Coronary Revascularization Procedures Research Articles

The predictive value of lesion-specific pericoronary fat attenuation index for major adverse cardiovascular events in patients with type 2 diabetes

BackgroundThe purpose of this study was to explore the prognostic significance of the lesion-specific pericoronary fat attenuation index (FAI) in forecasting major adverse cardiovascular events (MACE) among patients with type 2 diabetes mellitus (T2DM).MethodsThis study conducted a retrospective analysis of 304 patients diagnosed with T2DM who underwent coronary computed tomography angiography (CCTA) in our hospital from December 2011 to October 2021. All participants were followed for a period exceeding three years. Detailed clinical data and CCTA imaging features were carefully recorded, encompassing lesion-specific pericoronary FAI, FAI of the three prime coronary arteries, features of high-risk plaques, and the coronary artery calcium score (CACS). The MACE included in the study comprised cardiac death, acute coronary syndrome (which encompasses unstable angina pectoris and myocardial infarction), late-phase coronary revascularization procedures, and hospital admissions prompted by heart failure.ResultsWithin the three-year follow-up, 76 patients with T2DM suffered from MACE. The lesion-specific pericoronary FAI in patients who experienced MACE was notably higher compared to those without MACE (–84.87 ± 11.36 Hounsfield Units (HU) vs. –88.65 ± 11.89 HU, p = 0.016). Multivariate Cox regression analysis revealed that CACS ≥ 100 (hazard ratio [HR] = 4.071, 95% confidence interval [CI] 2.157–7.683, p < 0.001) and lesion-specific pericoronary FAI higher than − 83.5 HU (HR = 2.400, 95% CI 1.399–4.120, p = 0.001) were independently associated with heightened risk of MACE in patients with T2DM over a three-year period. Kaplan-Meier analysis showed that patients with higher lesion-specific pericoronary FAI were more likely to develop MACE (p = 0.0023). Additionally, lesions characterized by higher lesion-specific pericoronary FAI values were found to have a greater proportion of high-risk plaques (p = 0.015). Subgroup analysis indicated that lesion-specific pericoronary FAI higher than − 83.5 HU (HR = 2.017, 95% CI 1.143–3.559, p = 0.015) was independently correlated with MACE in patients with T2DM who have moderate to severe coronary calcification. Moreover, the combination of CACS ≥ 100 and lesion-specific pericoronary FAI>-83.5 HU significantly enhanced the predictive value of MACE in patients with T2DM within 3 years.ConclusionsThe elevated lesion-specific pericoronary FAI emerged as an independent prognostic factor for MACE in patients with T2DM, inclusive of those with moderate to severe coronary artery calcification. Incorporating lesion-specific pericoronary FAI with the CACS provided incremental predictive power for MACE in patients with T2DM.

Характеристика пацієнтів з ішемічною хворобою серця та стабільною стенокардією в Україні, оцінка підходів до їх лікування за даними багатоцентрового дослідження GO-OD

Treatment of coronary artery disease (CAD) and stable angina, includes lifestyle modification, pharmacological therapy and invasive interventions to achieve stabilization or regression of the disease. Knowledge of the current situation regarding the use of pharmacological therapy and evaluation of its effectiveness is necessary for further management optimization. Trimetazidine (TMZ) has previously been shown to reduce angina symptoms and increase exercise tolerance in patients with CAD and stable angina and may be among an option for optimizing antianginal treatment. However, the effectiveness of long-term treatment depends on patient adherence, so the use of TMZ once daily (OD) at a dose of 80 mg may improve satisfaction and adherence in patients with CAD and stable angina.Methods. The GO-OD study is a 3-month, non-interventional, observational, multicenter prospective study conducted in Ukraine in a real-world outpatient cardiology practice during February – August 2021. Physicians were instructed to continue monitoring and treating patients in accordance with usual practice and international guidelines. No additional diagnostic or monitoring procedures were performed. Clinical, instrumental and laboratory data, frequency of angina attacks, consumption of short-acting nitrates (SAN), adherence to antianginal drugs, as well as the overall efficacy, tolerability of TMZ OD 80 mg in real-world clinical practice were analyzed. The observation includes regular assessment of patients` clinical status, treatment optimization and its effectiveness at follow up visits.Results. The study included 1529 patients (mean age 62.5 years, 56 % men). In the absence of adequate control of risk factors, pharmacological control of symptoms, and limited use of interventional and surgical treatments, the frequency of angina episodes was high, most patients had a pronounced angina functional class according to the Canadian Society of Cardiology classification (10.5 % – CCS I, 60.1 % – CCS II, 29.5 % – CCS III). Thus, the average number of angina attacks per week in CCS I was 3.7, in CCS II – 5.2, and in CCS III – 7, 97 attacks. In addition to the severity of symptoms, the following pattern was observed: the higher the angina class, the more risk factors and comorbidities patients had. After 3 months of follow-up due to optimization of therapy, there was a significant (p&lt;0.001) decrease in the frequency of angina attacks – from (5.8±4.7 to 1.6±2.0)/week, and the use of SAN – from (4.2±4.3 to 0.8±1.6)/week). At the same time, in 3 month the % of patients with CCS II and III significantly decreased, while the % of patients with CCS I increased (48.4 % – CCS I, 45.7 % – CCS II, 6 % – CCS III). Adherence to medication was improved: 49 % of patients reported high adherence (vs. 18 % at baseline) and 12 % – low adherence (vs. 52 % at baseline). After 3 months of follow-up most of doctors rated the overall tolerability and effectiveness of the therapy as «very satisfied». Patients’ satisfaction with TMZ OD 80 mg therapy after 3 months of follow-up was 9.5 points [on a scale of 1 to 10 (very satisfied)]. Patients’ assessment of daily physical activity increased significantly: 2.42 versus 5.89 points at baseline (on a scale of 1 to 10 (severe limitation)).Conclusions. In general, the management of outpatients with CAD and stable angina in the current cardiologists’ practice, which was complicated by the COVID-19 pandemic, was not effective enough, resulting in a high frequency of angina attacks – almost 6 per week, and a significant limitation of daily activity due to angina symptoms.Significant deficiency in the management of studied population was insufficient correction of such important risk factors as hypertension, heart rate, dyslipidemia, and lifestyle-related risk factors (overweight and obesity, low level of physical activity). The baseline therapy of patients in the study was in line with current guidelines, but with an insufficient frequency of statin prescription (78 %) and ACE inhibitors (54.5 %); antianginal treatment with an average of 2 or more antianginal drugs was not optimal for controlling angina symptoms, and the frequency of coronary revascularization procedures was also insufficient, mostly during acute MI (58.0 %).Optimization of drug therapy as the first step in correcting the condition of patients with CAD and stable angina in accordance with all current recommendations with the inclusion of the original trimetazidine OD 80 mg once daily among antianginal drugs, as well as active monitoring of patients for 3 months allowed to reduce the frequency of angina attacks regardless of its initial FC, increase patient adherence to treatment and their functional activity.

The association of bariatric surgery with myocardial infarction and coronary revascularization: a propensity score match analysis of National Inpatient Sample

BackgroundMetabolic bariatric surgery (MBS) not only leads to a durable weight loss but also lowers mortality, and reduces cardiovascular risks. ObjectivesThe current study aims to investigate the association of bariatric metabolic surgery (BMS) with admissions for acute myocardial infarction (AMI), including ST-elevation myocardial infarction (STEMI) and non–ST-elevation myocardial infarction (NSTEMI), as well as, coronary revascularization procedures, including percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), and thrombolysis. SettingThe National Inpatient Sample (NIS) database. MethodsThe NIS data from 2016 to 2020 were analyzed. A propensity score matching in a 1:1 ratio was performed to match patients with history of MBS with non-MBS group. ResultsTwo hundred thirty-three thousand seven hundred twenty-nine patients from the non-MBS group were matched with 233,729 patients with history of MBS. The MBS group had about 52% reduced odds of admission for AMI compared to the non-MBS group (adjusted odd ratio: .477, 95% confidence interval: .454–.502, P value <.001). In addition, the odds of STEMI and NSEMI were significantly lower in the MBS group in comparison to the non-MBS group. Also, the MBS group had significantly lower odds of CABG, PCI, and thrombolysis compared to the non-MBS group. In addition, in patients with AMI, MBS was associated with lower in-hospital mortality (adjusted odd ratio: .627, 95% confidence interval: .469–.839, P value = .004), length of hospital stays, and total charges. ConclusionsHistory of MBS is significantly associated with reduced risk of admission for AMI including STEMI and NSTEMI, as well as the, need for coronary revascularization such as PCI and CABG.

Sex-specific genetic risks for adverse outcomes after coronary revascularization procedures.

Men and women have differing risks of adverse events after revascularization procedures and these differences could be partially driven by genetics. We studied the sex-specific differences in associations of polygenic risk scores (PRSs) with atrial fibrillation (AF), ischaemic stroke (STR), intracranial haemorrhage (ICH), myocardial infarction (MI) and gastrointestinal haemorrhage (GIH) in coronary revascularization patients. The study cohort comprised 5561 and 17578 revascularized women and men. All participants underwent genotyping and register-based follow-up from 1961 to 2021. We calculated PRSs for all individuals and used Cox models with interaction term to examine the sex-specific associations between the PRSs and adverse outcomes after revascularization. The AF-PRS was more strongly associated with AF in men [hazard ratio (HR) per 1 standard deviation increase, 1.16; 95% confidence interval (CI), 1.12-1.19; P = 7.6 × 10-22) than in women (P for interaction 0.006). Conversely, ICH-PRS was more strongly associated with ICH after revascularization in women (HR, 1.32; 95% CI, 1.08-1.62; P = 0.008) than in men (P for interaction 0.008). We observed no sex-specific differences for the associations of PRSs with STR, MI or GIH. The genetic risk of AF after revascularization is greater in men than in women, and vice versa for ICH. Sex-specific PRSs could be used to identify individuals in high genetic risk for these complications.

The role of postoperative trimetazidine therapy in on-pump coronary artery bypass surgery.

Coronary artery bypass surgery remains the gold standard in the treatment of patients with ischemic heart disease. However, the increased oxidative stress caused by the release of free radicals during the ischemia-reperfusion time is a well-known pathophysiological process during and after coronary revascularization procedures. It may lead to reversible and irreversible myocardial injury.

Coronary artery calcium (CAC) score for cardiovascular risk stratification in a Thai clinical cohort: A comparison of absolute scores and age-sex-specific percentiles

PurposesCoronary artery calcium (CAC) score provides a quantification of atherosclerotic plaque within the coronary arteries. This study aimed to examine the prevalence and CAC score distribution and to evaluate the association of each CAC score classifications with major adverse cardiovascular events (MACE) in a Thai clinical cohort. MethodsThis study was a retrospective observational cohort. We included patients aged above 35 years who underwent CAC score testing. The absolute and age-sex specific percentile classifications were categorized as 0, 1 to 10, 11 to 100, 101 to 400, and >400 and 0, <75th, 75th – 90th, and >90th, respectively. The endpoint was MACE, including cardiovascular death, myocardial infarction, heart failure hospitalization, coronary artery revascularization procedure, and stroke. Multivariable Cox regression was used to estimate the hazard ratios. The discriminative performance between classifications were compared using Harrell's C-statistics. The agreement was assessed via Cohen's Kappa. ResultsThis study included 440 patients, with approximately 70% of Thai patients exhibiting a CAC score. CAC score distributed higher in male than female and increased with age. Both CAC score classification demonstrated the acceptable predictive performance. However, fair agreement was observed between classifications (Cohen's kappa 0.51, 95%CI 0.42–0.59). Within the absolute classification, a higher CAC score was associated with increased hazard ratios for MACE across stratified age-sex-specific percentile levels. In contrast, the hazard ratios for MACE did not consistently rise with higher age-sex-specific percentile CAC score when stratified by absolute CAC score levels. ConclusionsBoth absolute and age-sex-specific percentile CAC score demonstrated acceptable performance in predicting MACE. However, the absolute CAC score classification may be more suitable for risk stratification within the Thai clinical cohort. Our findings offer supportive information that could inform future recommendations for CAC score testing criteria within national clinical practice guidelines.

Abstract 14656: Virtual Cardiac Rehabilitation is Rarely Used but May Augment Overall Attendance

Introduction: The COVID-19 public health emergency temporarily expanded Medicare reimbursement of cardiac rehabilitation (CR) to cover virtual CR. The purpose of this study was to evaluate the frequency of virtual CR use in Medicare and describe this emerging population of virtual CR patients, as there is currently limited data on the rates and patterns of virtual CR utilization. Methods: The study sample included 100% of Medicare beneficiaries undergoing surgical/percutaneous coronary revascularization or aortic valve replacement between July 2019 and December 2021 in the Medicare Virtual Research Data Center. Professional claims were used to identify CR use within one year of discharge using CPT codes (93797, 93798), and the disaster-related modifiers (“CR” or “DR”) were used to categorize CR visits as synchronized virtual sessions. Descriptive analysis compared patient characteristics and number of CR sessions attended between patients using virtual and facility-based CR. Results: Overall CR use was 32.5% in the entire sample (167066/513735). Any CR use was more prevalent among patients who were male, White, or 65-85 years old, and similar between coronary revascularization vs. aortic valve procedures. Only 14 states reported any virtual CR visits (CA, FL, GA, IL, IN, MI, MN, MO, NY, OR, PA, TN, TX, WI). Within these states, only 1% (886) of all CR users had at least one virtual CR session. The characteristics of patients who utilized virtual CR were largely similar to those who attended facility-based only CR. The median number of virtual sessions was 21 (IQR 26). Of patients who utilized virtual CR, 17.7% (157) also attended at least one facility-based CR session. Notably, combined virtual and facility-based CR utilizers attended a median of 33 (IQR 14) total CR sessions, compared to 25 (IQR 23) CR sessions for patients who attended only facility-based CR. Conclusion: Virtual CR was not widely available or used despite expanded Medicare reimbursement, yet our data suggests that the combined use of virtual and facility-based CR may be associated with a greater number of sessions attended (vs. facility-based only CR). Further research is needed to inform long-term policy decisions, particularly as it pertains to continued Medicare coverage of virtual CR.

Abstract 15339: CAD Polygenic Risk Score and Incident Complex Coronary Revascularization in Adults With Atherosclerosis

Introduction: A CAD polygenic risk score (CAD PRS) was previously shown to predict major vascular events among patients with established ASCVD. Whether genetic risk can predict the need for complex coronary revascularization procedures, including complex PCI or CABG, has not been established. Methods: The FOURIER trial randomized 27,564 patients with established ASCVD to evolocumab or placebo with a median follow-up of 2.2 years. Of these, 14,298 had genotype data and were used in this analysis. The CAD PRS was previously derived in a CAD GWAS and includes 2,293,205 SNPs. Clinical records were reviewed for coronary revascularization events to determine procedural characteristics and coronary anatomy. Complex revascularization was defined as complex PCI [multivessel PCI, &gt;3 lesions, &gt;3 stents, total stent length &gt;60mm, or bifurcation PCI] or CABG. Associations between the CAD PRS and revascularization events were analyzed by PRS quintile. Results: Patients with higher CAD PRS were significantly more likely to undergo complex coronary revascularization than those with low genetic risk (Q5 vs Q1: HR 1.71; 95% CI 1.23-2.37; P=0.002) (Fig A), with a greater than 2-fold higher risk of complex PCI (HR 2.11; 1.33-3.35) and a numerically higher risk of CABG (HR 1.28; 0.80-2.05). These findings were directionally consistent for the individual components of complex PCI, including multivessel PCI (HR 1.71; 0.97-3.00), &gt; 3 lesions (HR 1.85; 0.73-4.68), &gt; 3 stents (HR 3.77; 1.75-8.12), stent length &gt;60 mm (HR 2.07; 0.88-4.87), and bifurcation PCI (HR 2.17; 0.39-11.98) (Fig B). Conclusions: Among patients with established ASCVD, a CAD PRS predicted incident complex coronary revascularization procedures. Genetic prediction of advanced coronary disease requiring specific complex interventions has not previously been shown, and these findings may have the potential to yield novel approaches for reducing the need for these high-risk and costly procedures.

Sex-related differences for uric acid in the prediction of cardiovascular events in essential hypertension. A population prospective study.

Uric acid (UA) is an independent prognostic factor for cardiovascular events, but there are no data demonstrating a different risk profile between women and men. Thus, we tested whether UA is associated with a possible sex-related difference in fatal and non-fatal cardiovascular events. In this prospective population-based study we enrolled 1,650 never-treated Caucasian hypertensive outpatients referred to Catanzaro University Hospital (Italy). Inclusion criteria were newly diagnosed hypertensive patients, aged 20years or more. Exclusion criteria were secondary form of hypertension, previous cardiovascular events, rheumatic and non-rheumatic valvular heart disease, prosthetic valves, cardiomyopathies, type-2 diabetes, chronic kidney disease, malignant diseases, gout arthritis and secondary forms of hyperuricemia, liver diseases, peripheral vascular diseases, and heart failure. Anthropometric, clinical, and biochemical parameters were measured. UA prognostic role was investigated by Cox regression analyses. Receiver-operating characteristic curve analyses and area under the curve were used to determine the predictive validity and the optimal cut-off point of UA. We investigated following endpoints: coronary events (fatal and nonfatal myocardial infarction, unstable angina, coronary revascularization procedures, coronary death); fatal and nonfatal stroke; all-cause mortality and major adverse cardiovascular events (MACE). We enrolled 830 males and 820 females aged 52.2 ± 11.3years. During 9.5 ± 3.1years follow-up, there were 424 new clinical events (2.71%): 250 coronary (1.59%), 118 (0.75%) cerebrovascular, and 56 (0.40%) deaths. Comparison between groups demonstrated a higher and significant difference in incidence rate in females for MACE (3.08 vs 2.33%, P = 0.001), coronary (1.82 vs 1.36%, P = 0.014) and cerebrovascular events (0.93 vs 0.57%, P = 0.006). UA at multiple Cox regression analysis resulted a strong and significant predictor of coronary events (HR = 1.493;95% CI 1.375-1.621), cerebrovascular events (HR = 1.256;95% CI 1.109-1.423), MACE (HR = 1.415;95% CI 1.328- 53 1.508), and all-cause mortality (HR = 1.469;95% CI 1.237-1.745) in the whole population and in both groups with a HR higher in females. The best estimated cut-off values of uric acid for males and females predicted these endpoints equally well, but it was always lower in females than males. We demonstrate, that UA operates with a sex-related impact and best cut-off value in predicting cardiovascular outcomes and all-cause mortality, reflecting a possible sex difference in disease pathophysiology.

Comparison of HEAR and HEART Scores for Major Adverse Cardiovascular Events.

Early identification of patients with low and high risk for acute coronary syndrome in the emergency department (ED) is important for process management and proper resource use. The aim of this study was to comparethe HEAR and HEART scores to determine the risk for major adverse cardiovascular events (MACE) over 30 days. Demographic data and clinical evaluations of the patients who presented to theEDwith chest pain were recorded. ECGs were evaluated without knowing the clinical status of the patients. The HEART (including history, ECG, age, coronary risk factors, and troponin level) and HEAR (including four items with no troponin) risk scores were calculated. MACE was defined as all MI, all coronary revascularization procedures (PCI and CABG), all-cause death, cardiac arrest, cardiogenic shock, or life-threatening cardiac arrhythmias within 30 days. Patients with MACE were evaluated as Group 1, and patients without MACE were considered as Group 2, and the data from the two groups were compared. A total of 230 patients were included in the study. There were 56 (24.3%) patients with MACEs. According to the ROC analysis, the threshold value was determined as ≤3 for both scoring systems. According to this threshold value, sensitivity and specificity were found to be 0.77 and 0.78 for the HEAR scoreand 0.82 and 0.77 for the HEART score. Although the HEAR and HEART scoring systems are useful for the management of patients with chest pain in the ED, the HEART score was evaluated to be more effective.

THU306 Association Of Prediabetes With Cardiovascular Outcomes Among Veterans With Obesity

Abstract Disclosure: J. Pendse: None. J. Mathew: None. S. Maidman: None. K. Mangalick: None. A. Ramachandran: None. E. Siddiqui: None. J.O. Aleman Diaz: None. Introduction: Prediabetes occurs frequently in obesity and is independently associated with increased atherosclerosis in nondiabetic patients. We sought to compare the effects of prediabetes on cardiovascular interventions along the glycemic control spectrum in obesity within the Veterans Health Administration (VHA), the largest US healthcare system. Methods: We conducted a systematic, retrospective review using the VHA Corporate Data Warehouse through the Veterans Administration Informatics and Computing Infrastructure database. We compared patients with obesity and prediabetes (preDM) to patients with obesity and normoglycemia (NG). Inclusion criteria included a body mass index (BMI) ≥ 30 kg/m2, Hemoglobin A1C (HbA1c) &amp;lt; 6.5% between 2000 and 2016. The intervention group included patients with preDM, defined by HbA1c between 5.7% to less than 6.5%, and the control group included patients with NG, defined as HbA1c&amp;lt; 5.7%. The primary endpoint was incidence of coronary revascularization, defined as a composite of percutaneous cardiac intervention (PCI) or coronary artery bypass graft (CABG). Secondary outcomes included PCI, CABG, diagnostic cardiac catheterizations, and mortality. Groups were compared using Pearson’s Chi-squared test or student t-tests when appropriate with alpha set to 0.05, and were assumed to have normal distribution. Results: A total of 137,487 subjects were included in the study, with 91,611 subjects with preDM and 45,876 subjects with NG. The average BMI among the preDM group was 33.8 kg/m2 ± 3.6 and the average BMI among the NG group was 33.4 kg/m2 ± 3.3 (p&amp;lt;0.001). Obesity/preDM subjects had a higher rate of coronary revascularization (6.3%, n=5,749) compared to obesity/NG subjects (3.1%, n=1,408) (p&amp;lt;0.001). From a total of 7,157 revascularized veterans, all-cause mortality rate was increased in preDM subjects (6.6%, n=851) compared to NG subjects (5.8%, n=221) (p&amp;lt;0.001). Obesity/preDM subjects had a higher rate of all-cause mortality (3.9%, n=3607) compared to obesity/NG subjects (2.8%, n= 1273). Also of note, obesity/preDM subjects had higher rates of diagnostic catheterization (11.9%, n=10,858), PCI (5.4%, n=4,913), stent (0.57%, n=528), CABG (1.2%, n=1087) compared with rates in obesity/NG subjects with diagnostic catheterization (7.1%, n=3272), PCI (2.6%, n=1183), stent (0.30%, n=138), and CABG (0.56%, n=258). Evaluating composite cardiovascular outcomes including PCI, stent, and CABG, obesity/preDM subjects had higher rates (6.3%, n=5749) compared with obesity/NG subjects (3.1%, n=1408). Conclusion: In this retrospective study, we have concluded that veterans diagnosed with obesity/preDM had higher rates of composite cardiovascular outcomes, including significantly higher rates of coronary revascularization procedures, overall mortality, and mortality following revascularization compared to veterans with obesity/NG. Presentation: Thursday, June 15, 2023

Patient-specific modeling of blood flow in the coronary arteries

Patient-specific models of blood flow in the coronary arteries have entered clinical practice worldwide to aid in the diagnosis and management of heart disease. This technology leverages modern AI-based image segmentation methods to extract the geometry of the coronary arteries from noninvasive computed tomography volumetric imaging, computational physiology methods to define boundary conditions and computational fluid dynamic techniques to compute coronary artery flow and pressure. The methods described herein have been used to compute the fractional flow reserve (FFR) in the coronary arteries, namely the ratio of pressure in a coronary artery to the reference aortic pressure under conditions of maximum hyperemia induced by the intravenous administration of a vasodilator to mimic increased coronary artery blood flow as occurs during physical activity. The fractional flow reserve derived from coronary computed tomography angiography (CCTA) using patient-specific models of coronary artery blood flow is referred to as FFRCT and has been validated against invasive measurements using pressure wires in several hundred patients and subsequently evaluated in clinical trials in several thousand patients. Patient-specific models of coronary artery blood flow can be used to predict outcomes of coronary artery revascularization procedures, to identify patients at risk of having a heart attack, and to model tissue perfusion of the microcirculation by coupling with emerging models of cardiac function. This paper provides a state-of-the-art review of computational methods for, and applications of, quantifying blood flow in patient-specific models of the coronary arteries.

Effect of different coronary artery revascularization procedures on cognition: A systematic review

Coronary revascularization interventions have been associated with post-intervention cognitive decline. Hence, this systematic review aims to compare the long-term effects of different coronary revascularization interventions on cognition. The Cochrane Library and MEDLINE databases were searched for articles published between January 2009 and January 2023. Articles on clinical trials and cohort studies that compared at least two different interventions with a minimum three months follow up were included to evaluate the consequences of different intervention techniques on cognition. Each selected study was evaluated using a revised tool to assess the risk of bias in randomized trials (RoB 2), and Risk of Bias In Non-Randomized Studies - of Interventions(ROBINS-1) was used for evaluating non-randomized studies. Five eligible studies, with four different comparisons, were included. Out of these studies, three RCTs and two cohort studies were included A participants gone through different procedures; on-pump and off-pump coronary artery bypass grafting (CABG), Percutaneous coronary intervention (PCI conventional cardiopulmonary bypass (CCPB), the miniaturized cardiopulmonary bypass (MCPB) and endoscopic coronary artery bypass grafting (Endo-CABG). These comparisons showed that different interventions have different effects on cognition; however, there is no solid evidence of correlations between them. Thus, the results of this review suggest that there should be greater focus on comparing interventions and that a reasonable follow-up duration should be set to avoid the influence of confounders. There is also a need to determine the effect of long-term cognitive decline while reducing interference by other variables.

Empagliflozin is associated with lower cardiovascular risk compared with dipeptidyl peptidase-4 inhibitors in adults with and without cardiovascular disease: EMPagliflozin compaRative effectIveness and SafEty (EMPRISE) study results from Europe and Asia

BackgroundStudies that have reported lower risk for cardiovascular outcomes in users of Sodium–Glucose Cotransporter-2 Inhibitors (SGLT-2i) are limited by residual cofounding and lack of information on prior cardiovascular disease (CVD). This study compared risk of cardiovascular events in patients within routine care settings in Europe and Asia with type 2 diabetes (T2D) initiating empagliflozin compared to dipeptidyl peptidase-4 inhibitors (DPP-4i) stratified by pre-existing CVD and history of heart failure (HF).Methods and resultsAdults initiating empagliflozin and DPP-4i in 2014–2018/19 from 11 countries in Europe and Asia were compared using propensity score matching and Cox proportional hazards regression to assess differences in rates of primary outcomes: hospitalisation for heart failure (HHF), myocardial infarction (MI), stroke; and secondary outcomes: cardiovascular mortality (CVM), coronary revascularisation procedure, composite outcome including HHF or CVM, and 3-point major adverse cardiovascular events (MACE: MI, stroke and CVM). Country-specific results were meta-analysed and pooled hazard ratios (HR) with 95% confidence intervals (CI) from random-effects models are presented.In total, 85,244 empagliflozin/DPP4i PS-matched patient pairs were included with overall mean follow-up of 0.7 years. Among those with pre-existing CVD, lower risk was observed for HHF (HR 0.74; 95% CI 0.64–0.86), CVM (HR 0.55; 95% CI 0.38–0.80), HHF or CVM (HR 0.57; 95% CI 0.48–0.67) and stroke (HR 0.79; 95% CI 0.67–0.94) in patients initiating empagliflozin vs DPP-4i. Similar patterns were observed among patients without pre-existing CVD and those with and without pre-existing HF.ConclusionThese results from diverse patient populations in routine care settings across Europe and Asia demonstrate that initiation of empagliflozin compared to DPP-4i results in favourable cardioprotective effects regardless of pre-existing CVD or HF status.

Cardiac Rehabilitation Reduces 2-Year Mortality After Coronary Artery Bypass Grafting

BackgroundCardiac rehabilitation (CR) is a supervised outpatient exercise and risk reduction program offered to patients who have undergone coronary revascularization procedures. Multiple professional societal guidelines support the use of CR after coronary artery bypass grafting (CABG) based on studies in combined percutaneous coronary intervention and CABG populations with surrogate outcomes. This statewide analysis of patients undergoing CABG evaluated the relationship between CR use and long-term mortality. MethodsMedicare fee-for-service claims were linked to surgical data for patients discharged alive after isolated CABG from January 1, 2015, through September 30, 2019. Outpatient facility claims were used to identify any CR use within 1 year of discharge. Death within 2 years of discharge was the primary outcome. Mixed-effects logistic regression was used to predict CR use, adjusting for a variety of comorbidities. Unadjusted and inverse probability treatment weighting (IPTW) were used to compare 2-year mortality among CR users vs nonusers. ResultsA total of 3848 of 6412 patients (60.0%) were enrolled in CR for an average of 23.2 (SD, 12.0) sessions, with 770 of 6412 (12.0%) completing all recommended 36 sessions. Logistic regression identified increasing age, discharge to home (vs extended care facility), and shorter length of stay as predictors of postdischarge CR use (P < .05). Unadjusted and IPTW analyses showed significant reduction in 2-year mortality in CR users compared with CR nonusers (unadjusted: 9.4% reduction; 95% CI, 10.8%-7.9%; P < .001; IPTW: −4.8% reduction; 95% CI, 6.0%-3.5%; P < .001). ConclusionsThese data suggest that CR use is associated with lower 2-year mortality. Future quality initiatives should consider identifying and addressing root causes of poor CR enrollment and completion.

Has the Expansion of Health Insurance Coverage via the Implementation of the Affordable Care Act Influenced Inequities in Coronary Revascularization in New York City?

In 2014, New York City implemented the Affordable Care Act (ACA) leading to insurance coverage gains intended to reduce inequities in healthcare services use. The paper documents inequalities in coronary revascularization procedures (percutaneous coronary intervention and coronary artery bypass grafting) usage by race/ethnicity, gender, insurance type, and income before and after the implementation of the ACA. We used data from the Healthcare Cost and Utilization Project to identify NYC patients hospitalized with the diagnosis of coronary artery disease (CAD) and/or congestive heart failure (CHF) in 2011-2013 (pre-ACA) and 2014-2017 (post-ACA). Next, we calculated age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization. Logistic regression models were used to identify the variables associated with receiving a coronary revascularization in each period. Age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization in patients 45-64years of age and 65years of age and older declined in the post-ACA period. Disparities by gender, race/ethnicity, insurance type, and income in the use of coronary revascularization persist in the post-ACA period. Although this health care reform law led to the narrowing of inequities in the use of coronary revascularization, disparities persist in NYC in the post-ACA period.

#3042 AMBULATORY BLOOD PRESSURE LEVELS AFFECT THE ASSOCIATION OF INTRADIALYTIC HYPERTENSION WITH ADVERSE CARDIOVASCULAR EVENTS IN HEMODIALYSIS PATIENTS

Abstract Background and Aims Patients with intradialytic hypertension (IDH) display also higher ambulatory blood pressure (BP) levels during the whole 44-h interdialytic interval compared to patients without the phenomenon. Sustained high 44-h ambulatory BP levels is a potential risk factor for cardiovascular events and mortality in these individuals. The aim of this study is to evaluate the influence of elevated 44-h BP levels on the high cardiovascular risk of individuals with IDH. Method A total of 242 hemodialysis patients with valid 48-h ABPM with Mobil-O-Graph-NG had an extended follow up for a median of 57.8 months. IDH was defined as: rise in SBP greater or equal to 10 mmHg from pre- to post-dialysis and post-dialysis SBP greater or equal to 150 mmHg. The primary end-point was a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, resuscitation after cardiac arrest, hospitalization for heart failure, coronary or peripheral revascularization procedure. The secondary endpoint was cardiovascular mortality. Results 5 patients with and 197 without were included in this prospective analysis. Cumulative freedom from the primary and secondary endpoint was significantly lower for patients with IDH (logrank-p = 0.019), while freedom from the secondary endpoint did not differ significantly between the two groups (logrank-p = 0.321). Patients with IDH presented a significantly higher risk for the composite endpoint (HR = 1.651, 95%CI[1.083, 2.516]), without, however, showing a significant difference in the risk for cardiovascular mortality (HR = 1.320, 95%CI[0.762, 2.288]). After adjustment for 44-h SBP, the association of IDH with the primary endpoint slightly attenuated, while the association with the secondary outcome had no significant changes (HR = 1.421, 95%CI[0.906, 2.228] and HR = 1.270, 95%CI[0.708, 2.276], for primary and secondary outcome respectively). Conclusion IDH is associated with higher risk for adverse cardiovascular outcomes. High ambulatory BP during the interdialytic interval contributes to the excess cardiovascular risk observed in this population.

#5608 THE INFLUENCE OF AMBULATORY BP ON THE ASSOCIATIONS OF SEX WITH CARDIOVASCULAR EVENTS AND MORTALITY IN DIALYSIS PATIENTS: A PROSPECTIVE COHORT STUDY

Abstract Background and Aims Male patients with pre-dialysis CKD have worse ambulatory BP control than females and this is associated with higher mortality risk. Male hemodialysis patients have higher ambulatory BP levels compared to females. The aim of this study was to investigate the influence of ambulatory BP on the associations of sex with cardiovascular events and mortality in hemodialysis individuals. Method 129 male and 91 female hemodialysis patients with valid 48-hour ABPM were followed prospectively for 53.4±31.1 months. The primary endpoint was cardiovascular mortality; the secondary endpoint was a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, resuscitation after cardiac arrest, hospitalization for heart failure, coronary or peripheral revascularization procedure. Results Cumulative-freedom from the primary endpoint was significantly lower for women (logrank-p = 0.032), while cumulative-freedom from the secondary endpoint did not differ significantly between the two groups (logrank-p = 0.644). The crude risk for cardiovascular mortality was significantly higher for women (HR = 1.613, 95% CI [1.037, 2.509]). The crude risk for the combined cardiovascular endpoint was not different between the two genders (HR = 0.918, 95% CI [0.638, 1.320]). After adjusting for other risk factors (age, diabetes, dialysis vintage, coronary disease) no significant differences in the risk for both the primary and the secondary endpoint were observed between women and men (primary: HR = 1.464 (95% CI [0.929, 2.307]), secondary: 0.866 (95% CI [0.596, 1.260])). After additional adjustment for 44-hour ambulatory BP the above relationships did not alter (primary: HR = 1.498, 95% CI [0.947, 2.368]), secondary: (HR = 0.911, 95%CI [0.625, 1.327])). Conclusion In contrast to patients with pre-dialysis CKD, ambulatory BP does not appear to significantly influence the relationship between gender and adverse cardiovascular outcomes in hemodialysis patients.

Benefits of early transplantation in patients with chronic renal failure undergoing coronary revascularization

Objective: This study aimed to evaluate the effectiveness of post-revascularization surgery in reducing future cardiac events among kidney transplant candidates. Additionally, the role of non-invasive diagnostic techniques and the use of coronary angiography in determining the prognosis of patients scheduled for kidney transplantation were examined. Material and Methods: A retrospective analysis was conducted on 202 renal transplant recipients who underwent their first coronary revascularization procedure after initiating renal replacement therapy between January 2021 and December 2021. Demographic data collected included patient age, sex, race, duration of prior end-stage renal disease, and primary renal diagnosis. Results: The study population consisted of 120 men and 82 women, with a mean age of 56.9 years. Diabetes mellitus (DM) and hypertension (HT) were present in 58.4% and 89.6% of the patients, respectively. Coronary angiography was performed in 30% of patients considered at risk. The median graft rejection time was 145 days according to Kaplan-Meier analysis. Discussion: Coronary artery disease (CAD) has a significant negative impact on the pre-, intra-, and post-transplant survival of patients with chronic kidney disease. Myocardial revascularization is recommended in selected patients with unstable cardiac symptoms or chronic kidney disease, providing long-term survival benefits. Collaborative decision-making between cardiologists and nephrologists is crucial to provide optimal care for this high-risk patient population. Lifestyle modifications, risk factor control, and careful patient selection for myocardial revascularization are key in managing coronary artery disease in chronic kidney disease patients. Conclusion: Managing coronary artery disease in chronic kidney disease patients, especially those who are candidates for kidney transplantation, requires a comprehensive approach. Optimal treatment strategies should consider the intricate relationship between cardiovascular and renal factors. Collaborative care involving cardiologists, nephrologists, and transplant specialists, as well as a focus on both myocardial revascularization and medical therapy, can lead to improved outcomes. Further research is needed to refine treatment guidelines and strategies for this high-risk patient population.

The Association of Homelessness With Rates of Diabetes Complications: A Population-Based Cohort Study.

To estimate the rates of diabetes complications and revascularization procedures among people with diabetes who have experienced homelessness compared with a matched cohort of nonhomeless control subjects. A propensity-matched cohort study was conducted using administrative health data from Ontario, Canada. Inclusion criteria included a diagnosis of diabetes and at least one hospital encounter between April 2006 and March 2019. Homeless status was identified using a validated administrative data algorithm. Eligible people with a history of homelessness were matched to nonhomeless control subjects with similar sociodemographic and clinical characteristics. Rate ratios (RRs) for macrovascular complications, revascularization procedures, acute glycemic emergencies, skin/soft tissue infections, and amputation were calculated using generalized linear models with negative binomial distribution and robust SEs. Of 1,076,437 people who were eligible for inclusion in the study, 6,944 were identified as homeless. A suitable nonhomeless match was found for 5,219 individuals. The rate of macrovascular complications was higher for people with a history of homelessness compared with nonhomeless control subjects (RR 1.85, 95% CI 1.64-2.07), as were rates of hospitalization for glycemia (RR 5.64, 95% CI 4.07-7.81) and skin/soft tissue infections (RR 3.78, 95% CI 3.31-4.32). By contrast, the rates of coronary revascularization procedures were lower for people with a history of homelessness (RR 0.76, 95% CI 0.62-0.94). These findings contribute to our understanding of the impact of homelessness on long-term diabetes outcomes. The higher rates of complications among people with a history of homelessness present an opportunity for tailored interventions to mitigate these disparities.