Difference In Major Adverse Cardiovascular Events Research Articles

Different antithrombotic strategies to prevent cardiovascular complications in Kawasaki patients: a systematic review and meta-analysis

BackgroundCoronary artery aneurysm (CAA) poses significant cardiovascular risks, particularly in Kawasaki disease (KD) patients. This systematic review and meta-analysis aim to evaluate and compare antithrombotic strategies in preventing CAA formation secondary to Kawasaki disease and the ensuing CAA cardiovascular complications.MethodsFollowing PRISMA guidelines, we systematically searched major databases, namely PubMed, Scopus, Web of Science, and Embase. Major adverse cardiovascular events (MACE), myocardial infarction (MI), stenosis, bleeding, occlusion, and coronary artery lesion (CAL) formation were primary outcomes. Consolidated Standards of Reporting Trials (CONSORT) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) scores assessed study quality. A meta-analysis, as well as sensitivity analysis and meta-regression, was performed to compare the efficacy of pharmacological strategies on the outcomes.ResultsThe study included 21 studies with 1045 patients for CAA complications and 41536 patients for CAA formation prevention. In children with CAA secondary to Kawasaki disease, the addition of warfarin to aspirin was associated with a significantly lower odds of myocardial infarction (OR = 0.26, 95% CI: 0.11–0.60, I2 = 25%) and mortality (OR = 0.18, 95% CI: 0.04–0.88, I2 = 0%) compared to aspirin alone. However, there was no significant difference in MACE (OR = 0.38, 95% CI: 0.08–1.93, I2 = 60%) and occlusion (OR = 0.17, 95% CI: 0.02–1.92, I2 = 58%). Sensitivity analysis showed reduced thrombosis (OR = 0.29, 95% CI: 0.14–0.62, I2 = 0%), MACE (OR [95% CI] = 0.22[0.06–0.84], I2 = 46%), and occlusion (OR [95% CI] = 0.08[0.02–0.44], I2 = 36%). Meta-regression did not yield significant results.ConclusionsAs for the acute phase of KD, no benefit was conferred from adding high-dose aspirin to the routine IVIG alone regimen. However, the complexity of outcomes and the diversity in antithrombotic interventions underscore the need for tailored approaches and further research.

Trends in dual antiplatelet therapy regimens and clinical outcomes among patients with acute coronary syndrome undergoing percutaneous coronary intervention with drug‐eluting stents: A multicenter real‐world study

AbstractBackgroundThe patterns of dual antiplatelet therapy (DAPT) use and the associated clinical outcomes in current practice remain limited. This study evaluates DAPT regimen patterns and clinical outcomes among acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI).MethodsThis multicenter retrospective cohort study included ACS patients treated with PCI from January 2017 to February 2022 at five tertiary hospitals in Thailand. DAPT was categorized as nonpotent (NP‐DAPT) or potent (P‐DAPT). We described DAPT trends, with major adverse cardiovascular events (MACEs) and major bleeding, as primary efficacy and safety outcomes. Outcomes were assessed using inverse probability treatment weighting (IPTW) with Cox's proportional hazards model.ResultsThe study included 1877 patients with ACS undergoing PCI. The mean age was 64.51 years (standard deviation 11.34), with 639 (34.04%) female patients and 1159 (61.75%) presenting ST‐elevation myocardial infarction (STEMI). Of these, 924 (49.23%) received NP‐DAPT, and 953 (50.77%) were prescribed P‐DAPT. Crude MACE incidence was lower in the P‐DAPT compared to the NP‐DAPT group (6.82% vs. 10.28%). After applying IPTW and conducting Cox's proportional hazard analysis, no significant differences in MACE were observed between groups (hazard ratio [HR]: 0.85, 95% confidence interval [CI]: 0.58–1.25, p = 0.408), nor in major bleeding (HR: 0.80, 95% CI: 0.37–1.70, p = 0.555). P‐DAPT was associated with any higher bleeding risk (HR: 1.52, 95% CI: 1.13–2.03, p = 0.005).ConclusionStandard DAPT remains predominant among Thai ACS patients, with NP‐DAPT prescriptions approaching those of P‐DAPT. Despite similar rates of MACE and major bleeding between the groups, P‐DAPT was associated with a higher risk of any bleeding.

Modified Balloon Use After Rotational Atherectomy Reduces Major Adverse Cardiovascular Event Rates in Severely Calcified Coronary Lesions: A Systematic Review and Meta-Analysis.

Background/Objectives: Calcified coronary lesions require plaque modification techniques for optimal stent apposition, of which rotational atherectomy (RA) is the most commonly used one. Challenging cases require the use of additional dedicated devices (such as modified balloons, MB); however, data available for evidence-based device selection are limited. The aim of this study is to determine the impact of the balloon-based technology used after successful RA treatment on outcomes. Methods: This study was carried out according to the PRISMA guidelines. MEDLINE, CENTRAL and Embase databases were systematically searched for eligible randomized and non-randomized studies. Results: A total of nine studies and 1024 patients were included in the analysis. Patients were treated with RA followed by either plain balloon angioplasty (RA + BA) or modified balloon (RA + MB) treatment prior to stent implantation. There was no significant difference in MACE (major adverse cardiovascular events; OR: 0.53; 95% CI: 0.21-1.34; p = 0.153), all-cause mortality (OR: 0.68; 95% CI: 0.33-1.42; p = 0.265), and target lesion revascularization (OR: 0.64; 95% CI: 0.27-1.55; p = 0.264) between the two groups. However, a sensitivity analysis demonstrated a significant decrease in MACE for patients with severely calcified lesions (OR: 0.42; 95% CI: 0.25-0.70; p = 0.009) in the RA + MB group. The analyses of the safety outcomes of slow flow/no reflow (OR: 0.59; 95% CI: 0.29-1.22; p = 0.128) and coronary artery perforation (OR: 1.18; 95% CI: 0.70-1.99; p = 0.480) showed no difference between the two groups. Conclusions: Our meta-analysis suggests that the benefit of the more invasive RA + MB treatment is statistically significant for severely calcified lesions, but is not associated with additional procedural complications.

Abstract 4135975: Anticoagulation versus Antiplatelets in Coronary Artery Ectasia and Acute Coronary Syndrome: A Systematic Review and Meta-analysis

Introduction: Coronary artery ectasia (CAE) is a rare but well-recognized anatomical abnormality of the coronary arteries with a prevalence of up to 9% in patients presenting with acute coronary syndrome (ACS). While anticoagulants have been suggested to reduce recurrent events, the optimal antithrombotic therapy in CAE and ACS remains unclear. Research Question: What is the comparative effect of anticoagulation therapy versus no anticoagulation in patients with CAE and ACS receiving background antiplatelet therapy? Goals: To perform a systematic review and meta-analysis evaluating the efficacy of anticoagulation in preventing major adverse cardiovascular events (MACE) among patients with CAE and ACS. Methods: We searched PubMed, Embase, and Cochrane to identify studies comparing the use of anticoagulants versus no use of anticoagulants as part of the antithrombotic therapy in patients presenting CAE and ACS, and reported MACE. Statistical analysis was performed using R version 4.2.2 adopting the Mantel-Haenszel random-effects model. Heterogeneity was assessed using Cochrane's Q statistic and Higgins and Thompson’s I2 statistics. Pooled risk ratios were used to evaluate the effectiveness of anticoagulant therapy in CAE and ACS. Results: We included 3 studies, including 1 randomized controlled trial and 2 observational studies, comprising a total of 441 patients, of whom 162 (36.7%) received anticoagulants, including vitamin K antagonists (warfarin and acenocoumarol) or direct oral anticoagulants (rivaroxaban, apixaban, and dabigatran). Time of follow-up ranged from 12 to 52 months, mean age was 57.9 ± 11.4 years, and 388 (87.9%) were male. We found no significant difference in MACE between patients who received anticoagulation and patients who did not (RR 0.64; 95% CI 0.31, 1.32; p=0.22; I2 = 0%). Additionally, there was no difference in the risk of re-infarction (RR 0.71; 95% CI 0.43, 1.18; p=0.19; I2 = 0%). Finally, there was no significant difference in risk of bleeding between both groups (RR 1.41; 95% CI 0.70, 1.85; p=0.19; I2 = 0.59%). Conclusion: Our findings suggest that, among patients with CAE and ACS, anticoagulation does not reduce the risk of MACE or re-infarction as compared with no anticoagulation.

Abstract 4140100: Outcomes of Percutaneous Coronary Intervention of the Left Main Coronary Artery Bifurcation: Insights from PROGRESS-BIFURCATION registry

Background: There is limited data on the long-term outcomes of percutaneous coronary intervention (PCI) in patients with left main coronary artery (LM) bifurcation lesions. Methods: This retrospective, observational, cohort study was performed across 6 centers in the United States, Russia, and Turkey between 2013-2024, as part of the Prospective Global Registry of Percutaneous Coronary Intervention in Bifurcation Lesions (PROGRESS-BIFURCATION, NCT05100992). We examined procedural characteristics and follow-up outcomes of patients with versus without LM bifurcation lesions undergoing PCI. Multivariable adjusted hazard ratios (aHR) with 95% CI were calculated using Cox regression. Results: Of 1,089 patients who underwent bifurcation PCI, 289 (26.5%) underwent LM PCI. Patients in the LM group were older (70.1±11.9 vs 65.4±11.5 years; p<0.001) and had more comorbidities, such as diabetes, heart failure, prior PCI, and prior coronary artery bypass graft surgery. Two-stent techniques were more commonly used in LM patients vs. non-LM patients (39.3% vs 26.5%, p<0.001), with similar technical success (94.8% vs 95.9%, p=0.41) and procedural success (93.1% vs 93.1%; p=0.99). The incidence of in-hospital major adverse cardiovascular events (MACE) was higher in LM patients (7.9% vs 4.5%, p=0.04). During long-term follow-up LM PCI patients had higher mortality (aHR 3.17; 95% CI 1.22-8.18; p<0.001), without significant differences in MACE (aHR 1.81; 95% CI 0.93-3.52; p=0.08), myocardial infarction (aHR 0.50; 95% CI 0.07-3.52; p=0.50), and target-vessel PCI revascularization (aHR 2.56; 95% CI 0.75-8.78; p=0.14). Conclusion: Follow-up mortality in patients undergoing bifurcation PCI, classified according to whether they underwent left main or non-left main PCI.

Revisiting the Efficacy and Safety of Bivalirudin in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Percutaneous Coronary Intervention: Insights From a Mixed Treatment Comparison Meta-Analysis of Randomized Trials.

Randomized trials of bivalirudin in patients with ST elevation myocardial infarction (STEMI) have yielded heterogeneous results. Our aim was to evaluate the efficacy and safety of four antithrombin regimens-unfractionated heparin (UFH), bivalirudin (stopped soon after percutaneous coronary intervention [PCI]), extended bivalirudin (continued for a few hours after PCI), and combined UFH and a Gp2b3a inhibitors (GPI) in patients who present with STEMI. A PubMed, EMBASE, and clinicaltrials.gov databases were searched for randomized clinical trials (RCTs) of the above antithrombin in patients with STEMI. The primary outcome was net adverse cardiovascular events (NACE). The primary ischemic endpoint was major adverse cardiovascular events (MACE), and the primary safety endpoint was major bleeding, and other endpoints included all-cause mortality and stent thrombosis. The primary analysis compared the effect of these antithrombin regimens in reference to UFH using a mixed treatment comparison meta-analysis. In the 14 RCTs evaluating 25,415 patients with STEMI, when compared to UFH monotherapy, extended bivalirudin lowered NACE (OR = 0.71 with 95% CI: 0.53-0.96; moderate level of confidence) driven by a significant decrease in major bleeding (OR = 0.42 with 95% CI: 0.26-0.68; high level of confidence) without any significant difference in MACE or all-cause mortality. When compared with UFH monotherapy, UFH+GPI reduced risk of MACE (OR = 0.76 with 95% CI: 0.60-0.97; high level of confidence) but at the expense of an increase in major bleeding (OR = 1.48 with 95% CI: 1.11-1.98; high level of confidence) with no difference in NACE or all-cause mortality. For major bleeding, extended bivalirudin infusion ranked #1, bivalirudin ranked #2, UFH monotherapy ranked #3, and combined UFH and GPI ranked #4. For NACE, extended bivalirudin infusion ranked #1, bivalirudin ranked #2, combined UFH and GPI ranked #3, and UFH monotherapy ranked #4. Cluster plots for MACE and major bleeding demonstrated that extended bivalirudin had the best balance for efficacy and safety. In patients undergoing PCI for STEMI, extended bivalirudin offers the best balance for primary ischemic (MACE) and safety (major bleeding) outcomes.

Long-Term Impact of Pregnancy on Clinical Outcomes in Individuals With Hypertrophic Cardiomyopathy

BackgroundThe effect of pregnancy on individuals with hypertrophic cardiomyopathy (HCM) is not well investigated. ObjectivesThe purpose of this study was to assess the impact of pregnancy on all-cause mortality and clinical outcomes among individuals with HCM. MethodsUsing the TriNetX research network, we identified individuals within reproductive age (≥18-45 years) with a diagnosis of HCM between 2012 and 2022 (n = 10,936). Patients were stratified based on pregnancy history into 2 groups a) those with a history of pregnancy/high-risk pregnancy supervision and b) those without a history of pregnancy or subsequent antenatal/pregnancy supervision encounters throughout the study period. Propensity score matching resulted in 3,399 patients in each cohort. The primary outcome was all-cause mortality. Secondary outcomes include a composite of arrhythmic events (defined as sudden cardiac death, appropriate shocks, sustained ventricular tachycardia/ventricular fibrillation), major adverse cardiovascular events (MACE), and acute heart failure exacerbation during 10 years of follow-up. ResultsPregnancy in patients with HCM was associated with a comparable risk of all-cause mortality (adjusted OR: 0.89; 95% CI: 0.7-1.14; P = 0.37) at 10-year follow-up. There was no difference in MACE (adjusted OR: 1.02; 95% CI: 0.85-1.22; P = 0.80) and arrhythmic events (adjusted OR: 0.93; 95% CI: 0.73-1.18; P = 0.55) between both groups. In subgroup analysis of obstructive HCM, the findings were similar between both pregnancy and no pregnancy groups. ConclusionsPregnancy in individuals with HCM was not associated with a higher risk of adverse outcomes at long-term follow-up. Further efforts are warranted to better understand the short-term outcomes in this high-risk population.

Trends in major cardiac events after ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention from 2003 to 2017: the western Denmark heart registry

Abstract Background In Denmark, primary percutaneous coronary intervention (PCI) has been the national reperfusion strategy since 2003. We recently reported a gradual decline in 1-year mortality in patients treated with pPCI-treated STEMI from 2003 to 2017. To elucidate potential causes of this observation, we examined temporal trends in the 1-year risk of major adverse cardiovascular events (MACE). Purpose To examine trends in 1-year risks of MACE following STEMI treated with pPCI from 2003 to 2017. Methods Using the Western Denmark Heart Registry, we identified STEMI patients undergoing first-time pPCI from 2003 to 2017 and divided the patients into four time periods. The main outcome was 1-year risk of MACE, defined as recurrent myocardial infarction, ischaemic stroke, or cardiovascular death. Cause-specific adjusted hazard ratios (HR) were used to assess temporal trends using the first period (2003-2006) as reference. Further, temporal trends were compared to an age-, sex-, and calendar-year matched general population. Results From 2003 to 2017, 18,540 pPCI-treated STEMI patients were identified (median [Q1-Q3] age, 64 [55-74] years); 13,639 men [74%]). Trends in 1-year risk of MACE showed a gradual reduction over time from 13.0% in 2003-2006, 11.8% in 2007-2010, 9.7% in 2011-2014, to 8.7% in 2015-2017 (Figure). The adjusted relative risk reduction was 33% when comparing 2015-2017 with 2003-2006 (adjusted HR 0.67, 95% CI 0.58-0.76). Comparable relative risk reductions were observed for all three individual components of MACE of 33-35%. Compared to the matched general population, the 1-year risk difference in MACE decreased from 11% in 2003-2006 to 7% in 2015-2017. Conclusions In a high-income European country with a fully implemented pPCI strategy, 1-year risk of MACE declined by approximately one-third after first-time STEMI between 2003 to 2017. This MACE reduction was substantially larger than observed in the matched general population, i.e., confirming an important reduction in the excess risk associated with STEMI.

Inappropriate dosing of direct oral anticoagulants in patients with atrial fibrillation undergoing percutaneous coronary intervention

Abstract Background Underdose (inappropriate low-dose) of direct oral anticoagulants (DOAC) is sometimes prescribed due to concerns of bleeding risk in patients with atrial fibrillation (AF). In AF patients with coronary artery disease requiring percutaneous coronary intervention (PCI), careful treatment is required to prevent bleeding events because of intensive antithrombotic therapy with a combination of oral anticoagulants and antiplatelet agents. Purpose The purpose of this study was to investigate the prevalence of underdose of DOAC and its impact on clinical outcomes in AF patients with coronary artery disease undergoing PCI. Methods This multicenter observational cohort study enrolled patients with AF on DOAC undergoing PCI between January 2015 and March 2021 at 15 institutions. Appropriateness of DOAC dose was determined according to the manufacturer's labeling recommendations in Japan. Clinical outcomes within 1 year, including major adverse cardiovascular events (MACE), all-cause mortality, ischemic stroke, and major bleeding events, were evaluated. Results Of 630 patients enrolled, 168 patients (26.7%) received underdose, 227 (36.0%) received appropriate low-dose, 213 (33.8%) received appropriate standard-dose, and 22 (3.5%) received overdose. Because of the extremely small number of patients in the overdose group, the primary analysis of the present study was a comparison between the underdose group (n=168) and the appropriate dose group (appropriate low-dose and standard-dose groups) (n=440). Although the incidence of MACE, all-cause mortality, and major bleeding events was not significantly different between the 2 groups (log-rank p=0.872, p=0.170, and p=0.725), ischemic stroke more frequently occurred in the underdose group compared with the appropriate dose group (log-rank p=0.010) (Figure 1). The multivariable Cox regression analysis determined underdose of DOAC as an independent predictor for ischemic stroke (adjusted HR 3.288, 95% CI: 1.189-9.088, p=0.022). Conclusions Compared with appropriate dose of DOAC, underdose was associated with a higher incidence of ischemic stroke, despite no significant difference in MACE, all-cause mortality, and major bleeding events, in AF patients undergoing PCI.Figure 1

Impact of chronic kidney disease on patients with Myocardial Infarction with Non Obstructive Coronary Arteries (MINOCA)

Abstract Background Chronic kidney disease (CKD) in patients with myocardial infarction (MI) is associated with more advanced disease, a higher risk of complications and poorer prognosis, as well as increased mortality. The aim of this study is to assess the impact of CKD in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA) and its influence on the prognosis of these patients. Methods it was an observational, prospective and analytic study. We analyzed all consecutive patients with MI who underwent coronary angiography admitted to our Hospital between 2016 and 2023; MINOCA patients were classified following the 2023 ESC Guidelines definition. The patients were divided into two groups depending on whether they had CKD or not. Median follow-up was 43 months [20-71]. Results we included 136 patients with MINOCA, of whom 11 (8.1%) had CKD. Patients with impaired kidney function were older and mostly male. They also exhibited a higher prevalence of classic cardiovascular risk factors such as hypertension, diabetes, or dyslipidemia. However, there were fewer smokers in this group. We did not find significant differences in coronary artery anatomy (smooth or small plaques) between both groups. Additionally, the majority of patients in both groups had preserved left ventricular function. Despite that, patients with CKD typically had ST segment elevation in the ECG and higher myocardial injury biomarkers’ levels as well as NT-proBNP. During hospitalization, patients without renal dysfunction had more complications (11.2% vs 0%, p=0.062) such as inotropic requirements, stroke or cardiogenic shock, but overall there were very few. In terms of treatment, it was fairly similar in both groups, although patients with kidney disease received diuretics significantly more often. Throughout the follow up, there were no significant differences in MACE (major adverse cardiovascular events) between death (27.3% vs 7.4%, p=0.06), readmission (10% vs 10.8%, p=1) or MI (0% vs 3.4%, p=1), but patients with CKD suffered more frequently from stroke (40% vs 4.2%, p<0.01). Conclusions 1) Patients with MINOCA and CKD are typically older and predominantly male with a high prevalence of cardiovascular comorbidities (hypertension, diabetes, dyslipidaemia). 2) The severity of MI appears to be slightly higher in this group, as evidenced by more ST-segment elevation upon admission and higher hs Troponine T levels. However, they experience fewer cardiovascular complications and maintain normal left ventricular function. 3) Although we found no significant differences in major adverse cardiovascular events (MACE), patients with CKD were more likely to suffer from stroke.Table 1Table 1

Prognostic implications of p2y12 inhibitor pre-treatment in non-st segment elevation acute coronary syndromes undergoing late invasive strategy - a national registry analysis

Abstract Background Current guidelines recommend considering P2Y12 pre-treatment (PreT) in patients (pts) with non-ST segment elevation acute coronary syndrome (NSTE-ACS) expected to undergo a late invasive strategy, based on individual bleeding risk. Purpose Investigate in-hospital morbidity and mortality in NSTE-ACS pts undergoing a late invasive strategy (coronary angiography (CAG) performed >24h post-admission) comparing those receiving P2Y12 inhibitors (P2Y12i) PreT with those who did not. Methods Retrospective multicenter analysis of NSTE-ACS pts from the Portuguese Registry on Acute Coronary Syndromes (ProACS) undergoing a late invasive strategy from October 2010 to October 2023. Exclusion criteria: previous treatment with P2Y12i or anticoagulants; atrial fibrillation. Two cohorts were defined: pts receiving PreT with P2Y12i before undergoing CAG (group 1) and pts without PreT (group 2). Comparative analyses included baseline characteristics, clinical findings, CAG findings and treatment. Primary outcome was in-hospital major adverse cardiovascular events (MACE), a composite of all-cause mortality, re-infarction, stroke and congestive heart failure. The secondary outcome included individual events and major bleeding. Results 3776 pts were included (mean age:66±12 yrs,29% female), 1530 in group 1 and 2246 in group 2. Group 1 had lower prevalence of dyslipidemia (60 vs 66%, p<0.001), prior stroke (7 vs 5%, p=0.003), myocardial infarction (16 vs 21%) and percutaneous coronary intervention (12 vs 15%) (both p=0.001). On admission, there were no differences regarding Killip-Kimball class (class I - 90 vs 90%,p=0.501) and pts in group 1 less frequently had left ventricular disfunction (left ventricular ejection fraction <50% - 20 vs 24%,p=0.032). Group 1 had higher incidence of obstructive CAD (84 vs 77%,p<0.001), more frequently required more than 1 CAG during admission (8 vs 4%,p<0.001), but multivessel disease did not significantly differ (52 vs 52%,p=0.667). Coronary angioplasty was more frequent in group 1 (63 vs 60%,p=0.019) as was coronary artery bypass graft (13 vs 10%,p=0.002). Regarding anti-thrombotics, group 1 had higher prescription rates of clopidogrel (68 vs 56%), aspirin (99 vs 81%), unfractionated heparin (21 vs 8%), enoxaparin (80 vs 56%), but lower of fondaparinux (12 vs 41%) (all p<0.001). There were no differences in the primary outcome (9 vs 9%,p=0.906) and secondary outcomes: in-hospital mortality (1 vs 1%), re-infarction (1 vs 1%), ischemic stroke (1% vs 0,4%) and congestive heart failure (7% vs 8%) (all p>0.05). Group 1 had higher rates of major bleeding (0.8 vs 0.2%, OR 3.48, CI 95% 1.22-9.89, p=0.013). Conclusions In patients with NSTE-ACS undergoing a late invasive strategy, PreT with P2Y12i showed no statistically significant differences in MACE, despite association with higher rates of major bleeding.Baseline characteristicsPrimary and secondary outcomes

Favorable impact of FFRCT on myocardial revascularization outcomes: results from an observational real-world registry

Abstract Background Based on excellent clinical outcomes data, coronary computed tomography angiography (CCTA)-derived fractional flow reserve (FFRCT) is endorsed by guidelines to diagnose obstructive coronary artery disease (OCAD)(1). Dedicated outcome analyses in revascularized patients are essential to assess the additional value of FFRCT in revascularization. Purpose To assess the impact of FFRCT use on the postprocedural myocardial injury (PMI) and long-term outcomes of patients with OCAD undergoing myocardial revascularization. Methods Patients with suspected OCAD on CCTA (at least one stenosis of >50% in any vessel) were included from a 2013-2021 tertiary hospital registry. Propensity score adjusted Cox- regression and logistic regression analysis were used to assess the impact of FFRCT on the outcomes of OCAD patients post-revascularization. PMI was defined as cardiac troponin (cTn)>5 times the 99th percentile URL for percutaneous coronary intervention (PCI) and cTn>10 times the 99th percentile URL for coronary artery bypass graft (CABG) (2). Major adverse cardiovascular events (MACE) comprised all – cause mortality, acute myocardial infarction (AMI), stroke, hospitalization for heart failure (HHF) and new revascularization. Results From a registry of 7541 patients, suspected CCTA - derived OCAD was reported in 1601 cases. 559 OCAD patients were revascularized: 386(69.05%) by PCI, 166(29.7%) by CABG and 7(1.25%) by PCI and CABG. FFRCT was performed in 252(45.1%) patients. During a follow-up of 4.4±2.2 years, MACE occurred in 137(24.5%) patients: 43(7.7%) died, 21(3.8%) patients were hospitalized for AMI, 14(2.5%) patients had a stroke, 12 (2.1%) patients had HHF and 77(13.8%) patients had a new revascularization. Survival analysis indicated significant differences in MACE and all-cause mortality–rates between FFRCT use and no FFRCT use (log- rank p = 0.033 and 0.004, Fig 1). Multivariable propensity–adjusted Cox–regression analysis showed a non–significant trend towards reduced MACE risk by using FFRCT (HR 0.736, 95% CI 0.513-1.055, P=0.095) and a significant reduction in all-cause mortality risk (HR 0.476, 95% CI 0.230–0.985, P=0.046). Sub-analysis in the PCI and CABG groups showed no significant association between FFRCT and MACE. Among the 477 patients with available cTn values, 203 (42.5%) had PMI. In the CABG group, FFRCT use correlated with low PMI incidence (5.3% vs. 15.6%, p=0.044). However, multivariable Cox regression analysis revealed no significant association between FFRCT use and PMI(Fig 2). Conclusion This observational designed study reveals for the first time that FFRCT reduces post-myocardial revascularization MACE, primarily driven by reduced all-cause mortality. No clear reduction of PMI was observed suggesting that FFRCT value extends beyond procedural enhancements. Although derived from a large real-world registry, these promising observations need to be confirmed by randomized studies.Figure 1Figure 2

Triggers of type 2 myocardial infarction: implications for long-term prognosis

Abstract Background Type 2 myocardial infarction (T2MI) is characterized by a mismatch between myocardial oxygen supply and demand, unrelated to acute coronary thrombosis. This discrepancy arises from triggers, which may or may not be of cardiac origin. Common cardiac triggers include coronary artery spasm, coronary embolism, and arrhythmias, whereas non-cardiac triggers encompass factors such as anemia, hypertension/hypotension, sepsis, renal damage, and respiratory failure. However, identifying these triggers isn't always straightforward. Aim Our study aimed to identify, whenever possible, the triggers contributing to the oxygen supply-demand mismatch in T2MI cases, as defined by the Fourth Universal Definition of Myocardial Infarction. Additionally, we sought to explore the correlation between these triggers and patient prognosis. Methods We enrolled all consecutive patients diagnosed with non-ST-segment elevation myocardial infarction (NSTEMI) who met the criteria for T2MI and underwent coronary angiography within 72 hours of diagnosis. Patients were categorized into three groups based on the trigger causing T2MI: cardiac, non-cardiac, and unidentified. The primary endpoint was the occurrence of major adverse cardiovascular events (MACEs), including all-cause mortality, new myocardial infarction, hospitalization for heart failure, and ischemic stroke, during long-term follow-up. We estimated MACE-free survival using Kaplan-Meier curves and compared it among the three groups using the log-rank test. Multivariable logistic regression analysis was performed to identify independent predictors of MACE. Results The final cohort comprised 598 T2MI patients, with 308 having a cardiac trigger, 147 having a non-cardiac trigger, and 143 with an unidentified trigger. The mean age of the overall population was 69.6±13.1 years, with a median follow-up time of 25 (13-49) months. Kaplan-Meier curves demonstrated statistically significant differences in MACEs based on the trigger causing T2MI (p<0.001). Specifically, patients with an unidentified trigger exhibited a better prognosis, while those with a non-cardiac trigger had a worse prognosis during long-term follow-up. Multivariable logistic regression analysis confirmed that not having an identified trigger is an independent protective factor for MACEs (HR 0.63, 95% CI 0.45-0.89, p=0.009, unidentified trigger vs cardiac + non-cardiac trigger). Conclusions T2MI is prevalent in clinical practice, yet reliable outcome predictors remain elusive. Our findings indicate a relationship between the type of trigger precipitating T2MI and patient prognosis, notably demonstrating that the absence of a specific identifiable trigger is linked to a more favorable long-term outcome. Further studies are needed to better define the prognostic stratification of these patients.MACE-free survival Kaplan Meier

Serum Apolipoprotein-A2 Levels Are a Strong Predictor of Future Cardiovascular Events in Patients Undergoing Percutaneous Coronary Intervention.

Because apolipoprotein-A2 (ApoA2), a key component of high-density lipoprotein cholesterol (HDL-C), lacks clear clinical significance, we investigated its impact on cardiovascular events in patients undergoing percutaneous coronary intervention (PCI). We examined 638 patients who underwent PCI with a new-generation drug-eluting stent for acute or chronic coronary syndrome and had their apolipoprotein levels measured between 2016 and 2021. The patients were divided into 2 groups based on the median serum ApoA2 values, and the incidence of major adverse cardiovascular events (MACE) was assessed. Of the 638 patients, 563 (88%) received statin treatment, with a median serum LDL-C level of 93 mg/dL. Furthermore, 137 patients (21.5%) experienced MACE, and Kaplan-Meier analysis revealed that the higher ApoA2 group had a significantly lower incidence of MACE than the lower ApoA2 group (30.9% vs. 41.6%). However, the other apolipoproteins, including ApoA1, ApoB, ApoC2, ApoC3, and ApoE, showed no significant differences in MACE. Multivariable Cox hazard analysis indicated that ApoA2 was an independent predictor of MACEs (hazard ratio, 0.666; 95% confidence interval, 0.465-0.954). Furthermore, ApoA2 levels exhibited the strongest inverse association with high-sensitivity C-reactive protein levels (rs=-0.479). Among all the apolipoproteins, the serum ApoA2 level may be the strongest predictor of future cardiovascular events and prognosis in patients undergoing PCI.

Efficacy and safety of levosimendan in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: The LEVOCEST trial.

Primary angioplasty is the standard procedure for patients with ST-segment elevation myocardial infarction (STEMI). However, myocardial reperfusion results in additional cell damage. Levosimendan, due to its pleiotropic effects, may be a therapeutic alternative to prevent this damage. The objective of this study was to evaluate whether this drug can reduce infarct size in patients with STEMI. Patients were randomized to receive a 24-h infusion of either levosimendan (0.1 μg/kg/min) or placebo after the primary angioplasty. The main objective was to assess the size of the infarct by cardiac resonance at 30 days and 6 months after the event. Other variables such as left ventricular ejection fraction (LVEF) and adverse ventricular remodeling (AVR) were assessed by speckle-tracking echocardiography and magnetic resonance. Major adverse cardiovascular events (MACE) were also collected. 157 patients were analysed (levosimendan, n = 79; placebo, n = 78). We found that after 6 months, patients treated with levosimendan had a greater reduction in infarct size (13.19% ± 9.5% vs.11.79% ± 9%, p = 0.001), compared with those in the placebo group (13.35% ± 7.1% vs. 13.43% ± 7.8%, p = 0.38). There were no significant differences in MACE between both groups. Levosimendan is a safe and effective therapeutic option for reducing infarct size in patients with STEMI.

The prognostic difference study on the individualized clopidogrel administration in Hmong and Dong patients based on the CYP2C19 gene polymorphism after percutaneous coronary intervention.

This study explored the distribution characteristics of CYP2C19 gene polymorphism among Hmong and Dong patients in the Qiandongnan region of Guizhou province after percutaneous coronary intervention (PCI). The aim was to assess the clinical impact of individualized clopidogrel administration based on CYP2C19 genotypes. A total of 208 patients were classified into ultra-fast, fast, intermediate, and slow metabolic groups. They were randomly assigned to clopidogrel individualized administration (IA) or conventional treatment (CA) groups. Patients were followed for 6 months to evaluate major adverse cardiovascular events (MACE) and adverse reactions. The CYP2C19 genotype distribution was in Hardy-Weinberg equilibrium, showing consistency in the population. While no significant ethnic differences were found in genotype and metabolic distribution, allele distribution varied, with Hmong patients exhibiting a higher proportion of CYP2C19*1 alleles than Dong patients. Following individualized administration, the IA group demonstrated lower incidences of non-fatal myocardial infarction and emergency revascularization compared to the CA group. Bleeding events were higher in the IA group, but the total MACE incidence was lower. No statistical difference in MACE and adverse drug reactions (ADR) was observed in the CA group across metabolic types, but MACE incidence was higher in intermediate and slow metabolic groups. In the IA group, no significant difference in MACE was noted among metabolic types, but ADR incidence varied significantly, particularly in dyspnea. The study highlighted significant CYP2C19 allele distribution differences between Hmong and Dong patients post-PCI in Qiandongnan. Patients with slow metabolic profiles demonstrated higher MACE incidence with conventional clopidogrel dosage, whereas CYP2C19-guided therapy reduced MACE without increasing bleeding risk. These findings supported clinical individualized clopidogrel administration in post-PCI patients in the Qiandongnan region, contributing to rational clopidogrel use.

Complete versus culprit-only percutaneous coronary intervention in elderly patients with acute coronary syndrome and multivessel coronary artery disease: A systematic review and meta-analysis

BackgroundCulprit-only percutaneous coronary intervention (PCI) is commonly performed for acute coronary syndrome (ACS) with multivessel coronary artery disease (MVD) in the elderly. Complete revascularization has been shown to benefit the general population, yet its safety and efficacy in older patients are uncertain. MethodsFollowing PRISMA guidelines, we systematically searched PubMed, Embase, and Cochrane databases for randomized controlled trials (RCTs) comparing complete versus culprit-only PCI in patients ≥65 years old with ACS and MVD. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes included myocardial infarction (MI), ischemia-driven revascularization (IDR), all-cause mortality, and cardiovascular mortality. Data were pooled using a random effects model with a restricted maximum likelihood estimator to generate risk ratios (RRs). ResultsFive RCTs with 4105 patients aged ≥65 years were included. Compared with culprit-only PCI, complete revascularization reduced MI (RR 0.65; 95 % CI 0.49–0.85; p < 0.01). MACE (RR 0.75; 95 % CI 0.54–1.05; p = 0.09) and IDR (RR 0.41; 95 % CI 0.16–1.04; p = 0.06) were not significantly different between both strategies among those aged ≥65. However, there was a significant reduction in MI (RR 0.69; 95 % CI 0.49–0.96; p-value = 0.03), MACE (RR 0.78; 95 % CI 0.65–0.94; p < 0.01), and IDR (RR 0.60; 95 % CI 0.41–0.89; p < 0.01) in those aged ≥75. ConclusionsIn elderly patients aged ≥65 years with ACS and MVD, a strategy of complete revascularization by PCI reduces MI compared to culprit-only PCI with no significant difference in MACE and IDR. However, complete revascularization reduced MI, MACE, and IDR in those aged ≥75 years suggesting a possible benefit in this age group.

Symptom-to-balloon time and risk of ventricular arrhythmias in patients with STEMI undergoing percutaneous coronary intervention: The VERY-STEMI study

BackgroundVentricular arrhythmias (VAs) mainly occur in the early post-myocardial infarction (MI) period. However, studies examining the association between total myocardial ischemia time interval and the risk of new-onset VAs during a long-term follow-up are scarce. MethodsThis study (symptom-to-balloon time and VEntricular aRrhYthmias in patients with STEMI, VERY-STEMI study) was a multicenter, observational cohort and real-world study, which included patients with ST-segment elevation MI (STEMI) undergoing percutaneous coronary intervention (PCI). The primary endpoint was cumulative new-onset VAs during follow-up. The secondary endpoints were the major adverse cardiovascular events (MACE) and changes in left ventricular ejection fraction (ΔLVEF, %). ResultsA total of 517 patients with STEMI were included and 236 primary endpoint events occurred. After multivariable adjustments, compared to patients with S2BT of 24 h-7d, those with S2BT ≤ 24 h and S2BT > 7d had a lower risk of primary endpoint. RCS showed an inverted U-shaped relationship between S2BT and the primary endpoint, with an S2BT of 68.4 h at the inflection point. Patients with S2BT ≤ 24 h were associated with a lower risk of MACE and a 4.44 increase in LVEF, while there was no significant difference in MACE and LVEF change between the S2BT > 7d group and S2BT of 24 h-7d group. ConclusionsS2BT of 24 h-7d in STEMI patients was associated with a higher risk of VAs during follow-up. There was an inverted U-shaped relationship between S2BT and VAs, with the highest risk at an S2BT of 68.4 h.

Sex, racial, ethnic, and geographical disparities in major adverse cardiovascular outcome of glucagon-like peptide-1 receptor agonists among patients with and without diabetes mellitus: A meta-analysis of placebo-controlled randomized controlled trials

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have been pivotal in the management of type 2 diabetes mellitus (T2DM) and in the reduction of major adverse cardiovascular events (MACE). Notably, large cardiovascular outcomes trials (CVOTs) demonstrate significant disparities in inclusion, based on sex, race, ethnicity, and geographical regions. We examined the impact of GLP-1RA on MACE in patients with or without T2DM, based on sex, race, ethnicity, and geography. A literature search for placebo controlled randomized controlled trials on GLP-1RA treatment was conducted. Thorough data extraction and quality assessment were carried out, focusing on key outcome, and ensuring a robust statistical analysis using a random effects model to calculate log odds ratio (OR) with 95% confidence intervals (CIs). A total of 8 CVOTs comprising 71,616 patients were included. Compared with placebo, GLP-1RAs significantly reduced MACE in both sexes (females: logOR -0.19, (95% CI, -0.28 to -0.10), p < 0.01) versus (males: logOR -0.17, (95% CI, -0.23 to -0.10), p < 0.01), (p interaction NS), and among Asians (logOR -34 (95% CI, -0.53 to -0.15), p < 0.01), and Whites (logOR -17 (95% CI, -0.25 to -0.09), p < 0.01), with no difference in MACE among Blacks and Hispanics. Odds of MACE were also reduced in Asia (logOR -31 (95% CI, -0.50 to -0.11), p < 0.01), and Europe (logOR -27 (95% CI, -0.40 to -0.13), p < 0.01), but there was no statistical difference in MACE in North America and Latin America. Significant reductions in MACE with GLP-1RA treatment were demonstrated between both sexes and across certain ethnicities and certain geographical regions.

Non-invasive vascular measures as prognostic predictors for older patients with non-ST elevation acute coronary syndrome.

Adverse cardiac events are common in older patients with non-ST elevation acute coronary syndrome (NSTEACS), yet prognostic predictors are still lacking. This study investigated the long-term prognostic significance of non-invasive measures including endothelial function, carotid intima-media thickness (CIMT), and vascular stiffness in older NSTEACS patients referred for invasive treatment. NSTEACS patients aged 75 years and older recruited to a multicentre cohort study (NCT01933581) were assessed for baseline endothelial function using endoPAT logarithm of reactive hyperemia index (LnRHI), CIMT using B-mode ultrasound, and vascular stiffness using carotid-femoral pulse wave velocity (cfPWV). Long-term outcomes included major adverse cardiovascular events (MACE), a composite of death, reinfarction, urgent revascularization, stroke/transient ischemic attack, and significant bleeding. Recruitment resulted in 214 patients assessed for LnRHI, 190 patients assessed for CIMT and 245 patients assessed for cfPWV. For LnRHI group (median follow-up 4.73 years [IQR: 1.41-5.00]), Cox regression analysis revealed a trend towards increased risk of MACE (HR: 1.24 [95% CI: 0.80-1.93]; P = 0.328) and mortality (HR: 1.49 [95% CI: 0.86-2.59]; P = 0.157), but no significance was reached. No difference for other components of MACE was found. For CIMT group (median follow up 4.74 years [IQR: 1.55-5.00]), no statistically significant difference in MACE was found (HR: 0.92 [95% CI: 0.53-1.59]; P = 0.754). Similarly, for cfPWV group (median follow-up 4.96 years [IQR: 1.55-5.00]), results did not support prognostic significance (for MACE, HR: 0.95 [95% CI: 0.65-1.39]; P = 0.794). Endothelial function, CIMT and vascular stiffness were proven unsuitable as strong prognostic predictors in older patients with NSTEACS. NCT01933581.