Diagnosis Of Infarction Research Articles

Long-term prognosis associated with undetectable high-sensitivity cardiac troponin T concentrations in the emergency department

Abstract Background The long-term prognostic implications of low or undetectable high-sensitivity cardiac troponin T (hs-cTnT) levels in patients presenting with chest pain in the emergency department (ED) have not been thoroughly studied. Furthermore, the prognosis has not been compared to the general population. Purpose This study aimed to investigate the long-term risk of all-cause mortality and cardiovascular outcomes in patients with chest pain but no myocardial injury, compared with the general population in Sweden. Methods Among all visits to 7 major EDs in Sweden from December 9, 2010 to August 31, 2017, we included the first visit by patients ≥18 years of age with chest pain and ≥1 hs-cTnT measurement. Visits in patients with myocardial injury (any hs-cTnT >14 ng/l), including those associated with a diagnosis of myocardial infarction (MI) were excluded. Standardized mortality ratios (SMRs) and incidence ratios (SIRs) were estimated to compare risks of death and future MI with the general population. Hazard ratios (HRs) with 95% CIs were calculated for comparisons of mortality and major adverse cardiovascular events (MACE) between visits with undetectable (<5 ng/l) and low (5-14 ng/l) hs-cTnT concentrations. Results A total of 112,694 visits were included, of which 69,571 (62%) and 43,123 (38%) occurred in patients with hs-cTnT <5 ng/l and 5-14 ng/l, respectively. All-cause mortality was overall lower compared to the standardized Swedish population (SMR 0.51, 95% CI: 0.49-0.54, and 0.88, 95% CI: 0.85-0.90), while risks of a future MI were higher (SIR 1.33, 95% CI: 1.25-1.42, and 1.53, 95% CI: 1.46-1.59). Hs-cTnT concentrations <5 ng/l were associated with a lower all-cause mortality in men ≥55 years and in women ≥65 years of age, respectively (figures 1 and 2). During a median follow-up of 6.4 years (IQR 4.8-8.0), 1769 (2.5%) and 5535 (13%) deaths occurred in patients with hs-cTnT <5 and 5-14 ng/l, respectively. The adjusted risks of death and MACE were 1.7- (HR 1.70, 95% CI: 1.60-1.80) and 1.6-fold (HR 1.63, 95% CI: 1.54-1.73) higher in patients with hs-cTnT 5-14 ng/l compared to patients with hs-cTnT <5 ng/l. Conclusions Patients with chest pain and low or undetectable hs-cTnT concentrations have an overall lower risk of death, but a higher risk of future MIs, compared with the age-standardized general population. In addition, detectable Hs-cTnT concentrations below the 99th percentile cutoff value are associated with long-term risks of death and MACE.Crude mortality rateStandardized mortality ratio

Non-HDL cholesterol and residual risk of myocardial infarction and death in statin-treated patients with and without diabetes

Abstract Background Patients with coronary artery disease continue to be at risk of myocardial infarction despite lipid-lowering treatment with statins. However, it is uncertain whether non-high-density lipoprotein (non-HDL) cholesterol identifies increased residual risk in patients with and without diabetes. Purpose To test the hypothesis that non-HDL cholesterol identifies residual risk of myocardial infarction and death in statin-treated patients with and without diabetes. Methods Contemporary cohort study of consecutive patients undergoing coronary angiography (CAG) for evaluation of coronary artery disease between 2011 and 2020. Analyses were performed in the semi-national Western Denmark Heart Registry. Non-HDL cholesterol was calculated within one year after CAG as total cholesterol minus HDL cholesterol and divided into four groups according to percentile level (<25th, 25th-74th, 75th-94th, and ≥95th percentile). Outcomes were diagnosis of myocardial infarction and all-cause death occurring between one year after CAG and end of follow-up (July 31, 2022). Risk according to non-HDL-C percentile group was estimated as adjusted hazard ratio (95% confidence interval). Results A total of 105,804 patients underwent CAG. We included 54,037 statin-treated patients with median duration of follow-up 4.6 years. Among 11,400 patients with diabetes, we observed 587 myocardial infarctions and 2,654 patients died. In 42,637 patients without diabetes, we observed 1,548 myocardial infarctions and 5,842 patients died. The risk of myocardial infarction was similarly increased in patients with and without diabetes. Compared to non-HDL cholesterol <25th percentile, the adjusted hazard ratios were in patients with diabetes 1.2 (95% CI: 0.9-1.5) for 25th-74th percentile, 1.3 (95% CI: 0.9-1.9) for 75th-94th percentile, and 2.2 (95% CI: 1.3-4.0) for ≥95th percentile, and in patients without diabetes 1.0 (95% CI: 0.9-1.2), 1.3 (95% CI: 1.0-1.6), and 2.0 (95% CI: 1.4-3.0). Non-HDL cholesterol was associated with increased risk of death in patients without diabetes with adjusted hazard ratios of 1.0 (95% CI: 0.9-1.1), 1.3 (95% CI: 1.2-1.5), and 2.1 (95% CI: 1.6-2.6), however this association was attenuated in patients with diabetes (0.9 (95% CI: 0.8-1.0), 1.0 (95% CI: 0.9-1.2), and 1.2 (95% CI: 0.9-1.7)). Results were similar when stratifying on presence of obstructive coronary artery disease in both patients with and without diabetes. Conclusion In statin-treated patients with and without diabetes, non-HDL cholesterol identified residual risk of myocardial infarction. Further, elevated non-HDL cholesterol was associated with increased risk of all-cause death in patients without diabetes.Figure 1.Figure 2.

Diagnostic performance of the 0/2 hours ESC algorithm with high-sensitivity cardiac troponin T in an unselected community United States cohort

Abstract Background There are no robust data addressing the United States (US) experience with the 0/2 hours (h) European Society of Cardiology (ESC) algorithm using high-sensitivity cardiac troponin T (hs-cTnT). Purpose To evaluate the diagnostic performance of the 0/2h ESC-recommended absolute deltas in a US population. Methods Observational US cohort study of ED patients undergoing 0 and 2 h hs-cTnT measurements. The 99th percentiles upper reference limits (URL) used were 10 ng/L for women and 15 ng/L for men. Diagnostic outcomes were the adjudicated diagnoses of acute myocardial infarction (MI, type 1 or 2). Results A total of 1084 patients met inclusion criteria, amongst which 49% were women. Chest discomfort was reported in 521 (48%) patients. Among patients with a baseline hs-cTnT≤99th URL (n=434), 4 MIs occurred. To rule-out MI, an absolute 0-2h delta change <4 ng/L resulted in a sensitivity of 100% (95% CI: 39.8, 100) and a negative predictive value (NPV) of 100% (95% CI: 99.1, 100). To rule-in MI, an absolute 0-2h delta ≥10 ng/L had a specificity of 99.8 % (95% CI: 98.7, 99.9) and positive predictive value (PPV) of 75% (95% CI: 19.4, 99.4). Among patients with a baseline hs-cTnT >99th URL (n=650), 110 MIs occurred. In these patients, both rule-out (sensitivity 65%, NPV 91%) and rule-in (specificity 7.2%, PPV 11%) were poor using the ESC-recommended absolute deltas. Among patients with modest hs-cTnT increases (99th URL to 100 ng/L) neither the ESC-recommended absolute nor the Fourth Universal Definition of MI (UDMI)-recommended relative deltas provided acceptable performance. Among patients with marked hs-cTnT increases at presentation (>100 ng/L), a relative delta change >20% as recommended by the UDMI resulted in a superior rule-in performance, with a specificity of 92.0% (95% CI 74.0, 99.0) and PPV of 84.6% (57.4, 95.7). Conclusions In our unselected US-cohort of patients undergoing hs-cTnT, the 0/2h ESC algorithm had a good diagnostic performance in patients without myocardial injury at presentation. Conversely, in patients with myocardial injury at baseline, the ESC-recommended absolute deltas performed poorly to determine who had MI. In patients with marked hs-cTnT increases >100 ng/L at presentation, the UDMI recommended 20% relative change showed good rule-in performance.

Frailty measured using an electronic frailty index and outcomes in older patients with myocardial infarction

Abstract Background Frailty is common amongst older patients with myocardial infarction and is an independent predictor of poor clinical outcomes. Despite this, frailty is not systematically or objectively measured nor routinely used in risk stratification. The electronic Frailty Index (eFI) is a frailty assessment tool which uses electronic health records to identify and classify frailty and has been shown to correlate well with in-person frailty assessment. However, the performance of the eFI in disease specific populations and its ability to predict individual patient outcomes is unclear. Purpose To assess the relationship between frailty, measured using the eFI, and the management and outcomes of older patients with myocardial infarction. Methods Consecutive patients admitted to hospital in the South East of Scotland between 01/10/2014 and the 01/03/2021 with a primary diagnosis of myocardial infarction were identified using International Classification of Disease (ICD-10) code I21 or I22. Patients under the age of 65 (n= 3,601) and those with no biomarker evidence of myocardial injury were excluded (n=1,301). The provision of guideline recommended therapy, recurrent hospital admission due to myocardial infarction, heart failure or stroke and 12-month all-cause mortality were compared between groups based on eFI classification (fit, mild, moderate or severely frail). Results Of the 3,930 patients (mean age 78 [SD 8] years, 43% female, 83% Caucasian), 2,324 (59%) were classified as frail with 1,421 (36%), 664 (17%), and 239 (6%) classified as mild, moderate and severely frail, respectively. The eFI was measurable in all patients. Patients with any degree of frailty were less likely to receive anti-platelet therapy, ACE inhibitor or angiotensin receptor blocker or beta-blocker therapy or undergo revascularisation with fewer than 1 in 10 patients with severe frailty undergoing inpatient coronary catheterisation (7.5% vs 57% non-frail, P <0.001 for all). Frailty was independently associated with an increased incidence of recurrent myocardial infarction, heart failure or stroke within 12 months with the odds greatest in those with severe frailty (OR 1.93 (95% CI 1.42-2.61%)). The primary outcome of all-cause death at 12-months occurred in 355 (25%), 226 (34%) and 109 (46%) patients with mild, moderate and severe frailty compared with 176 (11%) in non-frail patients (Figure 1). Frailty status was an independent risk factor for all-cause mortality with the risk of death greatest in those with severe frailty (HR 2.64 (95% CI 1.63 – 3.67, p<0.001)). Conclusion The eFI identified patients at increased risk of in-patient death, major adverse cardiovascular events, and all-cause mortality within 12 months following myocardial infarction. Measurement of the eFI from linked healthcare data is feasible and could be used to aide personalised risk stratification and service utilisation in older patients admitted with myocardial infarction.Cumulative incidence plotForest plot with adjusted hazard ratio

Incidence of depression in type 2 diabetes patients with and without cardiovascular disease

Abstract Background Information on how subtypes of incident cardiovascular disease (CVD) affect the rate of depression in patients with type 2 diabetes (T2D) can help identity high-risk patients. Purpose To compare the incidence of depression among patients with T2D with incident CVD relative to patients with T2D free of CVD but similar duration of T2D. Methods Patients diagnosed with incident T2D without CVD or psychiatric disease were identified from the Danish registries between 2000 and 2018. CVD was defined as the first diagnosis of acute myocardial infarction (AMI), heart failure (HF), stroke, or peripheral artery disease (PAD). The patients were followed 90 days after first T2D diagnosis until first occurrence of depression, emigration, death, one year after CVD development, or end of the study (December 31, 2019). We used time-dependent Poisson regression to estimate the incidence rate ratios (IRR) of depression following different types of CVD compared with patients without CVD. The model included age, sex, comorbidities, calendar year, T2D duration, educational level, and living situation as covariates. Results Among 175,916 incident T2D patients (median age 61 (IQR:51;70), 59% males) followed for 1,306,228 person-years (py), 34,825 experienced depression. The crude incidence rate of depression per 1000 py (95% confidence interval) in patients without CVD was 25.8 (16.8;37.9). Compared with T2D patients without CVD, adjusted IRR of depression following AMI, stroke, PAD, and HF was: 2.4 (1.8;3.1) 5.7 (5.3;6.2), 2.5 (2.2;2.9), 2.3 (2.1;2.6), respectively. Conclusions All CVDs was associated with increased rate of depression, but highest rate was seen in T2D patients with stroke.

Family history of myocardial infarction with non-obstructive coronary arteries (MINOCA)

Abstract Introduction Genetic factors play an important role in the development of myocardial infarction (MI), and a positive family history is a risk factor for MI. The significance of family history among patients with a working diagnosis of myocardial infarction with non-obstructive coronary arteries (MINOCA) is not known, and previous studies of family history in MI have not made a distinction between MINOCA and MI due to coronary artery disease (MI-CAD) based on angiographic findings. Purpose To investigate family history of MI with and without obstructive coronary arteries in patients with a working diagnosis of MINOCA. Methods A nationwide register-based case-control study of 15 462 MINOCA cases and 38 220 controls without MI with a non-obstructive coronary angiography due to chest pain, together with 204 424 MI-CAD cases, defined as MI with obstructive coronary arteries with a degree of stenosis >50%, between the years 1995-2020. Data from the Swedish coronary angiography and angioplasty register with information about angiographic findings was merged with information on first-degree relatives from the Swedish multi-generation register. Odds ratio (OR) was calculated with a 95% confidence interval (CI), to analyze the probability of MINOCA patients having first-degree relatives with 1) MINOCA, 2) MI-CAD, and 3) MI-CAD patients having first-degree relatives with MI-CAD. Logistic regression models adjusted for age, sex, hypertension, diabetes, hyperlipidemia and smoking status. Results A total of 161 MINOCA patients (1%) had ≥1 first-degree relative with MINOCA and the probability of having a positive family history of MINOCA did not differ compared to controls, with age and sex adjusted OR 1.08 (95% CI 0.89-1.31) and when adjusting for all covariates 1.08 (95% CI 0.87-1.34). Conversely, 1436 MINOCA patients (9%) had ≥1 first-degree relative with MI-CAD and the probability of having a positive family history of MI-CAD was higher compared to controls with age and sex adjusted OR 1.12 (95% CI 1.05-1.20) and when adjusting for all covariates OR 1.16 (95% CI 1.04-1.20). The sensitivity analysis showed that 24 972 MI-CAD (9%) patients had a positive family history of MI-CAD compared to controls, OR adjusted for age and sex 1.68 (95% CI 1.61-1.75), and OR adjusted for all covariates 1.68 (95% CI 1.60-1.75). Conclusions In this first study that examines family history of MINOCA, including data from over 250 000 coronary angiograms, a positive family history of MI-CAD was more common among patients with a working diagnosis of MINOCA compared to controls without MI and with non-obstructive coronary arteries. A family history of MINOCA was uncommon and was not associated with MINOCA. These results indicate that genetic factors and shared environmental factors within a family leading to CAD are important also for MINOCA, thus MI-CAD and MINOCA share underlying mechanisms.

Impact of volume and intensive cardiac care unit availability on mortality of patients with acute myocardial infarction- related cardiogenic shock treated at revascularization capable centers

Abstract Background Cardiogenic shock (CS) is associated with a high mortality. The purpose of this study was to assess the impact of hospital structure-related variables as volume of CS cases and availability of intensive cardiac care unit (ICCU) on hospital mortality in patients with ACS-related CS treated at high complexity revascularization capable centers (RCC) from a large nationwide registry. Methods This was a retrospective observational study including consecutive patients with main or secondary diagnosis of CS (ICD-10 code: R57.0) and ST elevation myocardial infarction (STEMI). Patients discharged from Spanish National Healthcare System (SNHS) RCC were included (2016-2020). Transfers between hospitals were assigned to reference hospital. Exclusion criteria were <35 years, voluntary discharges or stays ≤ 1 day. Low- and high-volumen hospitals were classified by k-means clustering with 79 cases as the cut-off point selected. The association between the volume of CS cases attended by each center, availability of ICCU and heart transplantation (HT) programs and in-hospital mortality was assessed by multilevel logistic regression models. Results The study population consisted of 3,065 CS-STEMI episodes, of whom 1,759 (57.4%) occurred in 26 centers with ICCU. Figure 1 shows the profile, management and complications of patients according to ICCU availability. A significantly greater number of circulatory support procedures a higher stroke incidence and a longer hospital stay were observed at hospitals with ICCU. A total of 17/44 hospitals (38.6%) were high-volume centers and 19/44 (43%) centers had HT programs available. Treatment at HT centers was not significantly associated with a lower mortality (p=0.264). Both high volume of cases and ICCU showed a non-significant trend to an association with lower mortality in the adjustment model (OR: 0.86 and 0.88, respectively). The interaction between both variables was significantly protective (OR 0.71; p=0.025). After propensity score matching mortality was lower in high volume hospitals with ICCU [OR = 0.79; p=0.0075] (figure 2). Conclusions Most CS STEMI patients from this series were attended at RCC with high volume of cases and ICCU available. The combination of high-volume and ICCU availability showed the lowest adjusted in-hospital mortality. These data should be taken into account when designing regional networks for CS management.Figure 1Figure 2

External validation of the myocardial-ischemic-injury-index: a machine learning algorithm for the early diagnosis of myocardial infarction

Abstract Introduction The myocardial-ischemic-injury-index (MI3) is a machine learning algorithm derived in 2019 for the early diagnosis of type 1 non-ST-elevation myocardial infarction (NSTEMI). MI3 incorporates age, sex, and two high-sensitivity cardiac troponin I (hs-cTnI) Architecht measurements. The performance of the MI3 algorithm is unknown in a setting where the time difference between the first and second troponin measurement is less than 3 hours. Thus, external validation seems mandatory before this algorithm could be considered for clinical use. Purpose To externally validate the performance of the MI3 algorithm and compare its performance with the ESC 0/1h-algorithm, the recommended algorithm by the European Society of Cardiology NSTEMI guidelines. Methods In a multicentre international diagnostic study, we prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of MI. Final diagnoses were centrally adjudicated by two independent cardiologists using all available medical records, including cardiac imaging, serial hs-cTn and 90-days follow-up. Hs-cTnI (Architect) concentrations were measured in a blinded fashion at presentation and serially thereafter. The primary endpoint was type 1 NSTEMI during the index visit. Results Among 6487 patients with two available hs-cTnI concentrations, type 1 NSTEMI was the adjudicated final diagnosis in 882 (13.6%) patients. The median time difference between blood draws was 60 minutes (IQR: 57-70). Model performance was good, with a very high area under the receiver-operating-characteristic curve (0.961 [95% CI: 0.957-0.965]) and an optimal calibration overall (intercept -0.09 [-0.2-0.02]; slope 1.02 [0.97-1.08]), Figure 1. The originally defined low-probability MI3 score<1.6 and high-probability MI3 score≥49.7 triaged 4186 (64.5%) patients towards rule-out (sensitivity 99.1% [98.2-99.5]; negative predictive value [NPV] 99.8% [99.6-99.9]) and 915 (14.1%) patients towards rule-in (specificity 95.0% [94.3-95.5]; positive predictive value [PPV] 69.1% [66.0-72.0]), respectively (Figure 2). Both the sensitivity and the NPV of the ESC 0/1h-algorithm were greater than of the MI3 algorithm (difference for sensitivity: 0.84% [0.18-1.51], P=0.008; difference for NPV: 0.18% [0.05-0.33], P=0.016). In contrast, the specificity and PPV for the MI3 algorithm were higher (difference for specificity: 3.85% [3.29-4.40], P<0.001; difference for PPV: 7.82% [5.9-9.74], P<0.001). Conclusion In patients with two hs-cTnI (Architect) measurements with a median time difference of 60 minutes, the MI3 algorithm showed a very high discrimination and good calibration for type 1 NSTEMI.Diagnostic performance MI3 algorithmCutoff performance of the MI3 algorithm

High sensitivity cardiac troponin I in response to handgrip in women with signs and symptoms of ischemia with no obstructive coronary arteries

Abstract Background Women with signs and symptoms of ischemia and no obstructive coronary arteries (INOCA) are suspected to have myocardial ischemia, ∼10% have prior myocardial scar often in the absence of acute myocardial infarction (AMI) diagnosis and the development of heart failure with preserved ejection fraction (HFpEF) is relatively frequent. The mechanisms contributing to AMI and HFpEF progression are poorly understood in INOCA. Purpose To compare clinical, invasive, and high sensitivity cardiac troponin I (hsTnI) parameters in women with INOCA at rest and in response to isometric handgrip exercise. Methods Women with suspected INOCA underwent cannulation of the coronary sinus (CS), handgrip exercise testing and serial CS plasma sampling before, after 3 minutes of isometric handgrip stress at 30% of maximal voluntary contraction, and after 5 minutes of recovery. hsTnI was measured using a commercial immunoassay (R-PLEX, Meso Scale Discovery, Rockville, MD) and compared using t-tests. Results A total of 54 women with complete invasive data were included with a mean age of 53 ± 10 years, mean body mass index 28 ± 7 kg/m2. 20 women (37% of the cohort) had detectable CS hsTnI from baseline. Among these women, median values were elevated in response to handgrip (Figure) (baseline median 33.75 (IQR 18.12-67.75) pg/mL vs peak handgrip median 56.23 (IQR 32.84-97.83) pg/mL, signed rank p=0.0007, baseline vs recovery median 52.35 (IQR 32.59-106.27) pg/mL, signed rank p=0.0002). Conclusion Among women with INOCA, handgrip stress leads to an increase in hsTnI in more than a third, demonstrating objective evidence of myocardial injury. More work is needed to better understand contribution of coronary microvascular dysfunction to HFpEF progression.

Abstract 12803: Disparities in Care Among COVID-19 Patients With ST-Elevation Myocardial Infarction Admitted in Rural and Urban Teaching Centers

Introduction: During the pandemic of COVID-19, resources ran scarce in various regions, which impacted access and availability of treatment options. Our study aims to compare outcomes of COVID-19-positive patients (CPP) who reported a diagnosis of ST-elevation myocardial infarction (STEMI) in either rural centers (RC) or urban teaching centers(UTC). Methods: De-identified data of CPP adults with STEMI from the 2020 National Inpatient Sample for admissions between April-December 2020 were analyzed. Patient characteristics and outcomes between RC and UTC were compared. Results: We found 4690 STEMI cases among CPP. Most cases were hospitalized in UTC(4255 cases, 90.7%), with 9.3% seeking care RC (Table 1). Cases in UTC were younger (mean age 66.28 years) and with a higher mean Charlson Comorbidity Index (CCI) score (mean score 4.31) than those at RC (mean age 71.75 years, p<0.01, mean CCI score 4.00, p<0.01). Medicare primarily covered both centers. A higher proportion of patients in RC were Whites (77.4%), while 50.0% of AMI cases at UTC were Whites. Patients at UTC also had a higher prevalence of prior stroke (6.3% vs. 3.4%, p=0.016) and lipid disorder (53.3% vs. 43.7%, p<0.01) than those in RC but showed a lower prevalence of diabetes (44.3% vs. 50.6%, p=0.012). No differences in the prevalence of prior myocardial infarction, hypertension, smoking, obesity, chronic kidney disease, and sex were noted. Cases in UTC reported a higher incidence of cardiogenic shock (18.2% vs. 3.4%, aOR 6.631, 95% CI 3.850-11.421, p<0.01), PCI use (42.1% vs. 20.7%, aOR 2.482, 95% CI 1.910-3.225, p<0.01), and death (44.4% vs. 40.2%, aOR 1.513, 95% CI 1.197-1.912, p<0.01). Conclusions: Adults with COVID-19 with STEMI admitted UTC were sicker with a higher mean CCI score and reported higher PCI use and mortality. Further studies investigating the distribution of resources during the pandemic and proposals to improve care access in rural and urban teaching hospitals should be conducted.

Abstract 18632: Mechanical Circulatory Support in Patients Without Cardiogenic Shock Undergoing Percutaneous Coronary Intervention

Background: The use of mechanical circulatory support (MCS) devices for high-risk percutaneous coronary intervention (PCI) has increased over the last decade. However, data on outcomes between MCS device type have been mixed and long-term outcomes are limited. Our aim was to examine the association between intravascular microaxial left ventricular assist device (LVAD) or intra-aortic balloon pump (IABP) use in patients without cardiogenic shock undergoing PCI. Methods: This retrospective study analyzed administrative claims data from a large, insured population across the United States. Patients who underwent PCI without cardiogenic shock from 4/1/2016 to 7/31/2022 were included. Using inverse probability treatment weighting (IPTW), we assessed for the association between device type and all-cause mortality during the index admission, 30-days, and up to 1-year. Secondary outcomes included stroke, bleeding, incident dialysis, repeat revascularization, and total healthcare costs. Results: We identified 2,879 patients undergoing PCI without cardiogenic shock, the mean (SD) age was 68.2 (12.5) years, 27% (n=764) were women, and 61% (n=1,757) had a primary diagnosis of acute myocardial infarction (AMI). After IPTW, intravascular LVAD use was not associated with a statistically significant difference in in-hospital (Odds ratio [OR] 1.30; 95% Confidence interval [CI]: 0.88-1.91, P =0.19) or 30-day (OR 1.19; 95% CI:0.84-1.69, P =0.33) mortality compared to IABP use. At 1-year, intravascular LVAD use was associated with a significant increase in mortality (Hazard ratio 1.23; 95% CI:1.04-1.46, P =0.01). Compared to those receiving an IABP, index admission mean total costs ($81,970 vs. $65,298; P <0.001) and mean monthly costs ($11,030 vs. $14,133; P <0.001) up to 1-year were significantly higher in those receiving an intravascular LVAD. There was no significant association between device type and stroke, bleeding, incident dialysis, and repeat revascularization at any timepoint (all, P >0.05). Conclusions: In patients without cardiogenic shock undergoing PCI, intravascular LVAD use was associated with higher costs but not associated with lower mortality. Randomized data is needed to improve device selection for these patients.

Abstract 12409: Ambient Fine Particulate Matter and Ozone Air Pollution Are Differentially Associated With Hospitalization for Unstable Angina and Acute Myocardial Infarction During Wildfire and Inversion Seasons

Background: Short-term increases (days to weeks) in fine particulate matter (PM 2.5 ) air pollution are associated with hospitalization for acute coronary syndromes (ACS). A changing climate is shifting sources of PM 2.5 toward summer wildfires in the western US. This study evaluated if short-term increases in PM 2.5 and ozone were associated with ACS risks in wildfire (June-October) and winter inversion (Nov.-March) seasons. Methods: Case-crossover analyses examined N=21,414 subjects with emergency or inpatient hospitalization at 11 Intermountain hospitals for ACS, including the primary diagnosis of myocardial infarction (AMI, n=20,287) or unstable angina (USA, n=1,127). PM 2.5 data were collected in January 1, 1999 to March 31, 2022 (ozone: 2006-2022) from community monitors on Utah’s Wasatch Front. Odds ratios (OR) and 95% confidence intervals (CI) were computed by Poisson regression with adjustment for weather data. Results: Subjects averaged 66±14 years of age and 31.0% were female. Overall PM 2.5 increases were associated with concurrent day (lag 0 days) ACS hospitalizations (OR=1.024 per +10 μg/m 3 , CI: 1.004, 1.043, p=0.019), driven by AMI (OR=1.025 per +10 μg/m 3 , CI: 1.004, 1.045, p=0.017). USA admissions were delayed to the second week [lag moving average (mAvg) days 7-13] after PM 2.5 increases (OR=1.090 per +10 μg/m 3 , CI: 1.024, 1.159, p=0.007) and PM 2.5 associations with USA were strengthened by adjustment for ozone. Analyzed by wildfire and inversion seasons, PM 2.5 associations differed for AMI and USA (Figure). Short-term increases in ozone in wildfire season were associated with lower USA risk at lag 1, lag 2, 3-day mAvg 0-2, and 1-week mAvg 0-6 and lower AMI risk at mAvg 7-13, but not with inversion season risks. Conclusions: Short-term increases in PM 2.5 air pollution were associated with ACS hospitalizations for AMI and USA, with patterns of risk differing between wildfire and inversion seasons. Ozone increases were not associated with greater risk.

2023 Guidelines on Coronary Artery Disease: At a Glance

The guidelines have been released in the recent ESC congress held in Amsterdam, Netherlands. The summary is in two headings, new recommendations and change of recommendations compared to the previous guidelines. The wording to use classes of recommendations— is recommended – Class I, should be considered – Class IIa, may be considered – Class IIb, not recommended – Class III. In this guidelines of ACS, both ST segment elevation myocardial infarction and non ST segment elevation acute coronary syndrome diagnosis, management are addressed combinedly rather than separately as done in previous guidelines.Figures emphasizing the importance of evaluation of symptoms, diagnosis, and management are the highlights of the guidelines. Example: At initial assessment think ACS − Abnormal ECG, Clinical context, Stable patient?

Revascularization strategies for multivessel coronary artery disease based on sex and age.

This study describes coronary revascularization strategies used by sex and age in the USA. A sex-stratified cohort study from the National Inpatient Sample from the Agency for Healthcare Research and Quality (USA) including patients admitted for coronary revascularization with primary or secondary diagnoses of chronic coronary syndrome or non-ST elevation myocardial infarction who underwent ≥3-vessel coronary artery bypass grafting or percutaneous coronary intervention from January 2019 to December 2020. The primary outcome was the use rate of coronary artery bypass grafting or multivessel percutaneous coronary intervention. Prespecified subgroups included age and non-ST elevation myocardial infarction. Among 121150 patients (21.7% women), there were no sex differences in age (women: 66.6 [66.5-66.7], men: 67.6 [67.5-67.7], standardized mean difference: 0.1) or non-ST elevation myocardial infarction incidence (women: 37.4%, men: 45.7%, standardized mean difference: 0.17). The majority of women (74.2%) and men (84.9%) underwent bypass grafting, which was unaffected by age, race or non-ST elevation myocardial infarction. Women were less likely to undergo bypass grafting than percutaneous intervention (adjusted odds ratio 0.49, 95% confidence interval 0.44-0.54; P < 0.001) and a disparity most pronounced in patients >80 years old (adjusted odds ratio 0.31, 95% confidence interval 0.22-0.45; P < 0.001). Most patients with multivessel coronary artery disease needing revascularization undergo bypass grafting, irrespective of sex, age or clinical presentation. The sex disparity in the use of bypass grafting is mostly seen among patients >80 years old.

Comprehensive validation of early diagnostic algorithms for myocardial infarction in the emergency department.

To comprehensively evaluate diagnostic algorithms for myocardial infarction using a high-sensitivity cardiac troponin I (hs-cTnI) assay. We prospectively enrolled patients with suspected myocardial infarction without ST-segment elevation from nine emergency departments in Japan. The diagnostic algorithms evaluated: (i) based on hs-cTnI alone, such as the European Society of Cardiology (ESC) 0/1-h or 0/2-h and High-STEACS pathways; or (ii) used medical history and physical findings, such as the ADAPT, EDACS, HEART, and GRACE pathways. We evaluated the negative predictive value (NPV), sensitivity as safety measures, and proportion of patients classified as low or high-risk as an efficiency measure for a primary outcome of type 1 myocardial infarction or cardiac death within 30 days. We included 437 patients, and the hs-cTnI was collected at 0 and 1 hours in 407 patients and at 0 and 2 hours in 394. The primary outcome occurred in 8.1% (33/407) and 6.9% (27/394) of patients, respectively. All the algorithms classified low-risk patients without missing those with the primary outcome, except for the GRACE pathway. The hs-cTnI-based algorithms classified more patients as low-risk: the ESC 0/1-h 45.7%; the ESC 0/2-h 50.5%; the High-STEACS pathway 68.5%, than those using history and physical findings (15-30%). The High-STEACS pathway ruled out more patients (20.5%) by hs-cTnI measurement at 0 hours than the ESC 0/1-h and 0/2-h algorithms (7.4%). The hs-cTnI algorithms, especially the High-STEACS pathway, had excellent safety performance for the early diagnosis of myocardial infarction and offered the greatest improvement in efficiency.

Health care use and costs attributable to cardiovascular disease in Ireland: a cross-sectional study

Abstract Cardiovascular disease (CVD) is the leading cause of mortality and disability in Europe but the use of health services and costs associated with CVD are poorly quantified. We examined health service use attributable to CVD and corresponding costs in Ireland. Data on 8113 participants aged 50+ of the first wave of The Irish Longitudinal Study on Ageing was used. CVD was defined as having a self-reported doctor diagnosis of myocardial infarction, angina, heart failure, stroke, atrial fibrillation or transient ischaemic attack. Outcomes were the self-reported number of general practitioner (GP) and outpatient department (OPD) visits, accident and emergency department (A&amp;E) attendances and hospitalisations over the 12 months preceding the interview. Negative binomial regression adjusted for socio-demographic confounders and other chronic conditions was used to study the effects of CVD on the outcomes. Average marginal effects (AME) were estimated to examine the additional use of health services attributable to CVD. We estimated the total additional costs attributable to CVD at the population level using Census 2022 data. Participants with CVD reported higher utilization of all health services. In adjusted models, having CVD was associated with additional 1.19 (95% CI: 0.99, 1.39) GP and 0.79 (95% CI: 0.65, 0.93) OPD visits over the past year. There were twice as many additional hospitalisations attributable to CVD in males compared to females (AME: 0.20 (95% CI: 0.16, 0.23) in males vs AME: 0.10 (95% CI: 0.07, 0.14) in females), with no difference observed in the additional use of other healthcare services by gender or age groups. The population-level costs of the additional healthcare service use attributable to CVD were an estimated €352.2 million (95% CI: €272.8, €431.7), 93% of which was due to use of secondary care services. There is a substantial additional use of health services due to CVD in Ireland, with hospital admissions being the biggest contributor to costs. Key messages • The vast majority of additional costs attributable to CVD in Ireland are generated through use of secondary care services. • While a shift is being implemented in Ireland to manage uncomplicated CVD cases in primary care, sustained efforts aimed at CVD primary prevention are required to contain health service costs.

Absence of visible infarction on cardiac magnetic resonance imaging despite the established diagnosis of myocardial infarction by 4th Universal Definition of Myocardial Infarction.

Myocardial scarring due to acute myocardial infarction (AMI) can be visualized by late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) imaging. However, a recent study revealed a group of Type 1 AMI patients with undetectable myocardial injury on LGE. This study aims to describe these cases in detail and explore possible explanations for this new phenomenon. A total of 137 patients diagnosed with either ST-elevation myocardial infarction (STEMI) or non-ST-elevation myocardial infarction (non-STEMI) diagnosed according to the 4th Universal Definition of Myocardial Infarction underwent LGE-CMR after invasive coronary angiography. Fourteen of them (10.2%) showed no LGE and were included in the final study population. Most patients presented with acute chest pain, 3 patients were diagnosed as STEMI, and 11 as non-STEMI. Peak high-sensitive cardiac troponin T ranged from 45 to 1173 ng/L. A culprit lesion was identified in 12 patients. Severe coronary stenoses were found in five patients, while seven patients had subtotal to total coronary artery occlusion. Percutaneous coronary intervention was performed in 10 patients, while 2 patients required coronary artery bypass grafting and no intervention was required in 2 patients. Cardiac magnetic resonance was performed 30 (4-140) days after the initial presentation. Most patients showed preserved left ventricular ejection fraction on CMR. No alternative reasons for the rise/fall of high-sensitive cardiac troponin T were found. The absence of LGE on CMR in patients with Type 1 AMI is a new finding. While insufficient spatial resolution of LGE imaging, delayed CMR performance, spontaneous reperfusion, and coronary collaterals may provide some explanations, further investigations are required to fully understand this phenomenon.

Methods of the PivotaL triAl of the Atellica VTLi point of care emergencY dePartment high sensitivity troponin evalUationS

BackgroundThe Atellica® VTLi point-of-care (POC) High Sensitivity Cardiac Troponin-I (hs-cTnI) assay is intended for use as an aid in the diagnosis of myocardial infarction (MI). Our primary objective is to assess its diagnostic performance in patients presenting with suspected acute coronary syndrome (ACS). MethodsThis prospective observational study will enrol ∼1500 patients at ∼20 U.S. Emergency Departments. After informed consent, adults (>21 years of age) with suspected ACS, and no prior enrollment in this study, will provide a fingerstick and venous blood sample within 2 h of ED presentation, >2 to ≤4 h, and >4 to ≤9 h (max. blood draw = 60 mL). HEART and EDACS scores will be prospectively documented. Patients without the first blood draw may be enrolled if the second draw was obtained. Capillary and venous whole blood will undergo Atellica VTLi assay testing, with remaining venous sample processed to plasma and run. All results will be blinded to the clinical care team. Site operators will undergo a 3-day familiarization period. Quality control testing will be performed daily. At 30 ± 3 days, patient mortality status, major adverse cardiac events, and rehospitalizations will be determined. A clinical endpoint adjudication committee, blinded to hs-cTnI VTLi result, will define the final diagnosis. Sensitivity, specificity, and predictive values will describe the assay performance. ResultsWe expect study completion within 114 weeks of enrollment of the first patient. ConclusionsIt is anticipated that the Atellica VTLi hs-cTnI assay validation study will define a performance equivalent to lab-based hs-cTnI, with results within ∼8 min at the point of care.

Artificial intelligence-based myocardial infarction diagnosis: a comprehensive review of modern techniques

Artificial intelligence-based myocardial infarction diagnosis: a comprehensive review of modern techniques

Stress-only versus rest-stress SPECT MPI in the detection and diagnosis of myocardial ischemia and infarction by machine learning.

Rest-stress SPECT myocardial perfusion imaging (MPI) is widely used to evaluate coronary artery disease (CAD). We aim to evaluate stress-only versus rest-stress MPI in diagnosing CAD by machine learning (ML). A total of 276 patients with suspected CAD were randomly divided into training (184 patients) and validation (92 patients) cohorts. Variables extracted from clinical, physiological, and rest-stress SPECT MPI were screened. Stress-only and rest-stress MPI using ML were established and compared using the training cohort. Then the diagnostic performance of two models in diagnosing myocardial ischemia and infarction was evaluated in the validation cohort. Six ML models based on stress-only MPI selected summed stress score, summed wall thickness score of stress%, and end-diastolic volume of stress as key variables and performed equally good as rest-stress MPI in detecting CAD [area under the curve (AUC): 0.863 versus 0.877, P = 0.519]. Furthermore, stress-only MPI showed a reasonable prediction of reversible deficit, as shown by rest-stress MPI (AUC: 0.861). Subsequently, nomogram models using the above-stated stress-only MPI variables showed a good prediction of CAD and reversible perfusion deficit in training and validation cohorts. Stress-only MPI demonstrated similar diagnostic performance compared with rest-stress MPI using 6 ML algorithms. Stress-only MPI with ML models can diagnose CAD and predict ischemia from scar.