and percutaneous coronary intervention (PCI) in 1 year and the long-term period.&#x0D; MATERIALS AND METHODS: A prospective observational study was conducted. Ninety-seven patients after AMI and PCI were included: Group 1 (n=51) patients exercising at home for the next year after PCI (HPT+), and Group 2 (n=46) no exercises (HPT). The evaluation was performed at baseline, in 1 year, and 8.90.9 years. The long-term response rate was 42 patients (82.4%) in the HPT+ group and 36 (78.3%) in the HPT- group.&#x0D; RESULTS: Patients in the HPT+ group had significantly higher physical performance at the cycle ergometer exercise test in 1 and 8.90.9 years: exercise time increased by 31.4% (p 0.001) and 40% (p 0.001), respectively, and the load increased by 15.6% (p 0.001) and 32.2% (p 0.001), whereas these indicators did not change significantly in HPT- group. Daily physical activity (PA) increased by 21.9% (p 0.01) in 1 year and 19.6% (p 0.01) in 8.90.9 years in the HPT+ group. PA did not change in the HPT- group in 1 year and decreased by 23.1% (p 0.001) in 8.90.9 years to a low level. The left ventricle ejection fraction in the HPT+ group increased by 2.4% (p 0.05) in 1 year and 6.8% (p 0.05) in 8.90.9 years with no changes in HPT- group. Quality of life increased more significantly in the HPT+ group by 50.6% (p 0.05) in 1 year and 71.6% (p 0.01) in 8.90.9 years versus 25.4% (p 0.05) and 46.9% (p 0.05), respectively, in the HPT- group. In the long-term period, the HPT+ group had fewer adverse clinical outcomes, with 22 patients compared with 28 (52.4 vs 77.8%, p 0.05).&#x0D; CONCLUSION: Patients with AMI and PCI who participated in a one-year HPT program had positively affected exercise tolerance, myocardial contractility, QoL, and adverse events in the long-term follow-up period.

Low-density lipoprotein cholesterol reduction with immediate combination therapy of statin and ezetimibe compared to statin monotherapy after percutaneous coronary intervention.

Current guidelines recommend astepwise initiation of lipid-lowering therapy after percutaneous coronary interventions (PCI) in treatment-naïve individuals. Patients might benefit from an earlier and stronger low-density lipoprotein-cholesterol (LDL-C) reduction through upfront combination therapies. This retrospective study included patients without previous lipid-lowering therapy undergoing acute or elective PCI with stent implantation between January 2016 and December 2019. Patients initiated on statin monotherapy vs. acombination of statin and ezetimibe were compared. The primary endpoint was an LDL‑C reduction into the target range of < 55 mg/dL at 3 months. The secondary endpoint was the occurrence of major cardiovascular events (MACE). Atotal of 204 lipid-lowering therapy naive patients were included, of whom 157 (77.0%) received statin monotherapy and 47(23.0%) combination therapy. Median LDL‑C levels were higher in patients initiated on combination therapy vs. monotherapy (140 mg/dL, interquartile range, IQR, 123-167 mg/dL vs. 102 mg/dL, IQR 80-136 mg/dL, p < 0.001). The LDL‑C reduction was greater in patients treated with combination therapy vs. statin monotherapy (-73 mg/dL, -52.1% vs. -43 mg/dL, -42.2%, p < 0.001). While the primary endpoint was similar between groups (44.7% vs. 36.1%, p = 0.275), combination therapy significantly increased the proportion of patients achieving the treatment target in the presence of an admission LDL-C > 120 mg/dL (46.2% vs. 26.2%, p = 0.031). The rates of MACE were similar between the two groups (10.6% vs. 17.8%, p = 0.237) at amedian follow-up of 2.2 years, IQR 1.46-3.10 years. Immediate initiation of high-intensity statin and ezetimibe treatment might be considered as the default strategy in treatment-naïve patients with high admission LDL‑C undergoing PCI.

Impact of stress hyperglycemia ratio on mortality in patients with critical acute myocardial infarction: insight from american MIMIC-IV and the chinese CIN-II study

BackgroundAmong patients with acute coronary syndrome and percutaneous coronary intervention, stress hyperglycemia ratio (SHR) is primarily associated with short-term unfavorable outcomes. However, the relationship between SHR and long-term worsen prognosis in acute myocardial infarction (AMI) patients admitted in intensive care unit (ICU) are not fully investigated, especially in those with different ethnicity. This study aimed to clarify the association of SHR with all-cause mortality in critical AMI patients from American and Chinese cohorts.MethodsOverall 4,337 AMI patients with their first ICU admission from the American Medical Information Mart for Intensive Care (MIMIC)-IV database (n = 2,166) and Chinese multicenter registry cohort Cardiorenal ImprovemeNt II (CIN-II, n = 2,171) were included in this study. The patients were divided into 4 groups based on quantiles of SHR in both two cohorts.ResultsThe total mortality was 23.8% (maximum follow-up time: 12.1 years) in American MIMIC-IV and 29.1% (maximum follow-up time: 14.1 years) in Chinese CIN-II. In MIMIC-IV cohort, patients with SHR of quartile 4 had higher risk of 1-year (adjusted hazard radio [aHR] = 1.87; 95% CI: 1.40–2.50) and long-term (aHR = 1.63; 95% CI: 1.27–2.09) all-cause mortality than quartile 2 (as reference). Similar results were observed in CIN-II cohort (1-year mortality: aHR = 1.44; 95%CI: 1.03–2.02; long-term mortality: aHR = 1.32; 95%CI: 1.05–1.66). In both two group, restricted cubic splines indicated a J-shaped correlation between SHR and all-cause mortality. In subgroup analysis, SHR was significantly associated with higher 1-year and long-term all-cause mortality among patients without diabetes in both MIMIC-IV and CIN-II cohort.ConclusionAmong critical AMI patients, elevated SHR is significantly associated with and 1-year and long-term all-cause mortality, especially in those without diabetes, and the results are consistently in both American and Chinese cohorts.