Higher Risk Of Major Adverse Cardiac Events Research Articles

Interpretable Predictive Modeling for Major Adverse Cardiac Events Following Lung Cancer Radiotherapy

<h3>Purpose/Objective(s)</h3> Patients with locally advanced non-small cell lung cancer (NSCLC) are at increased risk of developing major adverse cardiac events (MACE) following radiotherapy. Our group previously identified cardiac substructure dose constraints associated with increased risk of MACE. We employ a machine learning (ML) approach to further identify predictors of MACE and evaluate ML capacity for personalized MACE risk-stratification. <h3>Materials/Methods</h3> Retrospective analysis of 701 patients with locally advanced NSCLC treated with thoracic radiotherapy between 2003-2014. MACE included unstable angina, heart failure, myocardial infarction, coronary revascularization, and cardiac death. We used extreme gradient boosting for MACE prediction. Input features included 195 demographic and 240 radiation dose and/or anatomic. Cardiac substructures were manually delineated; heart and chamber volumes were indexed to body surface area (BSA). We split data 70/30 into training/testing, balanced by MACE. Hyperparameters were bootstrap-tuned with 50-round grid search. Area under the receiver operator characteristic curve (AUC) evaluated model performance. We trained our model on any MACE regardless of timeframe and tested performance at varying timepoints (90-day, 180-day, etc.). Shapley values measured feature importance and were used to construct personalized risk profiles for each patient. <h3>Results</h3> Among 701 patients, 70 developed ≥1 MACE. The median age was 65 and median time to first MACE was 20.6 months. Training AUC for any MACE: 0.67; testing AUC: 0.73. Our model displayed time dependent performance improvement, with high accuracy for MACE closer to radiation start. Testing AUC for 90-day MACE: 0.97; 180-day MACE: 0.94. Table 1 displays additional AUCs. The top 10 predictive features for MACE were coronary heart disease history, right atrial volume, left circumflex coronary artery (CA) volume (V) receiving 15 Gy (V15Gy), heart volume, lung V55Gy and V70Gy, hypertension, left ventricle V15Gy, left main CA volume, and left anterior descending CA V15Gy. Based on patients' Shapley-derived risk profile, radiation dose variables generally became less predictive of MACE as time from radiation increased, while demographics remained generally predictive. <h3>Conclusion</h3> ML modeling enabled high precision for predicting short-term MACE in locally advanced NSCLC patients who received radiotherapy, though long-term MACE was less accurate. ML techniques show promise for identifying patients at high risk of short-term MACE. Our Shapley-derived individual risk profiles may assist with baseline cardiac risk assessment and identify opportunities for risk mitigation. Prospective validation may help implement these tools into clinical practice.

Elevated HsCRP in Chronic Obstructive Pulmonary Disease: A Prospective Study of Long-Term Outcomes After Percutaneous Coronary Intervention.

ObjectiveAnti-inflammatory therapies are reported to have additional benefits beyond lipid control for patients with cardiovascular disease. However, no study has focused on the relationship between inflammation status and long-term outcomes for chronic obstructive pulmonary disease (COPD) patients, after percutaneous coronary intervention (PCI).Methods277 COPD-PCI patients were divided into two groups according to hsCRP status upon admission. Major adverse cardiac events (MACE) in high hsCRP patients were compared to patients with low hsCRP. Restricted cubic spline (RCS) analysis was performed using MACE hazard ratios (HR) to investigate interrelations with hsCRP, as a continuous variable.ResultsPatients in the high hsCRP group incurred more inflammation activation, in terms of higher white blood cell counts, neutrophil, lymphocytes, and had higher smoking rates, compared to those with lower hsCRPs. A significant increase in MACEs was observed in hsCRP high group, compared to the low hsCRP group (HR: 2.47, 95% CI: 1.22–5.00; p = 0.012). RCS curves suggest that HRs rise beyond 1.0, after the 0.24 juncture for Lg HsCRP (base 10 logarithm with hsCRP), HR per SD: 1.19 (95% CI: 0.96–1.48). Further subgroup analysis implies that elevated hsCRP is associated with a higher risk of MACEs across the sub-groups tested.ConclusionHsCRP could be a useful indicator for COPD-CAD patient prognosis, after PCI. This is because hsCRP highlights inflammation activation. More multi-center research, designed for COPD-CAD patients should be conducted to more accurately determine the cut-off value for hsCRP.

Artificial intelligence-enabled electrocardiographic algorithm for the detection of left ventricular dysfunction in emergency department patients undergoing high-sensitivity cardiac troponin T

Abstract Background Artificial intelligence-augmented electrocardiogram (AI-ECG) algorithms have been developed from the standard 12-lead ECG and validated for the recognition of left ventricular systolic dysfunction (LVSD), defined as LV ejection fraction (LVEF)≤35%. Whether AI-ECG facilitates identification of LVSD and is associated with adverse outcomes in emergency department (ED) patients undergoing high-sensitivity cardiac troponin (hs-cTnT) testing is uncertain. Purpose To investigate the diagnostic and prognostic performance of AI-ECG in ED patients undergoing hs-cTnT measurement. Methods Observational US cohort study of ED patients undergoing hs-cTnT measurement. Cases with hs-cTnT increases &amp;gt;sex-specific 99th percentiles were adjudicated following the Fourth Universal Definition of Myocardial Infarction (MI). Post-discharge major adverse cardiac events (MACE) included death, MI, heart failure (HF) hospitalization, stroke or transient ischemic attack, and new onset atrial fibrillation/flutter during 2-years follow-up. The AI-ECG network output, which is a continuous number between 0–1, that provides a probability of LVSD, was obtained for each patient from the first ECG during the index presentation. An AI-ECG threshold of ≥0.256 indicates a positive screen that correlates with a high probability of LVSD. Results Among 1977 patients, 1729 (87%) had a negative AI-ECG screen, while 248 (13%) had a positive AI-ECG screen. Patients with a positive AI-ECG screen were older and had more comorbidities. As compared to patients with hs-cTnT≤99th percentile in whom AI-ECG was positive in 5.8%, those with hs-cTnT&amp;gt;99th percentile had a positive AI-ECG in 22% of cases (p&amp;lt;0.0001). Based on adjudicated diagnoses, the frequency of a positive AI-ECG was 20% in myocardial injury, 38% in type 1 MI, and 20% in type 2 MI. At 2-years follow-up, as compared to patients with a negative AI-ECG, those with a positive AI-ECG had a higher risk for MACE (48% vs. 21%, p&amp;lt;0.0001, adjusted HR 1.39, 95% CI 1.11–1.75) (Figure 1), mainly because of more deaths (43% vs. 30%, p=0.004) and HF hospitalizations (36% vs. 13%, p&amp;lt;0.0001). A positive AI-ECG was associated with a higher risk for MACE (60% vs. 41%, p&amp;lt;0.0001, adjusted HR 1.30, 95% CI 1.02–1.64) in those with hs-cTnT increases &amp;gt;99th percentile, but not in those without hs-cTnT increases. Among patients with an echocardiogram during index presentation or within 30-days (n=452), the diagnostic accuracy of AI-ECG for LVEF ≤35% was 81.4% (95% CI 77.5, 84.9) with a negative predictive value of 96.5% (95% CI 94.0, 98.2). A normal LVEF (&amp;gt;50%) was observed in 87% of those with a negative AI ECG, whereas in those with a positive AI-ECG LVEF was reduced (&amp;lt;50%) in 60%. Conclusions Among ED patients evaluated with hs-cTnT, a positive AI-ECG screen for LVSD identifies patients at high risk of MACE. These findings are largely because of more deaths and HF hospitalizations in those with hs-cTnT increases &amp;gt;sex-specific 99th percentiles. Funding Acknowledgement Type of funding sources: None.

Trajectory of left ventricular ejection fraction in response to therapies in patients with muscular dystrophy.

Patients with muscular dystrophy (MD) are at elevated risk of serious cardiac complications and clinical assessment is limited due to inherent physical limitations. We assessed the utility of left ventricular ejection fraction (LVEF) derived from transthoracic echocardiogram (TTE) as a prognostic marker for major adverse cardiac events (MACE) in a mixed adult MD cohort. One hundred and sixty-five MD patients (median age: 36 (interquartile range [IQR]: 23.0-49.0) years; 65 [39.4%] females) were enrolled in our prospective cohort study. Diagnoses included dystrophinopathies (n=42), limb-girdle MD (n=31), type 1 myotonic dystrophy (n=71), and facioscapulohumeral MD (n=21). Left ventricular ejection fraction, ventricular dimensions at end-diastole and end-systole, and serial measures (n=124; follow-up period: 2.19 [IQR: 1.05-3.32] years) stratified patients for MACE risk. Cardiomyopathy was diagnosed in 60 (36.4%) patients of the broader cohort (median LVEF: 45.0 [IQR: 35.0-50.0] %). Ninety-eight MACE occurred over the 7-year study period. At baseline, patients with a LVEF&lt;55.0% had a high risk of MACE (adjusted odds ratio: 8.30; 95% confidence interval [CI]: 3.18-21.7), concordant with the analysis of LV dimensions. Forty-one percent of these patients showed an improvement in LVEF with the optimization of medical and device therapies. Relative to patients with preserved LVEF, patients with reduced LVEF were at an elevated risk of MACE (adjusted hazard ratio [aHR]: 7.21; 95% CI: 1.99-26.1), and improved LVEF resulted in comparable outcomes (aHR: 1.84; 95% CI: .49-6.91) associated with optimization of medical and device therapies. Reduction in QRS duration by CRT therapy was associated with an improvement in LVEF (average improvement: 12.8 [±2.30] %; p =.04). Reduction in LVEF indicates an increased risk of cardiovascular events in patients with MD. Baseline and serial LVEF obtained by TTE can prognosticate patients for MACE and guide clinical management.

Cardiac Comorbidity Risk Score: Zero-Burden Machine Learning to Improve Prediction of Postoperative Major Adverse Cardiac Events in Hip and Knee Arthroplasty.

BackgroundIn this retrospective, observational study we introduce the Cardiac Comorbidity Risk Score, predicting perioperative major adverse cardiac events (MACE) after elective hip and knee arthroplasty. MACE is a rare but important driver of mortality, and existing tools, eg, the Revised Cardiac Risk Index demonstrate only modest accuracy. We demonstrate an artificial intelligence‐based approach to identify patients at high risk of MACE within 4 weeks (primary outcome) of arthroplasty, that imposes zero additional burden of cost/resources.Methods and ResultsCardiac Comorbidity Risk Score calculation uses novel machine learning to estimate MACE risk from patient electronic health records, without requiring blood work or access to any demographic data beyond that of sex and age, and accounts for variable/missing/incomplete information across patient records. Validated on a deidentified cohort (age >45 years, n=445 391), performance was evaluated using the area under the receiver operator characteristics curve (AUROC), sensitivity/specificity, positive predictive value, and positive/negative likelihood ratios. In our cohort (age 63.5±10.5 years, 58.2% women, 34.2%/65.8% hip/knee procedures), 0.19% (882) experienced the primary outcome. Cardiac Comorbidity Risk Score achieved area under the receiver operator characteristics curve=80.0±0.4% (95% CI) for women and 80.1±0.5% (95% CI) for males, with 36.4% and 35.1% sensitivities, respectively, at 95% specificity, significantly outperforming Revised Cardiac Risk Index across all studied age‐, sex‐, risk‐, and comorbidity‐based subgroups.ConclusionsCardiac Comorbidity Risk Score, a novel artificial intelligence‐based screening tool using known and unknown comorbidity patterns, outperforms state‐of‐the‐art in predicting MACE within 4 weeks postarthroplasty, and can identify patients at high risk that do not demonstrate traditional risk factors.

Association between trimethylamine N-oxide and prognosis of patients with acute myocardial infarction and heart failure.

This study aimed to investigate the association between trimethylamine N-oxide (TMAO) and the prognosis and association between high-sensitivity C-reactive protein (hsCRP) and TMAO-associated cardiovascular risk in patients with acute myocardial infarction (AMI) complicated by heart failure (HF). A total of 985 patients presenting with AMI and HF were consecutively enrolled at the Fuwai Hospital between March 2017 and January 2020. Patients were stratified into groups according to tertiles of TMAO levels and the median hsCRP levels. The primary endpoint was major adverse cardiac events (MACE), including all-cause death, recurrence of myocardial infarction, and rehospitalization due to HF. During a median follow-up of 716days, 138 (14.0%) patients experienced MACE. Cox regression analyses showed that the adjusted hazard ratio (HR) for MACE was higher in patients in tertile 3 [TMAO>9.52μmol/L, HR: 1.85, 95% confidence interval (CI): 1.18-2.89; P=0.007] than in tertile 1 (TMAO<4.74μmol/L), whereas no significant differences were detected between the patients in tertiles 1 and 2 (TMAO=4.74-9.52μmol/L, HR: 0.96, 95% CI: 0.59-1.58; P=0.874). Restricted cubic spline regression depicted an S-shaped association between TMAO and MACE (P for nonlinearity=0.012). In the setting of hsCRP above the median level (6.68mg/L), per unit increase of TMAO was associated with a 20% increase of MACE risk (HR: 1.20, 95% CI: 1.05-1.37, P=0.009); increasing tertiles of TMAO were significantly associated with a higher risk of MACE (adjusted P=0.007 for interaction; P<0.001 for trend across tertiles). The Kaplan-Meier analysis indicated that patients in tertile 3 had a significantly lower event-free survival (P=0.001) when the hsCRP level was above the median level. No similar association between TMAO and MACE was observed when the hsCRP level was below the median level. High plasma TMAO levels were independently correlated with poor prognosis in patients with AMI complicated by HF, especially in those with higher hsCRP levels. There was an S-shaped relationship between TMAO and HR for MACE.

Incidence, Prediction, and Outcomes of Major Bleeding After Percutaneous Coronary Intervention in Chinese Patients.

The patterns of late major bleeding (MB) after percutaneous coronary intervention (PCI) remain unknown in Chinese patients. This study sought to determine the incidence, prediction, and long-term outcomes of late MB in Chinese patients. This was a retrospective cohort study from 14 hospitals in Hong Kong. Participants were patients undergoing first-time PCI without MB within 30days or death within 1 year. Patients were stratified by the presence of late MB, defined as MB between 30 and 365days. The primary endpoint was all-cause mortality. The secondary endpoints were major adverse cardiac events (MACE). A total of 32,057 patients were analyzed. After adjustment for baseline characteristics, periprocedural characteristics, and medications on discharge, the risks of all-cause mortality at 5 years were significantly higher with late MB (HR: 2.15; 95%CI: 1.92-2.41; P< 0.001). Late MB was also associated with a higher risk of MACE (HR: 1.57; 95%CI: 1.03-1.50; P< 0.001), myocardial infarction (HR: 1.25; 95%CI: 1.04-1.52; P = 0.02), and stroke (HR: 1.38; 95%CI: 1.09-1.73; P = 0.006). The CARDIAC (anti-Coagulation therapy, Age, Renal insufficiency, Drop In hemoglobin, baseline Anemia in Chinese patients) score had a good discriminating power for prediction of MB within 365days (area under the receiver-operating characteristic curve: 0.76). Late MB was independently associated with a higher risk of mortality, MACE, myocardial infarction, and stroke in patients undergoing PCI. The CARDIAC score is a simple model that can predict MB after PCI. Prevention of MB represents an important strategy to optimize cardiovascular outcomes for patients undergoing PCI.

Electrocardiogram-Based Machine Learning Emulator Model for Predicting Novel Echocardiography-Derived Phenogroups for Cardiac Risk-Stratification: A Prospective Multicenter Cohort Study.

Electrocardiography (ECG)-derived machine learning models can predict echocardiography (echo)-derived indices of systolic or diastolic function. However, systolic and diastolic dysfunction frequently coexists, which necessitates an integrated assessment for optimal risk-stratification. We explored an ECG-derived model that emulates an echo-derived model that combines multiple parameters for identifying patient phenogroups at risk for major adverse cardiac events (MACE). In this substudy of a prospective, multicenter study, patients from 3 institutions (n=727) formed an internal cohort, and the fourth institution was reserved as an external test set (n=518). A previously validated patient similarity analysis model was used for labeling the patients as low-/high-risk phenogroups. These labels were utilized for training an ECG-derived deep neural network model to predict MACE risk per phenogroup. After 5-fold cross-validation training, the model was tested on the reserved external dataset. Our ECG-derived model showed robust classification of patients, with area under the receiver operating characteristic curve of 0.86 (95% CI: 0.79-0.91) and 0.84 (95% CI: 0.80-0.87), sensitivity of 80% and 76%, and specificity of 88% and 75% for the internal and external test sets, respectively. The ECG-derived model demonstrated an increased probability for MACE in high-risk vs low-risk patients (21% vs 3%; P<0.001), which was similar to the echo-trained model (21% vs 5%; P<0.001), suggesting comparable utility. This novel ECG-derived machine learning model provides a cost-effective strategy for predicting patient subgroups in whom an integrated milieu of systolic and diastolic dysfunction is associated with a high risk of MACE.

Systemic Immune-inflammation Index in Acute Coronary Syndrome and its Role in Predicting Disease Severity: A Cohort Study

Introduction: Systemic Immune-inflammation Index (SII) is a novel marker of inflammation, used extensively in prognosticating various cancers. Recent studies have shown SII to be a predictor of adverse events and death in Acute Coronary Syndrome (ACS) patients who undergo intervention. The role of SII in medically managed SII patients has not been studied. There are no Indian studies available which study the prognosticative role of SII in ACS. Aim: To study systemic immune-inflammation index in acute coronary syndrome and its role in predicting disease severity and mortality. Materials and Methods: This prospective cohort study was conducted in Department of General Medicine at Father Muller Medical College Hospital, Mangaluru, India between February 2021 and July 2021. The study included 45 ST Elevation Myocardial Infarction (STEMI) and 45 Non ST Elevation Myocardial Infarction (NSTEMI)/Unstable Angina (UA) patients, aged 30 years or more. The SII, Neutrophil-to-Lymphocyte Ratio (NLR) and Total Leucocyte Count (TLC) were compared using independent sample t-test. Killip class, Thrombolysis In Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) 2.0 scores were used to determine disease severity. Pearson’s and Spearman’s correlation coefficient were used to determine correlation between parametric and non parametric parameters, respectively. Receiver Operator Curve (ROC) was used to see for predictability of outcomes. The role of SII to predict Major Adverse Cardiac Events (MACE) and death at one month follow- up period was assessed by Kaplan-Meier analysis and Cox regression analysis. Results: The mean SII was significantly higher in the STEMI group (20.9 vs 9.79; t-value= 3.65, p-value &lt;0.001). SII correlated significantly with Killip class (r=0.502), TIMI (r=0.417) and GRACE 2.0 scores (r=0.529), better than NLR or TLC. High SII were associated with a higher risk of MACE (Odds ratio=13.82, p-value &lt;0.001) and death (OR=4.413, p-value=0.015). The SII had an Area Under the Curve of 0.67 for predicting MACE and had a negative predictive value of 96%. Kaplan-Meier analysis showed that patients with higher SII had a lower survival at one month (median: 24.5 days vs 29.32 days, Log-rank=6.44, p-value=0.011). The SII predicted MACE and death better than left ventricular Ejection Fraction (EF) and troponin I. Conclusion: The SII is a cost-effective, novel marker of inflammation that can predict short term outcomes in ACS. This was the first cohort study which studied the role of SII in ACS in patients undergoing any type of intervention.

Additive prognostic value of high baseline coronary flow velocity to ejection fraction during resting echocardiography: 3-year prospective study

Background There is a lack of information about the prognostic value of high velocity in coronary arteries during echocardiography. The present study was aimed at investigating the three-year prognostic value of coronary velocity assessment in all patients who were referred for echocardiography examination. Methods The prospective study comprises 747 consecutive patients. Death, myocardial infarction (MI), acute coronary syndrome (ACS), and/or revascularisation were defined as major adverse cardiac events (MACE). Routine echocardiography was added with coronary velocity assessment in the left main, anterior descending, or circumflex coronary arteries by the Doppler method. Results During a median follow-up of 36 months, 192 patients experienced MACE. Deaths occurred more frequently in patients with high local velocity in proximal left-sided segments vs. in middle left-sided segments vs. patients without high coronary velocity (9 vs. 3 vs. 1%, p < 0.0001). Death/MI/ACS occurred in 17 vs. 7 vs. 1%, p < 0.0001, respectively. Age (HR 1.04, 95% CI 1.00; 1.06; p < 0.04), a velocity more than 65 cm/s in any proximal segments of the arteries (HR 4.7, 95% CI 1.9; 11.9; p < 0.002), ejection fraction (HR 0.97, 95% CI 0.94; 0.99; p < 0.007) were strong independent prognostic predictors of death/MI/ACS. The maximal velocity of coronary flow velocity had a significant additive prognostic value to ejection fraction. Conclusions The coronary velocity parameters give long-term prognostic information that can be used to identify persons with a high risk of MACE in consecutive non-selected patients.

Abstract 13808: Impact of Complex Percutaneous Coronary Intervention Features Among Patients With or Without Chronic Kidney Disease

Introduction: Among patients undergoing percutaneous coronary intervention (PCI), those with chronic kidney disease (CKD) sustain poor clinical outcomes. However, there is a paucity of data on the impact of complex PCI (CPCI) on long-term prognosis, according to the presence of CKD. Objective: To determine the prognostic impact of complex procedural features in patients undergoing PCI with and without CKD. Methods: Patients undergoing PCI at a tertiary-care center between 2012 and 2019 were stratified according to the presence of CKD and procedural complexity. A CPCI was defined by the presence of ≥1 of the following: stent length &gt;60 mm, ≥3 stents, ≥3 lesions, ≥3 target vessels, bifurcation with ≥2 stents, or chronic total occlusion. The primary outcome of interest was major adverse cardiac events (MACE), a composite of death, myocardial infarction (MI) and target vessel revascularization (TVR) at 1 year. Results: Out of 15,071 patients, our study population consisted of 4,537 (30.1%) with CKD of whom 1,151 (25.4%) underwent CPCI, while 2,983 (28.3%) patients without CKD underwent a CPCI. The prevalence of traditional risk factors was similar among patients within the same group (CKD and no-CKD), irrespective of PCI complexity. Nonetheless, patients undergoing CPCI had more extensive coronary artery disease (i.e., higher syntax score, severe calcification, and longer lesion length). CPCI was associated with a higher risk of MACE at 1 year in both groups, though a greater risk was observed in those without concomitant CKD, mainly driven by a higher risk of MI and TVR (Figure 1). However, the risk of all-cause death was significantly higher among CKD patients undergoing a CPCI, and there was no significant difference between those with and without CPCI in non-CKD group. Conclusions: CPCI is associated with an increase in the risk of 1-year MACE among patients with or without CKD. The larger increase in the risk of MACE is observed in those without CKD, than those with CKD.

Abstract 10967: Prognostic Value of a Novel Index: Computational Pressure-Flow Dynamics Derived Fractional Flow Reserve in Stable Coronary Artery Disease Patients with Nonischemic Lesions

Introduction: Computational pressure-flow dynamics derived fractional flow reserve (caFFR) is an angiographic-derived index to determine the fractional flow reserve (FFR) in patients with stable coronary artery disease (CAD), without the need of invasive pressure wire and hyperaemic stimulus in FFR. Although the safety of FFR-guided deferral of revascularization in non-ischemic lesions is well-established, clinical events still occur. The aim of the study is to investigate the prognostic implications of caFFR in those without significant ischemia. Methods: 513 stable CAD patients (mean age=64.3±11.1, 57.7% male) with all lesions being nonischemic, defined by caFFR&gt;0.75, without undergoing revascularization were recruited. The study population was divided into high (n=240) and low (n=273) caFFR groups, according to the median value of caFFR (0.89). The primary endpoint was 3-year major adverse cardiac events (MACE), defined as a composite of all-cause mortality, myocardial infarction (MI), target vessel revascularization (TVR) and hospitalization for heart failure. Results: A total of 44 composite events occurred, including 17 all-cause mortality, 2 MI, 8 TVR and 17 hospitalization for heart failure. Following multivariate adjustment, patients in low caFFR group had a significantly higher risk of MACE than those in high caFFR group (adjusted hazard ratio [HR], 3.02; 95% confidence interval [Cl], 1.19-7.71; P=0.02). Every 0.01 decrease in caFFR was associated with a higher risk of MACE (adjusted HR, 1.12; 95%Cl, 1.03-1.21; P&lt;0.01) cardiovascular mortality or TVR (adjusted HR, 1.16; 95%Cl, 1.04-1.32; P=0.02) and hospitalization for heart failure (adjusted HR, 1.18; 95%Cl, 1.04-1.34; P=0.01). Conclusions: In stable CAD patients without significant functional ischemia, caFFR provides valuable prognostic information on adverse cardiac outcomes. This novel index could enhance risk stratification in stable CAD patients with nonischemic lesions.

Abstract 11304: Association Between Somatic and Mental Health Chronic Conditions with Major Adverse Cardiac Events in Patients Enrolled in Cardiac Rehabilitation

Introduction: The presence of chronic somatic and mental health conditions is complex and challenging for patients and the health care system due to the health deficit accumulation, worsening outcomes, and increased health care utilization. While previous studies on multimorbidity have focused on somatic chronic conditions, we aim to assess the relation between somatic, mental, and combined somatic-mental multimorbidity (SMM) and impact on Major Adverse Cardiac Events (MACE) in patients enrolled in phase II outpatient cardiac rehabilitation (CR). Methods: Using the Rochester Epidemiology Project records-linkage system, we identified patients from Olmsted County, Minnesota who were 18 years old and attended (≥1) CR sessions at Mayo Clinic Rochester. The prevalence of 18 (somatic=13; mental=5) chronic conditions defined by the US Department of Health and Human Services was ascertained electronically. Results: We included 618 patients; 24.4% were female. Patients were 61.5±11.0 years old with 38.0% ≥65 years old. Overall median number of chronic conditions was 6 (Range 0-13) with 98.8% of patients having ≥2 conditions. The prevalence of combined SMM was 44.6%. Mean follow-up was 7.3± 4.5 years, 147 (23.7%) patients had MACE (number): acute coronary syndrome (46), percutaneous coronary intervention (33), heart failure (16), stroke (8), coronary artery bypass grafting (4), ventricular arrhythmias (4), or death (65). Risk of MACE in patients with SMM was significantly higher compared to patients with only somatic conditions (HR: 1.62, 95% CI: 1.14-2.30, p=0.01 ), Figure 1. The association remained significant after adjustment for age and sex ( p=0.006 ). Conclusions: Our results show that somatic-mental multimorbidity (SMM) in CR patients is highly prevalent and imposes a higher risk of MACE compared with patients who have only somatic conditions highlighting the importance of individualized assessment and care plans to reduce adverse events and mortality.

Prognostic value of cardiac inflammation in ST-segment elevation myocardial infarction: A 18F-fluorodeoxyglucose PET/CT study

Background18F-fluorodeoxyglucose (FDG) imaging is used to detect cardiac inflammation and predict functional outcome in acute myocardial infarction (MI). However, data on the correlation of post-MI acute cardiac inflammation evaluated by 18F-FDG imaging and major adverse cardiac events (MACE) are limited. Therefore, we sought to explore the prognostic value of cardiac 18F-FDG imaging in patients with acute ST-segment elevation MI (STEMI). MethodsThirty-six patients with STEMI underwent 18F-FDG positron emission tomography/computed tomography (PET/CT) 5 days after primary percutaneous coronary intervention. 18F-FDG activity in infarcted and remote regions, as well as peri-coronary adipose tissue (PCAT), were measured and expressed as the maximum standardized uptake value (SUVmax). Patients were followed to determine the occurrence of MACE. ResultsThe infarcted myocardium had a higher 18F-FDG intensity than the remote area. Moreover, the PCAT of culprit coronary arteries showed a higher 18F-FDG uptake than that of non-culprit arteries. Multivariate Cox regression analysis showed that increased SUVmax of PCAT [HR 5.198; 95% CI (1.058, 25.537), P = .042] was independently associated with a higher risk of MACE. ConclusionsEnhanced PCAT activity after acute MI is related to the occurrence of MACE, and 18F-FDG PET/CT plays a promising role in providing prognostic information in patients with STEMI.

A higher non-severe hypoglycaemia rate is associated with an increased risk of subsequent severe hypoglycaemia and major adverse cardiovascular events in individuals with type 2 diabetes in the LEADER study

Aims/hypothesisHypoglycaemia is a common side effect of insulin and some other antihyperglycaemic agents used to treat diabetes. Severe hypoglycaemia has been associated with adverse cardiovascular events in trials of intensive glycaemic control in type 2 diabetes. The relationship between non-severe hypoglycaemic episodes (NSHEs) and severe hypoglycaemia in type 2 diabetes has been documented. However, an association between more frequent NSHEs and cardiovascular events has not been verified. This post hoc analysis of the LEADER (Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results) trial aimed to confirm whether there is an association between NSHEs and severe hypoglycaemic episodes in individuals with type 2 diabetes. In addition, the possible association between NSHEs and major adverse cardiac events (MACE), cardiovascular death and all-cause mortality was investigated.MethodsLEADER was a double-blind, multicentre, placebo-controlled trial that found that liraglutide significantly reduced the risk of MACE compared with the placebo. In this post hoc analysis, we explored, in all LEADER participants, whether the annual rate of NSHEs (defined as self-measured plasma glucose <3.1 mmol/l [56 mg/dl]) was associated with time to first severe hypoglycaemic episode (defined as an episode requiring the assistance of another person), time to first MACE, time to cardiovascular death and time to all-cause mortality. Participants with <2 NSHEs per year were used as reference for HR estimates. Cox regression with a time-varying covariate was used.ResultsWe demonstrate that there is an association between NSHEs (2–11 NSHEs per year and ≥12 NSHEs per year) and severe hypoglycaemic episodes (unadjusted HRs 1.98 [95% CI 1.43, 2.75] and 5.01 [95% CI 2.84, 8.84], respectively), which was consistent when baseline characteristics were accounted for. Additionally, while no association was found between participants with 2–11 NSHEs per year and adverse cardiovascular outcomes, higher rates of NSHEs (≥12 episodes per year) were associated with higher risk of MACE (HR 1.50 [95% CI 1.01, 2.23]), cardiovascular death (HR 2.08 [95% CI 1.17, 3.70]) and overall death (HR 1.80 [95% CI 1.11, 2.92]).Conclusions/interpretationThe analysis of data from the LEADER trial demonstrated that higher rates of NSHEs were associated with both a higher risk of severe hypoglycaemia and adverse cardiovascular outcomes in individuals with type 2 diabetes. Therefore, irrespective of the cause of this association, it is important that individuals with high rates of hypoglycaemia are identified so that the potentially increased risk of cardiovascular events can be managed and steps can be taken to reduce NSHEs.Trial registrationClinicalTrials.gov (NCT01179048).Graphical abstract

Sex-differences in outcomes after percutaneous coronary intervention of chronic total occlusions: insights from a large single-center registry

Abstract Introduction Patients undergoing PCI of chronic total occlusions (CTO) are at high risk of both periprocedural and post-procedural adverse events. Whether sex-differences in outcomes exist after PCI of CTO remains unclear. Purpose We sought to investigate sex-differences in outcomes after CTO-PCI among an unselected real-world cohort of patients. Methods In our single-center retrospective study, patients who underwent elective CTO intervention from January 2000 to December 2019 were included. The primary endpoint of interest was major adverse cardiac events (MACE) defined as the composite of death, myocardial infarction (MI), and target vessel revascularization (TVR) at 1 year of follow-up. Results A total 1897 patients were included of which 368 were women (19.4%). Women were older (67±11.3 years vs. 62.6±10.9 years) and had a higher prevalence of comorbidities including diabetes and chronic kidney disease. Women had higher rates of procedure-related complications including increased risk of post-procedural bleeding requiring blood transfusion (3.0% vs 1.1%; p=0.007), and acute vessel closure (1.36% vs 0.2%; p=0.009). In multivariable-adjusted models for baseline confounders, female sex was associated with higher risk of MACE and TVR (Table 1). Conclusion Gender differences in CTO management are observed, with fewer females going for CTO revascularization in contemporary practice. Female sex is associated with procedural-related complications, higher MACE, and TVR even after successful CTO intervention. Funding Acknowledgement Type of funding sources: None.

Residual SYNTAX score in relation to culprit-plaque characteristics and cardiovascular risk in acute myocardial infarction:an optical coherence tomography study

Abstract Introduction The residual SYNTAX score (rSS) as the SYNTAX remaining after completion of percutaneous coronary intervention (PCI) was proved to be related to poor outcomes. Purpose This study aimed to investigate the association of culprit-plaque morphology with rSS and the predictive value of rSS for major adverse cardiac events (MACE) in patients with ST-segment elevation myocardial infarction (STEMI). Methods A total of 274 STEMI patients undergoing preintervention optical coherence tomography examination were included and divided into 3 groups – rSS=0 (n=72), 0&amp;lt;rss≤8&amp;gt;8 (n=68). Baseline clinical data and culprit-plaque characteristics were compared. MACE was defined as the composite of all-cause death, recurrence of myocardial infarction (MI), stroke and unplanned revascularization of any coronary artery. Results There was a significant difference in the prevalence of plaque ruptures, lipid-rich plaques, and calcification among the three groups (plaque rupture: 44.4% versus 59.0% versus 64.7%, lowest to highest rSS, p=0.04; lipid-rich plaque: 40.3% versus 54.5% versus 69.1%, lowest to highest rSS, p=0.003; calcification: 38.9% versus 52.5% versus 61.8%, lowest to highest rSS, p=0.024). Multivariate logistic regression analysis indicated that rSS&amp;gt;8 was an independent predictor for plaque rupture (OR: 2.21, 95% CI: 1.19–4.19, P=0.013). During a mean follow-up of 2.2 years, MACE occurred in 47 (17.2%) patients. In fully adjusted analyses, rSS was independently associated with MACE (HR: 1.06, 95% CI: 1.02–1.10, P=0.005); patients with rSS &amp;gt;8 had higher MACE risk compared to rSS=0 (HR: 2.68, 95% CI: 1.11–6.5, P=0.029). Conclusion In STEMI patients, culprit-plaque morphology was significantly correlated with rSS, and elevated rSS was independently associated with cardiovascular risk.&amp;lt;/rss≤8&amp;gt; Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences OCT findingsSurvival curves according to rSS

Impact of lipoprotein(a) as a residual risk on long-term cardiovascular outcomes in patients with acute coronary syndrome treated with statin

Abstract Background It is still uncertain that lipoprotein(a) [Lp(a)] concentration could be a residual risk for cardiovascular events among patients with acute coronary syndrome (ACS). Purpose The aim of the present study is to evaluate the impact of Lp(a) on long-term cardiovascular outcomes in patients with ACS treated with statins. Methods We studied 1758 consecutive ACS patients who underwent emergency percutaneous coronary intervention (PCI). We finally enrolled 1131 patients who had data of Lp(a) and were treated with statin. They were divided into two groups according to Lp(a) levels (15.0mg/dL). Primary endpoint was major adverse cardiac events (MACE), composite of all-cause death and myocardial infarction. Results The cumulative incidence of MACE was significantly higher in the high Lp(a) group than in the low Lp(a) group. After adjustment for other risk factors, the high Lp(a) group had a significantly higher risk of MACE compared with the low Lp(a) group (HR 1.59, 95% CI 1.01–2.48, p=0.04). Multivariate Cox hazard analysis also showed that increasing Lp(a) was associated with worse clinical outcomes (HR 1.33 per log Lp(a) 1 increase, 95% CI 1.05–1.69, p=0.02). Conclusions Elevated levels of Lp(a) is significantly associated with long-term cardiovascular outcomes among ACS patients treated with statin. Funding Acknowledgement Type of funding sources: None.

Major adverse cardiac events in symptomatic women with non-obstructive CAD on coronary CTA: pooled analysis from PROMISE and SCOT-HEART.

The presence of non-obstructive coronary artery disease (CAD) on coronary computed tomography angiography (CTA) has been associated with the occurrence of major adverse cardiac events (MACE). However, factors associated with the development of MACE in symptomaticwomen with non-obstructive CADon coronary CTA have not been fully elucidated. We sought to examine the influence of risk factors and coronary artery calcification on MACE in symptomaticwomen with non-obstructive CAD on coronary CTA. Women from PROMISE and SCOT-HEART trials with none or non-obstructive CAD on coronary CTA comprised the study cohort. Baseline characteristics and clinical presentation were assessed. Survival analysis using Kaplan-Meier curves was done to compare outcomes stratified by the atherosclerotic cardiovascular disease (ASCVD) risk score and the Agatston score. The primary endpoint was a composite of all-cause mortality, myocardial infarction, and revascularization. 2597 women had non-obstructive CAD or normal coronary CTA, with a median follow-up of 32months. Compared to women without MACE, women with MACE had lower high-density lipoprotein cholesterol (HDL-C) levels and higher mean ASCVD risk scores. Further, women with non-obstructive CAD and ASCVD ≥ 7.5% had higher risk of MACE than those with ASCVD < 7.5% [3.2% vs. 1.1%, adjusted HR (aHR) of 3.1 (95% CI 1.32, 7.23), P-value 0.009]. The Agatston calcium score, on the other hand, was not independently associated with MACE among this population of symptomatic women. Symptomatic women with non-obstructive CAD on coronary CTA are at higher risk for MACE, with the ASCVD risk score being independently associated with the occurrence of adverse events.

Metabolic-associated fatty liver disease and major adverse cardiac events in patients with chronic coronary syndrome: a matched case-control study.

A consensus of experts suggests that nonalcoholic fatty liver disease (NAFLD) does not appropriately reflect current knowledge and metabolic-associated fatty liver disease (MAFLD) is supposed to be a more suitable overarching concept. However, the association of MAFLD with cardiovascular outcomes in patients with coronary artery disease has not been examined yet. Thus, this study aimed to assess the impact of MAFLD on major adverse cardiac events (MACEs) in patients with chronic coronary syndrome (CCS). This study included 3306 patients with CCS who were diagnosed with MAFLD. Controls without MAFLD were matched (1:1) to cases by age and gender. All participants were followed up for the occurrence of MACEs. Finally, the association between MAFLD and the risk of MACEs was assessed. During an average of 55.09 ± 19.92months follow-up, 376 and 248 MACEs were observed in MAFLD and control groups, respectively. When compared with controls, Kaplan-Meier analysis showed that patients with MAFLD had significantly lower event-free survival rate and multivariate Cox regression analysis further revealed that MAFLD group had significantly increased MACEs risk (both p < 0.05). Stratification analysis suggested that patients with MAFLD overlapped with NAFLD or MAFLD-only had 1.33-fold and 2.32-fold higher risk of MACEs respectively compared with controls (both p < 0.05). This study firstly showed that MAFLD was significantly associated with the risk of MACEs in patients with CCS. Moreover, this relationship remained unchanged irrespective of whether satisfying the NAFLD criteria, providing novel evidence for the good utility of MAFLD criteria in clinical practice.