Higher Rates Of Major Adverse Cardiovascular Events Research Articles

USE AND OUTCOME OF DUAL ANTIPLATELET THERAPY FOR ACUTE CORONARY SYNDROME IN PATIENTS WITH CHRONIC KIDNEY DISEASE: INSIGHTS FROM THE CANADIAN OBSERVATIONAL ANTIPLATELET STUDY (COAPT), A MULTICENTRE PROSPECTIVE COHORT STUDY

<h3>BACKGROUND</h3> Chronic kidney disease (CKD) increases the risk of adverse outcomes in acute coronary syndrome (ACS). The optimal regimen of dual antiplatelet therapy (DAPT) post percutaneous coronary intervention (PCI) is challenging due to both increased bleeding and thrombotic risks in patients with CKD, particularly since these patients were under-represented in randomized controlled trials. We examined the patterns of DAPT use in ACS patients post PCI stratified by presence of CKD. <h3>METHODS AND RESULTS</h3> The multi-centre prospective Canadian Observational Antiplatelet Study (COAPT) enrolled patients with an ACS diagnosis from 43 hospitals between December 2011-May 2013. The present study is a subgroup analysis comparing type and duration of DAPT, and associated outcomes among patients with and without CKD defined as eGFR < 60 ml/min/1.73m2 (calculated by CKD-EPI). COAPT enrolled 1921 patients (mean age: 61; 21.4% female) with a median eGFR of 85 ml/min/1.73 m2 (25th and 75th percentiles [69, 97]). Of those, 275 (14.3%) had CKD. CKD patients were older, more likely to be female and have comorbidities including previous ACS, heart failure, hypertension, cerebrovascular disease, atrial fibrillation and gastrointestinal bleeding. Patients with CKD were less frequently prescribed the more potent P2Y12 inhibitors prasugrel/ticagrelor (18.5% vs 25.8%, p=0.01) and had a shorter duration of DAPT therapy than patients without CKD (median 382 vs 402 days, p=0.003). CKD was associated with major adverse cardiovascular events (MACE) at 12 months (p < 0.001) but not bleeding when compared to patients without CKD (figure 1). CKD was associated with MACE in both patients on prasugrel/ticagrelor (p=0.017) and those on clopidogrel (p < 0.001) (p for heterogeneity=0.70). CKD was associated with increased bleeding only among patients receiving prasugrel/ticagrelor (p=0.007), but not among those receiving clopidogrel (p=0.64) (p for heterogeneity=0.036). Patients with CKD were more frequently considered to have an ongoing indication for DAPT therapy during follow-up. Discontinuation of DAPT was more likely in patients with CKD due to the need for an oral anticoagulant. <h3>CONCLUSION</h3> Patients with CKD had a shorter DAPT duration and were less frequently prescribed potent P2Y12 inhibitors than patients without CKD. Overall, compared with patients without CKD, patients with CKD had higher rates of MACE and similar bleeding rates. However, among those prescribed more potent P2Y12 inhibitors, CKD was associated with more bleeding than those without CKD. Further studies are needed to better define the benefit/risk ratio, and establish a more tailored and evidence-based DAPT regimen for this high-risk patient group.

Effect of diabetic kidney disease on therapeutic strategies for coronary artery disease: ten year follow-up.

Background: The best treatment for coronary artery disease (CAD) in patients with type 2 diabetes (DM2) and chronic kidney disease is unknown.Methods: This retrospective study included MASS registry patients with DM2 and multivessel CAD, stratified by kidney function. Primary endpoint was combined of mortality, myocardial infarction, or additional revascularization.Results: Median follow-up was 9.5 years. Primary endpoint occurrences among strata 1 and 2 were 53.4% and 40.7%, respectively (P=.020). Mortality rates were 37.4% and 24.6% in strata 1 and 2, respectively (P<.001). We observed a lower rate of major adverse cardiovascular events (MACE) (P=.027 for stratum 1 and P<.001 for stratum 2) and additional revascularization (P=.001 for stratum 1 and P<.001 for stratum 2) for those in the surgical group. In a multivariate analysis, eGFR was an independent predictor of MACE (P=.034) and mortality (P=.020).Conclusions: Among subjects with DM2 and CAD the presence of lower eGFR rate was associated with higher rates of MACE and mortality, irrespective of treatment choice. CABG was associated with lower rates of MACE in both renal function strata. eGFR was an independent predictor of MACE and mortality in a 10-year follow-up.

Bleeding in the Elderly: Risk Factors and Impact on Clinical Outcomes After an Acute Coronary Syndrome, a Sub-study of the Randomized ANTARCTIC Trial.

Elderly patients are at high-risk of bleeding, but are under-represented in clinical trials. The aims were to determine the incidence and the predictive factors of bleeding and to assess the impact of bleeding on further ischemic outcomes in elderly patients after acute coronary syndrome (ACS) treated with percutaneous coronary intervention. From the 877 patients aged ≥75years included in the ANTARCTIC randomized trial, data on Bleeding Academic Research Consortium (BARC) bleeding complications and major adverse cardiovascular events (MACE), defined as the composite of cardiovascular death, myocardial infarction, and stroke, were collected over 1year. Clinically relevant bleeding events (BARC types 2, 3, or 5) were observed in 20.6% of patients (n=181) at 1year, of which, one third occurred in the first month. Anemia (adjusted hazard ratio [adj.HR] 3.98, 95% confidence interval [CI] 1.41-11.22; p=0.009), severe chronic renal failure (adj.HR 1.83, 95% CI 1.12-2.98; p=0.015), and femoral access (adj.HR 2.54, 95% CI 1.71-3.77; p<0.001) were independently associated with clinically relevant bleeding events, while age >85years (adj.HR 2.22, 95% CI 1.14-4.30; p=0.018) was independently associated with major bleeding events (BARC types 3 or 5). Patients with a clinically relevant bleeding event had a higher rate of MACE at 1year (adj.HR 2.04, 95% CI 1.24-3.38; p=0.005), with a particularly strong effect on stroke (adj.HR 5.55, 95% CI 2.04-15.06; p<0.001). Clinically relevant bleeding events were observed in one out of five elderly patients undergoing stenting for an ACS and were strongly associated with further stroke occurrence. Rather than the antiplatelet therapy, comorbidities and an age >85years predicted bleeding outcomes in this elderly population. Clinicaltrials.gov identifier: NCT01538446. https://www.clinicaltrials.gov .

Elevated circulating level of P2X7 receptor is related to severity of coronary artery stenosis and prognosis of acute myocardial infarction.

Acute myocardial infarction (AMI) is a severely life-threatening cardiovascular disease. Previous research has identified an association between the P2X7 receptor (P2X7R) and the development of atherosclerosis. However, the correlation of its expression with the clinical prognosis of patients with AMI remains unclear. The present study aimed to investigate the potential role of P2X7R in Chinese patients with AMI. Seventy-nine patients with AMI and 48 controls were consecutively enrolled in this prospective observational study. Circulating P2X7R mRNA expression levels and other clinical variables were determined upon admission to the hospital. Patients were followed up for 360 days, and the end-point was considered as the occurrence of major adverse cardiovascular events (MACE). Circulating P2X7R mRNA expression level in peripheral blood mononuclear cells of patients with AMI were significantly higher than those in controls and had promising diagnostic ability of AMI with an area under the curve of 0.928. Furthermore, P2X7R was demonstrated to be correlated positively with the severity of coronary artery stenosis. Additionally, this is the first study to indicate that higher P2X7R mRNA expression is associated with a higher rate of MACE within 360 days after AMI. The present study showed that the circulating level of P2X7R was elevated in AMI patients and was closely associated with the severity of coronary artery stenosis and prognosis of AMI.

Outcomes of Patients Who Undergo Elective Covered Stent Treatment for Coronary Artery Aneurysms

BackgroundCoronary artery aneurysms (CAA) are reported in up to 5% of patients undergoing coronary angiography. Treatment of CAAs with covered stents has been reported in several case reports, however there is limited evidence available on the effectiveness and safety of this interventional practice. PurposeTo evaluate the current practice and outcomes of elective treatment of coronary artery aneurysms with covered stents. MethodsWe conducted a systematic review of published case reports and case series of patients presenting with CAA that have been treated with covered stents in a non-emergency setting. ResultsA total of 63 case reports and 3 case series were included in the final analysis comprising data from 81 patients. The treated CAA was situated in a native coronary artery in 92.6%, and in a saphenous vein graft in 7.4%. Procedural success was achieved in 95.1%. The types of stents used were mainly polytetrafluoroethylene (75.3%) and Papyrus (11.1%). In 11.0% of cases additional abluminal drug eluting stents (DES) and in 6.8% additional adluminal DES were implanted. After a mean follow up of 13.4 months overall major adverse cardiovascular events (MACE), mortality, myocardial infarction, stroke, stent thrombosis and target lesion revascularization were reported in 26.2, 0.0, 7.6, 0.0, 4.6 and 18.5% of cases, respectively. ConclusionsThe use of covered stents for elective treatment of CAA appears to be effective and reasonably safe. Nevertheless, it is associated with higher MACE rate, driven mainly by higher target lesion revascularization. Further studies, particularly in form of randomized trials and controlled registries are warranted to identify patients who might profit the most from this procedure.

Predictive Value of the Age, Creatinine, and Ejection Fraction (ACEF) Score in Patients With Acute Fulminant Myocarditis.

ObjectivePatients with acute fulminant myocarditis often have more adverse cardiovascular events and higher mortality. The purpose of this study was to evaluate the usefulness of age, creatinine, and left ventricular ejection fraction (ACEF score), in determining the risk that acute fulminant myocarditis will lead to serious cardiovascular events, death, and cardiac dysfunction.MethodsWe retrospectively reviewed the demographics, laboratory tests, medications, echocardiographic examinations, in-hospital clinical outcomes, major adverse cardiovascular events (MACE), and survival rate at 1 year in the medical records of 220 consecutive subjects suffering from acute fulminant myocarditis from January 2013 to June 2019.ResultsTwo hundred twenty patients were divided into a survivor group and a non-survivor group. This study found that patients in the non-survivor group were older, had higher heart rates, and had more serious injuries to multiple organ functions. A high ACEF score at admission was independently associated with an unfavorable prognosis, and it was a predictor of in-hospital mortality. The current analysis extends the predictive performance of the ACEF scores at 30 days by evaluating echocardiographic data as applied to survivors of fulminant myocarditis and cumulative rates of MACE at 1 year. The results indicated that patients with high ACEF scores had poor recovery of cardiac function, and higher rates of MACE, all-cause death, and heart failure at 1 year than the low-ACEF group.ConclusionThe ACEF score was identified as an effective predictor of poor in-hospital outcomes, worse cardiac recovery after 30 days, and higher rates of MACE, all-cause death, and heart failure at 1 year in patients who had acute fulminant myocarditis. These data suggest that its predictive accuracy means the ACEF score could be used to assess the prognosis of patients with acute fulminant myocarditis.

Prognostic value of free triiodothyronine and N-terminal pro-B-type natriuretic peptide for patients with acute myocardial infarction undergoing percutaneous coronary intervention: a prospective cohort study

BackgroundAltered thyroid function and increased N-terminal pro-B-type natriuretic peptide (NT-proBNP) are prognostic factors in acute myocardial infarction (AMI). The study aims to investigate whether free triiodothyronine (fT3) and NT-proBNP are prognostic factors for long-term outcomes in patients with AMI undergoing percutaneous coronary intervention (PCI).MethodsThis was an observational, prospective, single-center study of consecutive patients enrolled at Fuwai Hospital between January, 2013 and December, 2013. The patients were divided into two groups according to fT3 levels: low fT3 (<2.5 pg/mL) and normal fT3 (2.50–4.09 pg/mL). The primary outcome of this study was the incidence of major adverse cardiovascular events (MACEs).ResultsThere were 252 patients with low fT3 and 561 patients with normal fT3. After >2 years of follow-up, patients with low fT3 levels had higher rates of MACEs than those with normal fT3 (27.0% vs. 7.8%, P<0.001). Univariable Cox proportional hazards regression analyses showed that NT-proBNP >802.7 pg/mL [hazard ratio (HR) =5.063, 95% confidence interval (CI): 3.176–8.071, P<0.001] and fT3 <2.5 pg/mL (HR =3.867, 95% CI: 2.646–5.651, P<0.001) were the strongest predictors of MACEs. After adjustment for traditional risk predictors, fT3 <2.5 pg/mL (HR =2.570, 95% CI: 1.653–3.993, P<0.001) was one of the most important independent predictors of MACEs. Patients with NT-proBNP ≤802.7 pg/mL and fT3 ≥2.5 pg/mL had the best prognosis, while patients with NT-proBNP >802.7 pg/mL and fT3 <2.5 pg/mL had the worst outcomes (P<0.001).ConclusionsLow fT3 is a strong predictor of poor prognosis after AMI. The fT3+NT-proBNP combination might be a valuable predictor of the long-term outcomes of PCI after AMI.

Abstract 17103: Elevated NT-proBNP Level is Not a Prognostic Marker for Patients Hospitalized With SARS-CoV-2 Infection

Introduction: NT-proBNP is a widely available and frequently utilized laboratory marker in patients with congestive heart failure. Its availability and use as a surrogate marker for elevated ventricular filling pressures and ventricular strain that frequently manifests as shortness of breath makes it an attractive laboratory marker to triage patients with SARS-CoV-2 infection. Hypothesis: Elevated NT-proBNP is correlated with higher mortality and/or rate of major adverse cardiovascular events (MACE) in patients admitted with SARS-CoV-2 infection. Methods: A retrospective analysis was performed on 225 patients admitted for SARS-CoV-2 infection at a major metropolitan hospital located in the Southwestern United States from the period of March 2020 to May 2020. NT-proBNP levels were recorded in 117 patients (52.7%) on admission. Elevated NT-proBNP was defined as: above 450 pg/ml in patients less than 50 years old, above 900 pg/ml if 50 to 75 years old, and above 1,800 pg/ml if above 75 years old. The primary endpoint was a composite of MACE and mortality during hospitalization. MACE was defined as stroke, myocardial infarction, DVT or PE and shock requiring vasopressor support. Two-sample Wilcoxon rank-sum (Mann-Whitney) test, Pearson’s chi square test and Fisher’s exact test were utilized for data analysis. Results: Of the 117 SARS-CoV-2 positive patients that had admission NT-proBNP levels available for analysis, 23 (19.66%) met age-adjusted criteria for elevated NT-proBNP. There was no significant correlation between elevated NT-proBNP levels and MACE (p = 0.482) or mortality (p = 0.737) in patients with SARS-CoV-2 infections. There was no statistical difference in total length of stay (p-value = 0.6384) or ICU admission (p-value = 0.354) between those with elevated admission NT-proBNP and those without. Conclusions: An elevated NT-proBNP at time of admission does not significantly correlate with higher rates of MACE, hospital length of stay, ICU admission, and mortality in patients admitted with SARS-CoV-2 infection.

Association of sleep duration and cardiovascular events

Abstract Background/Purpose Sleep duration have been associated with cardiovascular (CV) risk in general population. Nevertheless, their impact in real-world large cohort data remains unclear. Methods 4861 healthy Taiwanese subjects (mean age 68 years, 3535 males, 72.7%) were enrolled. Three groups were defined: short sleep duration &amp;lt;6 h, reference sleep duration 7 to 8 h, and long sleep duration &amp;gt;8h. Multivariate Cox proportional hazard models were used to examine the associations between sleep duration and major adverse cardiovascular events (MACE), composite of acute myocardial infarction, ischemic stroke, and CV death. Results Sleep duration of short, reference, and long were reported by 37.7%, 30.3%, 32.0% of the cohort, respectively. 165 (3.4%), 502 (10.3%), 108 (2.2%) suffered from CV death, MACE, ischemic stroke, respectively. After adjusting for age, sex, systolic blood pressure, diabetes, body mass index, low density lipoprotein, and numbers of involved coronary artery, only long sleep was associated with higher MACE (hazard ratio (HR): 1.317, 95% confidence interval (CI): [1.052 to 1.648], p value = 0.016), ischemic stroke (HR: 1.858, 95% CI: [1.162 to 2.969], p value = 0.010), and lower rate of MACE plus heart failure (HR: 1.228, 95% CI: [1.034 to 1.459], p value = 0.019). Conclusions Our study addressed long sleep duration was independently associated with higher rate of MACE, ischemic stroke and MACE plus heart failure in adult Chinese population in Taiwan. Funding Acknowledgement Type of funding source: None

Effect of alirocumab on incidence of atrial fibrillation after acute coronary syndromes: insights from ODYSSEY OUTCOMES

Abstract Background Atrial fibrillation (AF) is a marker of risk in patients presenting with acute coronary syndromes (ACS). The potential effect of inhibiting proprotein convertase subtilisin/kexin type 9 (PCSK9) on the incidence of AF is unknown. Methods The ODYSSEY OUTCOMES trial compared randomized treatment with the PCSK9 inhibitor alirocumab or placebo in patients with recent ACS and residual dyslipidaemia despite optimal statin therapy. The current analysis determined: 1) whether alirocumab treatment influenced incident AF; 2) whether a history of AF influenced the risk of major adverse cardiovascular events (MACE); and 3) whether there was interaction between AF at baseline and randomized treatment on MACE. AF was determined from the medical history and investigator reports of adverse events. Results Of 18,924 participants, 662 (3.5%) had a history of AF at randomization and 18,262 (96.5%) had no history of AF. Of the latter category, 499 (2.7%) had incident AF. Older age, randomization in South America or Eastern Europe, history of heart failure or myocardial infarction, and higher body mass index were factors associated with incident AF. Treatment with alirocumab or placebo did not influence incident AF (2.2% vs 2.6%, respectively; hazard ratio 0.90, 95% confidence interval 0.75–1.08; Figure). Patients with a history of AF had a greater burden of comorbidities, including cerebrovascular disease, peripheral artery disease, hypertension and heart failure; they also had higher rates of MACE (Table). There was no significant interaction between AF and randomized treatment on risk of MACE (P interaction=0.78) Conclusions Although treatment with alirocumab did not significantly modify the risk of incident AF after ACS in this analysis, future studies with more sensitive and systematic methods of ascertainment may be warranted. History of AF is a strong predictor of risk of recurrent MACE after ACS. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Sanofi, Regeneron Pharmaceuticals, Inc

The Atrial fibrillation Better Care (ABC) pathway is associated to a lower incidence of cardiac complications in patients with atrial fibrillation: a report from the ATHERO-AF study

Abstract Background The integrated management of atrial fibrillation (AF) patients according to the Atrial fibrillation Better Care (ABC, A, Avoid stroke with anticoagulation; B, better symptom management; C, Cardiovascular and comorbidity risk management) pathway has associated with a reduced incidence of thromboembolic events and mortality. However, whether this approach also results in a lower rate of cardiac complications is unknown. Purpose To investigate the rate of major adverse cardiovascular events (MACE) in AF patients according to compliance with the ABC pathway. Methods This prospective single-center cohort study included 1157 patients with nonvalvular AF from the ATHERO-AF study. The A, B, and C groups were defined as follows: “A” by a Time in Therapeutic Range ≥70% in vitamin K antagonists-treated patients or appropriate dose for patients on direct oral anticoagulants; “B” by a European Heart Rhythm Association (EHRA) symptom scale I-II (vs. III-IV), and “C” as optimized cardiovascular comorbidity management (i.e. use of ACE inhibitors in heart failure patients, blood pressure &amp;lt;140/90, use of statins and beta blockers in patients with prior ischemic heart disease). The primary end point was a composite of MACE including fatal/non-fatal myocardial infarction, coronary revascularization and cardiovascular death (progressive heart failure, sudden cardiac death and procedure-related death). Results Overall, 458 (39.6%) patients were optimally managed according to the ABC (ABC-compliant group), while the remaining 729 patients presented at least one uncontrolled component (ABC non-compliant group). During a mean follow up of 35 months, (2688 patient-years), 64 MACE were recorded 2.38%/year. Kaplan Meier curve analysis showed a significant higher rate of MACE in ABC non-compliant group compared to the ABC-compliant (54 and 10 MACE in each group, respectively, log-rank test p=0.006, figure). The risk of MACE increased by the number of uncontrolled ABC components: Hazard ratio HR) for 1 component 1.697, 95% Confidence Interval 95% CI 0.814–3.537, p=0.158; HR for 2 components 4.157, 95% CI 1.994–8.665, p&amp;lt;0.001); HR for 3 components 5.100, 95% CI 1.596–16.295, p=0.006. ABC non-compliant group remained associated with an increased risk of MACE using Cox proportional hazard regression analysis (HR 2.175, 95% CI 1.098–4.309, p=0.026) after adjustment for CHA2DS2VASc score, antiplatelet drugs and digoxin use. Conclusion The majority of AF patients is not currently optimally managed. An integrated care ABC approach is associated with a reduced risk of MACE in the AF population. Figure 1. Kaplan-Meier curves Funding Acknowledgement Type of funding source: None

Sex-based approach for the clinical impact of polycythaemia on cardiovascular outcomes in the general population.

Although the adverse cardiovascular effect of anaemia has been well described, the effect of polycythaemia on the cardiovascular outcomes of the general population remain unclear. The primary objective is to identify the association between polycythaemia and major adverse cardiovascular events (MACE), and the secondary objective is to identify the specific haemoglobin concentration more associated with an increased risk for MACE. This was a retrospective cohort study, 451 107 subjects were enrolled who underwent national health examinations from the Korean National Sample Cohort. We estimated the risk of MACE, a composite of cardiovascular mortality, incident myocardial infarction (MI), and stroke according to haemoglobin-based four categories. During 3.8-year of follow-up, polycythaemia group showed higher MACE [hazard ratio (HR) = 1.27 (1.13-1.44) and HR = 1.76 (1.08-2.88); in men and women, respectively], incident MI [HR = 1.37 (1.05-1.79) and HR = 3.46 (1.06-14.00)], and incident ischaemic stroke [HR = 1.27 (1.10-1.46) and HR = 1.72 (1.02-2.91)] than normal haemoglobin group (P < 0.001 in all cases). In the normal haemoglobin and polycythaemia groups, a 1 g/dL increase in haemoglobin level was associated with increased risks of MACE [HR = 1.04 (1.01-1.07) and HR = 1.05 (1.01-1.10) in men and women, each P < 0.05]. To investigate the specific haemoglobin concentration related to greater MACE incidence, we analysed the sensitivity/specificity of different haemoglobin levels: ≥16.5 g/dL in men and ≥15.0 g/dL in women showed the highest Youden's index (sensitivity + specificity - 1), with c-indices of 0.82 (0.81-0.83) and 0.83 (0.82-0.84), respectively. Even in the Korean general population, polycythaemia was significantly associated with higher rates of MACE, incident MI, and incident ischaemic stroke. Especially, subjects with haemoglobin levels ≥15.0 g/dL in women and ≥16.5 g/dL among men were associated with increased risks of MACE.

Coronary slow flow is associated with a worse clinical outcome in patients with Takotsubo syndrome

ObjectivePatients with Takotsubo syndrome (TTS) present an acute microvascular dysfunction that leads to an impaired myocardial perfusion and, in more severe forms, an impaired epicardial flow. However, clinical relevance of...

536 Prognostic Implications of Post-Percutaneous Intervention Troponin Rise in Non-ST Elevation Myocardial and Unstable Angina Patients

Troponin elevation after percutaneous coronary intervention (PCI) is common but its prognostic significance remains uncertain. We aimed to study the relationship between the level of troponin elevation post-PCI and adverse events in non-ST-elevation myocardial infarction (NSTEMI) and unstable angina (UA) patients. A retrospective analysis of all patients who underwent PCI for NSTEMI and UA between 2014-2018 was carried out. Primary outcome was major adverse cardiovascular events (MACE) in 12 months. Contingency analysis for MACE with different post-PCI troponin values was carried out. Registry analysis revealed that 1506 patients with mean age of 66.3±23.06 years with a male predominance (74.8 %) underwent PCI for NSTEMI and UA presentations. Contingency analysis of MACE by post-PCI troponin at different cut-offs revealed that in the NSTEMI patients the post-PCI troponin level did not increase MACE and remained steady around 11% until the troponin level was >40000 ng/L when MACE increased to 15%. However, in UA patients, the MACE was steady around 7% till the troponin level was >1000 ng/L, after which the MACE increased steadily to 25% when troponin was >10000 ng/L. Our results suggest that post-procedure troponin rise >1000 ng/L was associated with higher rate of MACE in UA patients. There was no obvious association between level of troponin and MACE rate in NSTEMI patients, until the level was >40,000. The clinical significance and indeed the necessity of routine post-PCI troponin measurement requires further review.

Prognostic significance of reticulated platelet levels in diabetic patients with stable coronary artery disease

Levels of reticulated platelets (RP) increase during high platelet turnover conditions, and have been shown to correlate with diabetes mellitus (DM) status. Little is known regarding the prognostic significance of levels of RP among patients with stable coronary artery disease (SCAD). The study consisted of patients with SCAD and DM, who visited our cardiology outpatient clinic between June 2016 and February 2017. RP levels were measured at baseline as immature platelet fraction (IPF)%, using flow cytometry. Outcomes at 2 years consisted of bleeding events and major adverse cardiovascular events (MACE), which included death, myocardial infarction, cerebrovascular accident and urgent revascularization. The study included 104 patients (mean age - 71.2 ± 9.5 years, 76.9% were male, and 83.7% had hypertension). IPF was significantly higher at baseline among patients who had suffered from a MACE (4.57% vs. 2.53%, p < .001), and lower in patients who had suffered from bleeding events, compared with those who had not (1.57% vs. 3.00%, p = .004). There were higher rates of MACE at higher IPF quartiles (p < .001, AUC-0.770), and higher rates of bleeding at the lowest quartiles (p = .007, AUC-0.781). In SCAD patients with DM, levels of RP are associated with a higher risk of MACE, and inversely correlated with the risk of bleeding.

P5514Impact of pro-inflammatory conditions on myocardial infarction with non-obstructive coronary arteries

Abstract Background Despite all the recent publications, including new guidelines, myocardial infarction with non-obstructive coronary arteries (MINOCA) is still a controversy “working diagnosis”. MINOCA patients have a characteristic risk profile, with a lower prevalence of classical risk factors (CVRF). The aim of this study is to analyze the relationship between known proinflammatory conditions and MINOCA. Methods Analytical and observational study developed in a University Hospital, which covers 220.000 individuals. We analyzed data of 109 consecutive MINOCA patients admitted to our center during a 3 years period (2016–2018). We used the definitions and the clinical management of the 2016 European Society of Cardiology Working Group Position Paper on MINOCA. The composite of proinflammatory conditions (PIC) includes vasculitis and other autoimmune pathologies; connective tissue diseases, the presence of active cancer and the fact of presenting the myocardial infarction as a complication during admission for a non-cardiovascular pathology. Follow up analysis included death from any cause and major adverse cardiovascular events (MACE). Survival analysis is based on Cox regression and represented by Kaplan Meier curves. Median follow up was 17 months. Results Around one-third of the MINOCA patients had PIC (34.8%). They tended to be older (67.9±14 vs 62.8±15, p 0.08), with no differences in rate of female sex (55.3 vs 49.3%, p 0.55) neither in traditional CVRF: Tobacco (40.5 vs 42.6%), diabetes (18.4 vs 26.8%), dyslipidaemia (39.5 vs 48.6%) or hypertension (55.3 vs 64.8%). Patients with PIC had a higher proportion of ischemic ECG at presentation (75.7 vs 53.5%, p 0.03), a tendency to worse ejection fraction (45.9 vs 28.2%, p 0.07) and higher in-hospital mortality (2.6 vs 0.0%, p 0.17). Levels of troponin were similar (4.0±6.0 vs 6.6±10.4, p 0.2) During follow-up (Figure 1), PIC was related to a higher all-cause-mortality (16.2 vs 1.5%, Hazard Ratio (HR) 10.7 (95% Confidence Interval [CI]: 1.3–89.0, p 0.03). Patients with PIC also showed a non-significant higher cardiovascular mortality (5.3 vs 1.4%, HR 3.5 [CI: 0.3–38.5], p 0.3) and higher rate of MACE (13.5 vs 9.2%, HR 1.6 [CI: 0.5–5.1], p 0.4). Conclusion In this study, MINOCA patients had a high prevalence of PIC, being present in more than one-third of them. They are linked to worse prognosis, with higher all-cause mortality and a non-significant increase in cardiovascular mortality and MACE, which could be significant with the appropriate number of patients.

P2532Incidence and outcome of perioperative myocardial infarction/injury after non-cardiac surgeries diagnosed by high-sensitivity cardiac troponin I

Abstract Background In order to differentiate perioperative myocardial infarction/injury (PMI) after non-cardiac surgery from preexisting cardiomyocyte injury from chronic disorders, recent studies have shown the importance of using an acute absolute increase as a criterion for PMI. For high-sensitivity troponin T (hs-cTnT), PMI defined as an absolute increase of 14ng/L (the 99th percentile) has been shown to be strongly associated with 30-day mortality. Until now, no data on hs-cTnI are available. This is a major unmet clinical need, as relevant differences between hs-cTnT and hs-cTnI have recently been identified and, as worldwide hs-cTnI is more commonly used as compared to hs-cTnT. We hypothesized that applying the same criterion to hs-cTnI, would reveal a similar association with outcomes. Purpose To evaluate the incidence and outcome of PMI diagnosed by hs-cTnI after non-cardiac surgery. Methods We included prospectively consecutive high cardiovascular risk patients undergoing non-cardiac surgery. Hs-cTnI concentrations were measured before surgery and, daily after surgery, for three days. PMI was defined as an absolute rise of ≥26ng/L (the 99th percentile of the assay studied) from baseline values. The primary outcome was major adverse cardiovascular events (MACE), a composite of cardiovascular death, myocardial infarction, acute heart failure and arrhythmias, and the secondary outcome was all-cause mortality, within 30 days and one year. Results We included 2,018 patients submitted to 2,551 surgeries. Patients had median age of 73 years (IQR 68–79) and 56% were male. After surgery, 231 patients (9%, 95% CI 8–10%) fulfilled PMI diagnostic criterion. Patients with PMI had higher rates of MACE than patients without PMI, at 30 days (13% vs. 2%; P&lt;0.001) and, at one-year follow-up (25% vs. 8%; P&lt;0.001). All-cause mortality was also higher in PMI patients within 30 days and one year (9% vs. 1.5% and, 22% vs. 8%, respectively; P&lt;0.001). In multivariate cox regression analysis, PMI showed a hazard ratio (HR) of 4.7 (95% CI, 2.9–7.6; P&lt;0.001) within 30 days, and a HR of 2.7 (95% CI, 2.0–3.7; P&lt;0.001) within one year for the occurrence of MACE. For total mortality, PMI showed a HR of 3.8 (95% CI, 2.1–6.8; P&lt;0.001) within 30 days and a HR of 2.0 (95% CI, 1.4–2.7; P&lt;0.001) after one year. Conclusion PMI is frequent and associated with high rates of MACE and mortality in short- and long-term follow-up after non-cardiac surgery, regardless of the high-sensitivity troponin assay used for diagnosis. Acknowledgement/Funding Swiss Heart Foundation, University basel, Abbott, Astra zeneca, Forschungsfond Kantonsspital Aarau, Cardiovascular Research Foundation Basel, FAPESP

P1527The applicability of the dual pathway approach criteria after coronary angiography

Abstract Background The combination of aspirin and low-dose rivaroxaban (dual pathway approach, DPA) has been approved for high-risk patients with stable coronary artery disease (CAD) in the COMPASS trial. Patients with CAD combined with ≥1 DPA criteria, defined as peripheral artery disease, renal failure, heart failure, or diabetes, have been proposed as high-risk patients eligible for DPA. Purpose To determine the prevalence of patients meeting the DPA criteria and the association with major adverse cardiovascular events (MACE) in patients with stable CAD after coronary angiography (CAG). Further, to evaluate use of the DPA criteria in CAD patients meeting the inclusion criteria in the COMPASS trial. Methods We studied patients included in the Western Denmark Heart Registry after examination by CAD 2004–11. Patients without CAD or myocardial infarction (MI) &lt;1 year before or 30 days after CAG were excluded. Patients were stratified according to 0 or ≥1 DPA criteria and being eligible/ineligible for the COMPASS trial. Event rates and incidence rate ratios (IRRs) of MACE (cardiac death, ischemic stroke, and MI) were estimated. Results Of 80,071 patients undergoing CAG, 18,689 (23%) patients had stable CAD. According to the DPA criteria, 7,730 patients (10%) were DPA eligible. Rates of MACE were 1.98 (95% CI 1.86–2.34) events per 100 person-years among DPA ineligible patients and 4.26 (95% CI 4.04–4.50) events per 100 person-years among DPA eligible patients (IRR 2.15, 95% CI 1.98–2.34). When stratifying patients according to eligibility in the COMPASS inclusion criteria, COMPASS eligible patients with 0 DPA criteria and COMPASS ineligible patients with ≥1 DPA criteria were at intermediate risk compared to patients meeting both (high risk) or none (low risk) of these criteria (Figure 1). Figure 1 Conclusion In a cohort of consecutive patients undergoing CAG, 1 in 10 patients would be eligible for DPA according to the DPA criteria. Patients with stable CAD and ≥1 DPA criteria had &gt;2-fold higher rate of MACE than CAD patients without any DPA criteria.

Aspirin better than clopidogrel on major adverse cardiovascular events reduction after ischemic stroke: A retrospective nationwide cohort study.

Several clinical trials reported that clopidogrel was superior to aspirin in secondary stroke prevention by reducing the risk of major adverse cardiovascular events (MACE). We aimed to compare the efficacy of clopidogrel with aspirin in reducing one-year risk of MACE based on real-world evidence from Taiwan Health Insurance Database. We identified ischemic stroke patients between 2000 and 2012 who took aspirin or clopidogrel within 7 days of stroke onset for 1-year follow-up. The primary outcome was one-year MACE including recurrent stroke, acute myocardial infarction, and death. Propensity score matching and conditional Cox proportional hazards regression were conducted to control the confounding factors. From 9,089 ischemic stroke patients, we found 654 patients on aspirin and 465 patients on clopidogrel who met the selective inclusion criteria. After propensity score matching, 379 patients were selected from each group. The clopidogrel group had a 1.78-fold MACE risk compared with the aspirin group at one-year follow-up (95% CI = 1.41-2.26, p<0.01). The MACE-free rate in the aspirin group was 15.74% higher than in the clopidogrel group at one-year follow-up. Sub-analysis of the three components of MACE showed that clopidogrel conferred higher risk of recurrent stroke (OR 1.43, 95% CI = 1.06-1.92, p 0.02) and acute myocardial infarction (OR 3.72, 95% CI = 1.04-13.3, p 0.04), but no different risk of death than that of aspirin. Among first-ever ischemic stroke patients, secondary stroke prevention using clopidogrel was associated with higher rates of MACE than aspirin. Aspirin might have better efficacy in secondary stroke prevention and was associated with lower risk of MACE. The real-world evidence raises the need to re-assess the current therapeutic options in secondary stroke prevention applying aspirin vs. clopidogrel.

Dysglycemia and increased left ventricle mass in normotensive patients admitted with a first myocardial infarction: prognostic implications of dysglycemia during 14\u2009years of follow-up

BackgroundLeft ventricle mass (LVM) can be influenced by various conditions including hypertension and/or inherent cardiomyopathies. Dysglycemia is also thought to exert an anabolic effect on heart tissue by hyperinsulinemia and thereby promoting increased LVM. The primary aim of this study was to assess the influence of dysglycemia on LVM evaluated by an oral glucose tolerance test (OGTT) in patients admitted with a first myocardial infarction (MI) without hypertension. The secondary aim was to assess the impact of dysglycemia on major adverse cardiovascular events (MACE) and all-cause mortality during long-term follow-up.MethodsPatients admitted with a first MI without known history of hypertension were included. All patients without previously known type 2 diabetes mellitus (T2DM) had a standardized 2-hour OGTT performed and were categorized as: normal glucose tolerance (NGT), impaired fasting glucose (IFG)/impaired glucose tolerance (IGT) and newly detected T2DM (new T2DM). LVM was measured by echocardiography using Devereaux formula and indexed by body surface area. Multivariate linear regression analysis was used to assess the impact of confounders (dysglycemia by OGTT, known T2DM, age, sex and type of MI) on LVM. Cox proportional hazard model was used to assess the impact of dysglycemia on all-cause mortality and a composite endpoint of MACE (all-cause mortality, MI, revascularisation due to stable angina, coronary artery bypass graft, ischemic stroke or hemorrhagic stroke).ResultsTwo-hundred-and-five patients were included and followed up to 14 years. In multivariate regression analysis, LVM was only significantly increased in patients categorized as new T2DM (β = 25.3; 95% CI [7.5–43.0]) and known T2DM (β = 37.3; 95% CI [10.0-64.5]) compared to patients with NGT. Patients with new T2DM showed higher rates of MACE and all-cause mortality compared to patients with IFG/IGT and NGT; however no significantly increased hazard ratio was detected.ConclusionsDysglycemia is associated with increasing LVM in normotensive patients with a first acute myocardial infarction and the strongest association was observed in patients with new T2DM and patients with known T2DM. Dysglycemia in normotensive patients with a first MI is not an independent predictor of neither MACE nor all-cause mortality during long-term follow-up compared to normotensive patients without dysglycemia.