Higher Risk Of MACE Research Articles

Subclinical left ventricular dysfunction in rheumatoid arthritis: findings from the prospective Porto-RA cohort.

Patients with rheumatoid arthritis (RA) have an increased risk of cardiac dysfunction and heart failure (HF) due to a pro-inflammatory state. Detecting cardiac dysfunction in RA is challenging as these patients often present preserved ejection fraction (EF) but may have subclinical ventricular dysfunction. Echocardiographic strain analysis is a promising tool for early detection of subclinical left ventricular systolic dysfunction (LVSD). This study assesses the prognostic role of strain analysis in RA. Prospective study of 277 RA patients without known heart disease and preserved EF, categorized by left ventricular global longitudinal strain (GLS): normal GLS (≤ -18%) vs. subclinical LVSD (> -18%). Primary outcome was a composite of myocardial infarction, HF hospitalization, stroke, or cardiovascular death (MACE). Mean age was 57years, 79% female. Although mean GLS was within normal (-20 ± 3%), subclinical LVSD was observed in 24% of patients (n = 67) and was positively correlated with older age (OR 1.54 per 10years; p < 0.001) and comorbid conditions, such as dyslipidemia (OR 2.27; p = 0.004), obesity (OR 2.29; p = 0.015), and chronic kidney disease (OR 8.39; p = 0.012). Subclinical LVSD was independently associated with a 3.9-fold higher risk of MACE (p = 0.003) and a 3.4-fold higher risk of HF hospitalization/cardiovascular death (p = 0.041). A GLS threshold of > -18.5% provided optimal sensitivity (78%) and specificity (74%) in identifying patients at elevated MACE risk (AUC = 0.78; p < 0.001). Subclinical LVSD, identified by reduced GLS, was strongly associated with adverse cardiovascular events in RA. Whether these findings have therapeutic implications is worth exploring in clinical trials.

Association of Cardiologist Clinic Visits with Cardiovascular Primary Prevention Outcomes Among People with HIV from Underrepresented Racial and Ethnic Groups in the Southern United States.

People with HIV (PWH) are at elevated risk for atherosclerotic cardiovascular disease (ASCVD). Underrepresented racial and ethnic groups (UREGs) with HIV in the southern U.S. are disproportionately affected, yet whether cardiology specialist care for this at-risk group improves blood pressure and lipid control or prevents cardiovascular events is unknown. We evaluated a cohort of PWH from UREGs at elevated ASCVD risk without known cardiovascular disease who received HIV-related care from 2015-2018 at four academic medical centers in the Southern United States with follow up through 2020. Primary outcomes were blood pressure control (<140/90 mmHg) and lipid control (LDL-C ≤ 100 mg/dl) over 2 years and time to first major adverse cardiovascular (MACE) event. Statistical analyses were adjusted for cohort/site and patient factors including HIV measures and comorbidities. Among 3972 included PWH (median age 47 years old, 32.6% female) without diagnosed cardiovascular disease, 276 (6.9%) had a cardiology clinic visit. Cardiology clinic visits were not significantly associated with subsequent blood pressure control (adjusted OR 0.78, 95% CI 0.49-1.24, p=0.29) or lipid control (adjusted OR 2.25, 95% CI 0.72-7.01, p=0.16). Over a median follow up of 5 years, patients who had a cardiology clinic visit had higher risk of MACE, overall mortality, and falsification endpoints (hospitalization or death from accident/trauma and pneumonia/sepsis) indicating a higher risk group overall, even after adjusting for measured risk factors. Among UREG PWH at elevated cardiovascular risk, a cardiology clinic visit was not associated with improved cardiovascular risk factors or reduced risk of cardiovascular events. Our study suggests that seeing a cardiologist is not alone sufficient to promote cardiovascular health or prevent cardiovascular events among PWH, but with low confidence given the higher risk among those who had a cardiology visit.

ST-segment depression and left ventricular systolic function recovery post-atrial fibrillation ablation in heart failure.

Catheter ablation (CA) of atrial fibrillation (AF) improves left ventricular ejection fraction (LVEF) in patients with heart failure with reduced ejection fraction (HFrEF). The impact of ST-segment depression before CA on LVEF recovery and clinical outcomes remains unknown. In the present study, we aimed to investigate the relationship between ST-segment depression during AF rhythm before CA and improvement in the LVEF and clinical outcomes in persistent atrial fibrillation (PerAF) patients with HFrEF. The present study included 122 PerAF patients (male; 98 patients, 80%, mean age: 69 [56, 76] years) from the Osaka Rosai Atrial Fibrillation ablation (ORAF) registry who had LVEF<50% and underwent an initial ablation. The patients who underwent percutaneous coronary intervention or coronary artery bypass grafting within the past 1month were not included in the enrolled patients. We assigned the patients based on the presence of ST-segment depression before CA during AF rhythm and evaluated improvement in the LVEF (LVEF≥15%) 1year after CA and the relationship between ST-segment depression and heart failure (HF) hospitalization/major adverse cardiovascular events (MACE), which are defined as a composite of HF hospitalization, cardiovascular death, hospitalization due to coronary artery disease, ventricular arrhythmia requiring hospitalization and stroke. The percentage of patients with improvement in the LVEF 1year after CA was significantly lower in the patients with ST-segment depression than those without (58.6% vs. 79.7%, P=0.012). Multiple regression analysis showed ST-segment depression was independently and significantly associated with improvement in the LVEF 1year after CA (HR: 0.35; 95% CI: 0.129-0.928, P=0.035). Kaplan-Meier analysis showed that the patients with ST-segment depression significantly had higher risk of HF hospitalization and MACE than those without (log rank P=0.022 and log rank P=0.002, respectively). Multivariable Cox proportional hazards analysis showed that ST-segment depression was independently and significantly associated with a higher risk of MACE (HR: 2.82; 95% CI: 1.210-6.584, P=0.016). ST-segment depression before CA during AF rhythm was useful prognostic predictor of improvement in the LVEF and clinical outcomes including HF hospitalization and MACE in PerAF patients with HFrEF.

New-onset atrial fibrillation, cardiovascular outcomes and all-cause mortality in patients with newly diagnosed cancer: A large population-based matched cohort study.

11184 Background: Studies have shown an association between atrial fibrillation (AF) and cancer, but the relationship is incompletely studied. there is also a paucity of data regarding the specific association between cancer type and AF risk . Notably, the longitudinal associations of new-onset AF with adverse cardiovascular (ACV) outcomes in Newly Diagnosed Cancer Patients remain unclear. Thus, through a comprehensive nationwide population-based study, we assessed the associations between new-onset AF and subsequent risks of ACV events and all-cause mortality. Methods: This large retrospective cohort study was conducted using the TriNetX database and included adults (&gt;18 years) with any new cancer diagnoses. We performed 1:1 propensity score matching (PSM) for demographics, BMI, nicotine dependence, comorbidities, cancer type, and medications to similar controls as cancer patients without AF. The primary outcome was new ACV events like heart failure (HF), major adverse cardiovascular events (MACE; coronary artery intervention myocardial infarction, or unstable angina), ischemic heart disease (IHD), and cerebrovascular events (CVE; cerebral infarction, carotid intervention, stroke, transient ischemic attack. The secondary outcome was all-cause mortality. Sensitivity analysis assessed statistical robustness. Hazard ratios (HR) were calculated to compare group outcomes. Results: Among the new diagnoses, 52,606 developed AF, and 374,959 remained AF free during the follow-up. After PSM, both cohorts (51,567 each) were well-matched. The mean follow-up duration was 4.8 (± 2.7) years. Among newly diagnosed cancer patients, those with incident AF had higher risk of MACE (HR 1.56; 95% CI 1.49–2.16), HF (HR 3.10; 95% CI 2.76–4.36), IHD (HR 1.68; 95% CI 1.41–2.01), CVE (HR 2.93; 95% CI 2.13–4.04), and all-cause mortality (HR 2.56; 95% CI 1.89–3.78) compared with those without incident AF. We noted a higher incidence rate during the initial months after the diagnosis of AF for both sexes. During the first year, the association with any ACV events (men: HR 2.78, 95% CI, 1.85–3.20; women: HR 1.81, 95% CI, 1.31–2.67) was more substantial than that following AF diagnosis for both sexes. New ‐onset AF was strongly associated with metastatic cancer. In sensitivity analysis, we excluded individuals with &lt;1 year of follow-up results were consistent, and all statistically significant associations remained unchanged. Conclusions: cancer patients who developed AF had significantly higher risks of subsequent adverse cardiovascular events and greater all-cause mortality. AF was strongly associated with metastatic disease. Our findings highlight the importance of strategies for AF prevention to mitigate macrovascular complications in all newly diagnosed cancer patients.

#2219 Glycemic control and adverse outcomes in patients with diabetes and CKD stage 4-5: a nationwide cohort study

Abstract Background and Aims Although poor glycemic control is strongly associated with adverse clinical outcomes, few studies have evaluated their risk across the full glycemic spectrum in patients with moderate to advanced chronic kidney disease (CKD). Guidelines for HbA1c targets are mainly derived from extrapolation of trials conducted in people with normal or mildly reduced kidney function. In non-dialysis CKD individualized targets are recommended, often aiming for less strict glycemic control, due to lack of evidence for the efficacy of lower HbA1c, and potentially greater harm. In this study, we analyzed long-term outcomes across the full spectrum of HbA1c in CKD stage 4-5. Method Using data from the Swedish Renal Registry, we included patients with diabetes and CKD stages 4-5. Adjusted cause-specific Cox models were used to analyze associations between the one-year baseline mean HbA1c level (&amp;lt;43, 43-52 [reference], 53-64, 65-74, 75-89, ≥90 mmol/mol) and the occurrence of major adverse cardiovascular events (MACE, a composite of cardiovascular death, hospitalization for myocardial infarction or stroke), kidney replacement therapy (KRT), all-cause mortality, and hospitalization/death due to hypoglycemia. Results We included 2571 patients (71 years, 64% men, eGFR 20 mL/min per 1.73m², HbA1c 59.7 mmol/mol [7.6%], 75% insulin users). At baseline, patients with a higher HbA1c level were younger, had a higher prevalence of cardiovascular disease and were more likely prescribed insulin. Kidney function and malnutrition-inflammation markers were, however, not different between groups. Over a median follow-up of 4.9 [4.6;5.2] years, 939 (37%) KRT, 1078 (42%) MACE, and 1523 (59%) deaths occurred. Increasing HbA1c was gradually associated with the risk of MACE (adjusted HR from 0.76 [95% CI: 0.60-0.96] for HbA1c &amp;lt;43 mmol/mol to 1.39 [1.01-1.92] for HbA1c ≥ 90 mmol/mol) (Fig.). In contrast, a J-shaped relationship was observed for the risk of all-cause mortality. Compared to the reference group (43-52 mmol/mol; 5-year absolute risk 52% [48-56]), a HbA1c &amp;lt;43 mmol/mol was not associated with a higher mortality (adjusted HR 1.03 [0.86-1.23], 5-year absolute risk 57% [51-63]), while any HbA1c above 75 mmol/mol was associated with a higher risk of death. The risks of KRT and severe hypoglycemia were not different across HbA1c levels. Conclusion In CKD stage 4-5, HbA1c above the general recommendation for non-CKD patients (43-52 mmol/mol) is associated with a higher risk of MACE and all-cause mortality, but not KRT, without increased risk of severe hypoglycemia. This suggests that targeting a lower HbA1c, together with other cardio-reno-metabolic prevention strategies, might contribute to improve health outcomes in this very high-risk population.

D-dimer and fibrinogen indicate ischemic risk in patients with atrial fibrillation after percutaneous coronary intervention

BackgroundThis study aimed to evaluate the association of antiphospholipid antibodies (aPL) and conventional markers of coagulation with ischemic and bleeding risk in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI).MethodsIn this prospective two-center observational cohort study, patients with AF and an indication for oral anticoagulation (OAC) were enrolled after PCI. Blood was drawn on day 1–3 after PCI. Dilute Russell’s viper venom time was used to determine lupus anticoagulant (LA) in OAC-free plasma. Anti-cardiolipin (aCL) IgG, IgM, and anti-β2-Glycoprotein 1 (aβ2GP1) IgG were analyzed by enzyme-linked immunosorbent assay (ELISA). Fibrinogen (FIB), d-dimer, and prothrombin fragment 1 and 2 (PF 1 + 2) were measured in citrated plasma. The primary ischemic outcome was time to major adverse cardiovascular events (MACE; death, myocardial infarction, or stroke) assessed at 6 months. Bleeding was defined according to International Society on Thrombosis and Haemostasis.Results158 patients were enrolled between May 2020 and May 2021 on day 1–3 after PCI. The median age was 78 years (interquartile range [IQR] 72–82), 111 (70%) were male, and 39 (25%) presented with acute coronary syndrome. D-dimer was elevated in 74 (47%) patients, FIB was increased in 40 (25%) and PF1 + 2 in 68 (43%) patients. 32 (20%) patients had ≥ 1 antiphospholipid antibody elevated (aPL; LA: 19 [12%], aCL: 14 [9%], aβ2GP1: 2 [1%]). The presence of aPL was neither significantly associated with MACE (HR 1.46, 95% CI [0.39–5.49], p = 0.579), nor bleeding (HR 1.07 [0.30–3.84], p = 0.917). Elevated d-dimer was significantly associated with higher risk for MACE (HR 5.06 [1.09–23.41], p = 0.038) and major bleeding (HR 7.04 [1.58–31.47], p = 0.011). Elevated D-dimer increased the predictive capacity of HAS-BLED for major bleedings (HAS-BLED: AUC 0.71 [0.60–0.83] vs. HAS-BLED + d-dimer: AUC 0.79 [0.70–0.88]; p = 0.025). Increased levels of FIB were associated with higher risk for MACE (HR 3.65 [1.11–11.96], p = 0.033).ConclusionBiomarkers of coagulation might be suitable to assess ischemic and bleeding risk in patients with AF following PCI.

The impact of patient-reported frailty on cardiovascular outcomes in elderly patients after non-ST-acute coronary syndrome

BackgroundAs life expectancy increases, the population of older individuals with coronary artery disease and frailty is growing. We aimed to assess the impact of patient-reported frailty on the treatment and prognosis of elderly early survivors of non-ST-elevation acute coronary syndrome (NSTE-ACS). MethodsFrailty data were obtained from two prospective trials, POPular Age and the POPular Age Registry, which both assessed elderly NSTE-ACS patients. Frailty was assessed one month after admission with the Groningen Frailty Indicator (GFI) and was defined as a GFI-score of 4 or higher. In these early survivors of NSTE-ACS, we assessed differences in treatment and 1-year outcomes between frail and non-frail patients, considering major adverse cardiovascular events (MACE, including cardiovascular mortality, myocardial infarction, and stroke) and major bleeding. ResultsThe total study population consisted of 2192 NSTE-ACS patients, aged ≥70 years. The GFI-score was available in 1320 patients (79 ± 5 years, 37% women), of whom 712 (54%) were considered frail. Frail patients were at higher risk for MACE than non-frail patients (9.7% vs. 5.1%, adjusted hazard ratio [HR] 1.57, 95% confidence interval [CI] 1.01–2.43, p = 0.04), but not for major bleeding (3.7% vs. 2.8%, adjusted HR 1.23, 95% CI 0.65–2.32, p = 0.53). Cubic spline analysis showed a gradual increase of the risk for clinical outcomes with higher GFI-scores. ConclusionsIn elderly NSTE-ACS patients who survived 1-month follow-up, patient-reported frailty was independently associated with a higher risk for 1-year MACE, but not with major bleeding. These findings emphasize the importance of frailty screening for risk stratification in elderly NSTE-ACS patients.

Real-World Impact of Blood Pressure Control in Patients With Apparent Treatment-Resistant or Difficult-to-Control Hypertension and Stages 3 and 4 Chronic Kidney Disease.

Chronic kidney disease (CKD) is a common comorbidity in patients with apparent treatment-resistant hypertension (aTRH). We assessed clinical outcomes, healthcare resource utilization events, and costs in patients with aTRH or difficult-to-control hypertension and stage 3-4 CKD with uncontrolled vs. controlled BP. This retrospective cohort study used linked IQVIA Ambulatory EMR-US and IQVIA PharMetrics Plus claims databases. Adult patients had claims for ≥3 antihypertensive medication classes within 30 days between 01/01/2015 and 06/30/2021, 2 office BP measures recorded 1-90 days apart, ≥1 claim with ICD-9/10-CM diagnosis codes for CKD 3/4, and ≥1 year of continuous enrollment. Baseline BP was defined as uncontrolled (≥130/80 mm Hg) or controlled (<130/80 mm Hg) BP. Outcomes included risk of major adverse cardiovascular events plus (MACE+; stroke, myocardial infarction, heart failure hospitalization), end-stage renal disease (ESRD), healthcare resource utilization events, and costs during follow-up. Of 3,966 patients with stage 3-4 CKD using ≥3 antihypertensive medications, 2,479 had uncontrolled BP and 1,487 had controlled BP. After adjusting for baseline differences, patients with uncontrolled vs. controlled BP had a higher risk of MACE+ (HR [95% CI]: 1.18 [1.03-1.36]), ESRD (1.85 [1.44-2.39]), inpatient hospitalization (rate ratio [95% CI]: 1.35 [1.28-1.43]), and outpatient visits (1.12 [1.11-1.12]) and incurred higher total medical and pharmacy costs (mean difference [95% CI]: $10,055 [$6,741-$13,646] per patient per year). Patients with aTRH and stage 3-4 CKD and uncontrolled BP despite treatment with ≥3 antihypertensive classes had an increased risk of MACE+ and ESRD and incurred greater healthcare resource utilization and medical expenditures compared with patients taking ≥3 antihypertensive classes with controlled BP.

Longitudinal Control of Lipid Levels in Patients With Premature Coronary Artery Disease

BackgroundLipid-lowering therapy (LLT) is a central aspect of the treatment of patients with coronary artery disease (CAD), and the benefits of LLT accrue over time. However, there are limited real-world data on longitudinal lipid control in patients with premature CAD. ObjectivesThe purpose of this study was to assess longitudinal attainment of guideline-recommended lipid goals and outcomes in a contemporary cohort of patients with premature CAD. MethodsWe enrolled males younger than 50 years and females younger than 55 years with coronary stenosis of >50% and examined achievement of lipid goals, LLT characteristics, and cardiovascular outcomes (major adverse cardiovascular event [MACE]). ResultsOf 476 patients who presented with acute coronary syndrome (ST-elevation myocardial infarction, non-ST-segment elevation myocardial infarction, unstable angina) (68%), stable angina (28%), or other symptoms, 73.2% achieved low-density lipoprotein cholesterol (LDL-C) <1.8 mmol/L on at least 1 occasion, but only 27.3% consistently stayed in the target range for 3 years after diagnosis. Although 73.9% of patients received high-intensity LLT at the time of diagnosis, only 43.5% had good adherence over the following 3 years. In multivariable analysis, 1 mmol/L increase in time-weighted average exposure to LDL-C, but not the lowest achieved LDL-C, was associated with a higher risk of MACE, hazard ratio 2.02 (95% CI: 1.48-2.76), when adjusted for sex, age, hypertension, diabetes, and smoking. ConclusionsWe found low rates of longitudinal lipid target achievement in patients with premature CAD. Cumulative LDL-C exposure, but not lowest achieved LDL-C, was associated with risk of MACE. This highlights the critical importance of longitudinal control of lipids levels and identifies opportunities to improve LLT and maximize the time-dependent benefits of lipid-lowering.

A comprehensive network meta-analysis: comparison of long-term outcomes between intravascular ultrasound, optical coherence tomography, and angiography-guided stent implantation

Abstract Background Intravascular ultrasonography (IVUS) and optical coherence tomography (OCT) guided stent implantations are alternative techniques that are adjunct to angiography-guided (ANG) percutaneous coronary interventions in patients with coronary artery disease (CAD), especially for optimal stent deployment. We aimed to conduct a network meta-analysis including studies comparing those three techniques. Methods We searched PubMed, Scopus, and Cochrane libraries for eligible studies that compared IVUS, OCT, and angiography-guided stent implantation in patients with CAD. After excluding studies, which were irrelevant, duplicated, and had inappropriate results, 54 randomized, propensity-score matched, and observational studies with 232.181 patients were included in this meta-analysis. Results Number of studies compared ANG and IVUS was higher than the other two comparisons. Indirect evidence of network estimates between OCT and IVUS was higher than direct estimate (60% vs. 40%). Minimal parallelism and mean path length of each estimation was suitable with numbers low than 2 for both for comparisons. ANG had higher MACE (RR =1.30; 1.22-1.39, p&amp;lt;0.001), all cause-death (RR=1.45;1.30-1.61, p&amp;lt;0.001), cardiac death (RR=1.72;1.54-1.92, p&amp;lt;0.001), myocardial infarction (RR=1.34; 1.23-1.45, p&amp;lt;0.001), target lesion revascularization (RR=1.20; 1.13-1.26, p&amp;lt;0.001), and stent thrombosis (RR=1.58;1.34-1.85, p&amp;lt;0.001) risks compared to IVUS. There was no difference between OCT and IVUS regarding all outcomes. MACE (RR=1.51;1.26-1.81, p&amp;lt;0.001), cardiac death (RR=2.13;1.41-3.21, p&amp;lt;0.001), and myocardial infarction (RR=1.42;1.05-1.93, p&amp;lt;0.001) risks were higher in ANG groups than in OCT group. Highest benefit was established with OCT for MACE (p-score = 0.973), with IVUS for all-cause death (p-score= 0.792), with OCT for cardiac death (p-score=0.921), with OCT for myocardial infarction (p-score =0.823), with IVUS for target lesion revascularization (p-score=0.865), and with IVUS for stent thrombosis (p-score=0.930). Heterogeneity was appropriate for all outcomes (I2 &amp;lt;70%). There was no publication bias for all outcomes. Conclusion This comprehensive network meta-analysis indicated that angiography-guided stent implantation had higher risk of MACE, cardiac death, myocardial infarction, target lesion-revascularization, and stent thrombosis when compared to IVUS and had higher risk of MACE, cardiac death, and myocardial infarction than OCT.

Impact of patient-reported frailty on cardiovascular outcomes in elderly patients with non-ST-elevation myocardial infarction

Abstract Background Due to the increasing life expectancy, more older people will be affected by coronary artery disease (CAD). The evaluation of frailty and comorbidity is crucial when elderly patients with non–ST-segment elevation myocardial infarction (NSTEMI) are treated, as frailty can increase the risk of adverse clinical outcomes. Purpose The aim of this registry was to assess the predictive value of patient-reported frailty on the treatment and prognosis of elderly non-ST-elevation myocardial infarction (NSTEMI) patients. Methods A post-hoc analysis was performed in patients included in the POPular Age trial and POPular Age egistry, which both enrolled elderly patients with NSTEMI. Frailty was assessed within one month after admission using the Groningen Frailty Indicator (GFI), which is a widely-used questionnaire that includes both physical, cognitive, social and psychological domains. Missing data was imputed by predictive mean matching when at least one item for the questionnaire was registered. Patients with a GFI score of 4 or higher were defined as frail. We evaluated the impact of frailty on both major adverse cardiovascular events (MACE, consisting of cardiovascular mortality, myocardial infarction and stroke) and major or clinically-relevant non-major bleeding (BARC 2, 3 or 5) at one year. Outcomes were then evaluated by stratifying the population in invasively managed patients, who underwent coronary angiography (CAG), versus conservatively-managed patients. Results The total included population consisted of 2229 patients ≥70 years presenting with NSTEMI. The GFI score was available in 1320 patients (mean age 79 years, 51% women), of whom 712 were considered frail (54%, mean GFI score 4.3 ± 2.8). In total, 1027 patients (78%) were invasively-managed. Frail patients were at higher risk for MACE than non-frail patients (9.7% vs. 5.1%, adjusted hazard ratio [HR] 1.62, 95% confidence interval [CI] 1.05-2.51), but not for major or clinically-relevant non-major bleeding (12.5% vs. 14.5%, HR 0.93, 95% CI 0.69-1.28). In frail patients, invasive management was strongly associated with a lower incidence of MACE (6.7% vs. 17.0%, adjusted HR 0.40, 95% CI: 0.24-0.66, p &amp;lt; 0.001). Yet, in non-frail patients, invasive management was not associated with a lower risk for MACE (4.8% vs. 6.9%, adjusted HR 0.81, 95% CI: 0.32-2.06, p = 0.66). This difference in outcomes could not be primarily explained by frailty status (p-value for interaction = 0.19). Conclusions Patient-reported frailty was independently associated with higher risk for MACE but not for major or clinically relevant nonmajor bleeding in elderly patients presenting with NSTEMI. The results may consolidate the importance of frailty screening in risk stratification in elderly patients presenting with NSTEMI.Figure 1.KM MACE in frail vs. nonfrailFigure 2.Forest plot inv vs. consv

Worsening preoperative functional status increases morbidity and mortality in patients undergoing coronary artery bypass grafting: A propensity matched study of the ACS-NSQIP database

IntroductionDependent functional status is correlated with increased mortality in patient undergoing coronary artery bypass grafting (CABG). However, patients who are partially dependent and totally dependent may have different peri‑operative outcome profiles. This study aims to retrospectively examine the effect of different levels of functional dependency on post-CABG morbidity and mortality. MethodsPatients who underwent a CABG from 2005 to 2021 were identified in the ACS-NSQIP database. Subjects were stratified into independent (IFS), partially dependent (PDFS), and totally dependent functional status (TDFS). A 5:1 propensity matching between IFS and each functional dependent group was performed, respectively. The 30-day peri‑operative outcomes of PDFS and TDFS were compared to that of IFS. Peri-operative outcomes between PDFS and TDFS were compared using multivariable logistic regression, adjusted for demographics and co-morbidities. ResultsThere were 968 PDFS with 4779 matched IFS and 247 TDFS with 1202 matched IFS. Compared to IFS, PDFS and TDFS had higher mortality, sepsis, bleeding, and length of stay>7 days. TDFS have higher MACE, cardiac/pulmonary/renal complications, and OR return than IFS. Compared to PDFS, TDFS had higher mortality (aOR 1.68, p = 0.03), higher risk of MACE (aOR 1.88, p<0.01), cardiac events (aOR 2.74, p<0.01), perioperative sepsis (aOR 1.73, p = 0.03), pulmonary complications (aOR 2.16, p<0.01), and returning to OR (aOR 1.68, p = 0.02). ConclusionOur study shows that dependent functional status is associated with increased morbidity and mortality after CABG. Additional post-CABG complication monitoring and care may be required for TDFS.

Safety Endpoints With Vadadustat Versus Darbepoetin Alfa in Patients With Non–Dialysis-Dependent CKD: A Post Hoc Regional Analysis of the PRO2TECT Randomized Clinical Trial of ESA-Treated Patients

In the PRO2TECT trials, vadadustat was found to be noninferior to darbepoetin alfa in hematologic efficacy but not for major adverse cardiovascular events (MACE; all-cause death or nonfatal myocardial infarction or stroke) in patients with non-dialysis-dependent chronic kidney disease (NDD-CKD). We investigated the regional differences in MACE in the PRO2TECT trials. Phase 3, global, open-label, randomized, active-controlled clinical trial. A total of 1,725 erythropoiesis-stimulating agent (ESA)-treated patients with anemia and NDD-CKD. 1:1 randomization to receive vadadustat or darbepoetin alfa. The primary safety end point was the time to first MACE. At baseline, patients in Europe (n=444) were primarily treated with darbepoetin alfa, showed higher proportions on low ESA doses (<90U/kg/wk epoetin alfa equivalents) with a hemoglobin concentration of≥10g/dL compared with patients in the US (n=665) and non-US/non-Europe (n=614) regions. The MACE rates per 100 person-years in the 3 vadadustat groups across regions were 14.5 in the US, 11.6 in Europe, and 10.0 in the non-US/non-Europe groups, whereas event rates in the darbepoetin alfa group were considerably lower in Europe than in the US and non-US/non-Europe groups (6.7 vs 13.3 and 10.5, respectively). The overall hazard ratio for MACE for vadadustat vs darbepoetin alpha was 1.16; 95% CI, 0.93-1.45, but varied by geographical region, with a greater hazard ratio seen in Europe (US, 1.07; 95% CI, 0.78-1.46; Europe, 2.05; 95% CI, 1.24-3.39; non-US/non-Europe, 0.91; 95% CI, 0.60-1.37); interaction between study treatment and geographical region, P=0.07). In Europe, ESA rescue was associated with a higher risk of MACE in both groups. Several analyses are exploratory. In this trial, there was a low risk of MACE in the darbepoetin alfa group in Europe. Patients in Europe were generally on low doses of ESA, with hemoglobin already within target range. The low risk of MACE may have been related to a limited need to switch and titrate darbepoetin alfa compared with the non-US/non-Europe group. Akebia Therapeutics, Inc. ClinicalTrials.gov identifier: NCT02680574.

Residing in a Food Desert and Adverse Cardiovascular Events in US Veterans With Established Cardiovascular Disease

Residents living in a "food desert" are known to be at a higher risk for developing cardiovascular disease (CVD). However, national-level data regarding the influence of residing in a food desert in patients with established CVD is lacking. Data from veterans with established atherosclerotic CVD who received outpatient care in the Veterans Health Administration system between January 2016 and December 2021 were obtained, with follow-up information collected until May 2022 (median follow-up: 4.3 years). A food desert was defined using the United States Department of Agriculture criteria, and census tract data were used to identify Veterans in these areas. All-cause mortality and the occurrence of major adverse cardiovascular events (MACEs; a composite of myocardial infarction/stroke/heart failure/all-cause mortality) were evaluated as the co-primary end points. The relative risk for MACE in food desert areas was evaluated by fitting multivariable Cox models adjusted for age, gender, race, ethnicity, and median household income, with food desert status as the primary exposure. Of the 1,640,346 patients (mean age 72 years, women 2.7%, White 77.7%, Hispanic 3.4%), 25,7814 (15.7%) belonged to the food desert group. Patients residing in food deserts were younger; more likely to be Black (22% vs 13%)or Hispanic (4% vs 3.5%); and had a higher prevalence of diabetes mellitus (52.7% vs 49.8%), chronic kidney disease (31.8% vs 30.4%,) and heart failure (25.6% vs 23.8%). Adjusted for covariates, food desert patients had a higher risk of MACE (hazard ratio 1.040 [1.033 to 1.047]; p <0.001) and all-cause mortality (hazard ratio 1.032 [1.024 to 1.039]; p <0.001). In conclusion, we observed that a large proportion of US veterans with established atherosclerotic CVD reside in food desert census tracts. Adjusting for age, gender, race, and ethnicity, residing in food deserts was associated with a higher risk of adverse cardiac events and all-cause mortality.

Temporal trends in cardiovascular burden among patients with prostate cancer receiving androgen deprivation therapy: a population-based cohort study

BackgroundAlthough androgen deprivation therapy (ADT) is associated with cardiovascular risks, the extent and temporal trends of cardiovascular burden amongst patients with prostate cancer receiving ADT are unclear.MethodsThis retrospective cohort study analyzed adults with PCa receiving ADT between 1993–2021 in Hong Kong, with follow-up until 31/9/2021 for the primary outcome of major adverse cardiovascular events (MACE; composite of cardiovascular mortality, myocardial infarction, stroke, and heart failure), and the secondary outcome of mortality. Patients were stratified into four groups by the year of ADT initiation for comparisons.ResultsAltogether, 13,537 patients were included (mean age 75.5 ± 8.5 years old; mean follow-up 4.7 ± 4.3 years). More recent recipients of ADT had more cardiovascular risk factors and used more cardiovascular or antidiabetic medications. More recent recipients of ADT had higher risk of MACE (most recent (2015–2021) vs least recent (1993–2000) group: hazard ratio 1.33 [1.11, 1.59], P = 0.002; Ptrend < 0.001), but lower risk of mortality (hazard ratio 0.76 [0.70, 0.83], P < 0.001; Ptrend < 0.001). The 5-year risk of MACE and mortality for the most recent group were 22.5% [20.9%, 24.2%] and 52.9% [51.3%, 54.6%], respectively.ConclusionsCardiovascular risk factors were increasingly prevalent amongst patients with prostate cancer receiving ADT, with increasing risk of MACE despite decreasing mortality.

History of peripheral artery disease and cardiovascular risk of real-world patients with acute coronary syndrome: Role of inflammation and comorbidities

BackgroundPatients with acute coronary syndromes (ACS) remain at risk of cardiovascular disease (CVD) recurrences. Peripheral artery disease (PAD) may identify a very high risk (VHR) group who may derive greater benefit from intensified secondary prevention. MethodsAmong ACS-patients enrolled in the prospective multi-center Special Program University Medicine (SPUM), we assessed the impact of PAD on major cardiovascular events (MACE: composite of myocardial infarction, stroke and all-cause death) and major bleeding. Multivariate analysis tested the relation of each significant variable with MACE, as well as biomarkers of inflammation and novel markers of atherogenesis. ResultsOut of 4787 ACS patients, 6.0% (n = 285) had PAD. PAD-patients were older (p < 0.001), with established CVD and signs of increased persistent inflammation (hs-CRP; 23.6 ± 46.5 vs 10.4 ± 27.2 mg/l, p < 0.001 and sFlt-1; 1399.5 ± 1501.3 vs 1047.2 ± 1378.6 ng/l, p = 0.018). In-hospital-death (3.2% vs 1.4%, p = 0.022) and -MACE (5.6% vs 3.0%, p = 0.017) were higher in PAD-patients. MACE at 1 year (18.6% vs 7.9%,p < 0.001) remained increased even after adjustment for confounders (Adj. HR 1.53, 95% CI: 1.14–2.08, p = 0.005). Major bleeding did not differ between groups (Adj. HR 1.18; 95% CI 0.71–1.97, p = 0.512). Although PAD predicted MACE, PAD-patients were prescribed less frequently for secondary prevention at discharge. ConclusionsIn this real-world ACS patient cohort, concomitant PAD is a marker of VHR and is associated with increased and persistent inflammation, higher risk for MACE without an increased risk of major bleeding. Therefore, a history of PAD may be useful to identify those ACS patients at VHR who require more aggressive secondary prevention.

Association of intermittent vs continuous androgen deprivation therapy with cardiovascular disease and endocrine/metabolic disorders in patients with metastatic prostate cancer.

82 Background: There is mixed evidence on the risks of cardiovascular disease (CVD) and endocrine/metabolic disorders associated with long-term intermittent and continuous androgen deprivation therapy (iADT and cADT, respectively) for metastatic prostate cancer (mPC). This study examined these risks in patients (pts) with mPC receiving iADT vs cADT in the US. Methods: This was a retrospective cohort study of SEER-Medicare pts with mPC initiating ADT (2010–2017), with ≥36 months of continuous insurance coverage, unless death occurred, who did not receive chemotherapy or a second-generation anti-androgen during follow-up. iADT and cADT cohorts were defined by treatment patterns and gaps in therapy. Comorbidities and clinical events were identified using ICD-9/10-CM codes. Outcomes examined were major adverse cardiovascular events (MACE [myocardial infarction (MI), stroke, cardiomyopathy/heart failure (HF), pulmonary embolism (PE), ischemic heart disease (IHD), or all-cause mortality]) and endocrine/metabolic events (diabetes, hypercholesterolemia, bone fractures, or osteoporosis). Inverse probability of treatment weighting (IPTW) was used to adjust for differences between cohorts; weighted Cox models were used to estimate the hazard ratio (HR) of the outcomes. Subgroup analyses examined pts by CVD history; a sensitivity analysis was performed restricting the definition of MACE to include CVD-related mortality as a component, i.e., MACESA (MI, stroke, cardiomyopathy/HF, PE, IHD, or CVD-related mortality). Results: 2234 pts with mPC were included; 478 (21%) received iADT and 1756 (79%) cADT. Median follow-up time was 27 and 13 months, and time on ADT (excluding gaps for iADT pts) was 24 and 19 months for the iADT and cADT cohorts, respectively. Deaths occurred in 39% of iADT pts vs 55% of cADT pts; PC was the most common cause of death in both cohorts. In adjusted analyses, pts receiving cADT had a higher risk of MACE vs iADT. No differences in risk of endocrine/metabolic events were observed. Subgroup analysis showed that baseline history of CVD did not alter the results for MACE. Sensitivity analysis results showed no difference in risk of MACESA between pts receiving cADT vs iADT. Conclusions: Pts with mPC receiving cADT had a higher risk of MACE (including all-cause mortality), and no difference in risk of endocrine/metabolic events, compared with those receiving iADT. When MACE was restricted to include CVD-related mortality, there was no difference in risk between cohorts. [Table: see text]

Differential prognosis of patients that are candidates for standard, short or prolonged dual antiplatelet treatment discharged after an acute coronary syndrome

BackgroundCurrent evidence supports the efficacy of prolonged dual antiplatelet treatment (DAPT) for patients at high-ischemic risk and low bleeding risk as well as the efficacy and safety of short DAPT in high-bleeding risk (HBR) patients. MethodsWe evaluated patterns of DAPT candidates in all patients discharged in 2 hospitals after an acute coronary syndrome (ACS). Patients categorized in 3 groups: 1) short-DAPT candidates if they met 1 major o 2 minor criteria for HBR, by the 2019 ARC-HBR criteria; 2) prolonged-DAPT candidates if were not HBR and had recurrent ACS, complex percutaneous coronary interventions or diabetes; 3) standard 12 months DAPT if were not include in the previous 2 groups. Major bleeding (MB) was registered according to 3 or 5 of the BARC consortium definitions. ResultsWe included 8252 patients and 3215 (39 %) were candidates for abbreviated DAPT, 3119 (37.8 %) for prolonged DAPT, and 1918 (23.2 %) for 12 m DAPT. Relevant differences were observed between the 3 categories beyond the bleeding risk. Median follow-up was 57 months. Multivariate analysis identified higher risk of all-cause mortality (HR: 1.96 95 % CI 1.45–2.67; p < 0.001), cardiovascular mortality (HR: 2.10 95 % CI 1.39–3.19; p < 0.011), MACE (HR: 1.69 95 % 1.50–2.02; p < 0.001) and MB (sHR: 3.41 95 % CI 1.45–8.02; p = 0.005) in candidates to short DAPT. Candidates to prolonged DAPT had higher risk of MACE (HR: 1.17 95 % CI 1.02–1.35; p = 0.027). ConclusionsAlmost two thirds of patients discharged after an ACS would be candidates for short or prolonged DAPT and these patients are at higher risk of MACE and mortality.

Korean vs. Western Exercise Capacity Nomograms for Korean Patients With Cardiovascular Disease.

Exercise capacity is known to be an independent predictor of cardiovascular events and mortality. However, most previous studies were based on Western populations. Further study is warranted for Asian patients according to ethnic or national standards. We aimed to compare prognostic values of Korean and Western nomograms for exercise capacity in Korean patients with cardiovascular disease (CVD). In this retrospective cohort study, we enrolled 1,178 patients (62 ± 11 years; 78% male) between June 2015 and May 2020, who were referred for cardiopulmonary exercise testing in our cardiac rehabilitation program. The median follow-up period was 1.6 years. Exercise capacity was measured in metabolic equivalents by direct gas exchange method during the treadmill test. The nomogram for exercise capacity from healthy Korean individuals and a previous landmark Western study was used to determine the percentage of predicted exercise capacity. The primary endpoint was the composite of major adverse cardiovascular events (MACE; all-cause death, myocardial infarction, repeat revascularization, stroke and hospitalization for heart failure). A multivariate analysis showed that the risk of primary endpoint was more than double (hazard ratio [HR], 2.20; 95% confidence interval [CI], 1.10-4.40) in the patients with lower exercise capacity (< 85% of predicted) by Korean nomogram. The lower exercise capacity was one of the strong independent predictors along with left ventricular ejection fraction, age, and level of hemoglobin. However, the lower exercise capacity by Western nomogram could not predict the primary endpoint (HR, 1.33; 95% CI, 0.85-2.10). Korean patients with CVD with lower exercise capacity have higher risk of MACE. Considering inter-ethnic differences in cardiorespiratory fitness, the Korean nomogram provides more suitable reference values than the Western nomogram to determine lower exercise capacity and predict cardiovascular events in Korean patients with CVD.

Abstract 13406: Atrial Fibrillation and Atrial Flutter as Predictors of Cardiovascular Outcomes in Patients Hospitalized With Covid-19 Infection

Introduction: Patients with atrial structural changes have a higher risk of developing atrial arrhythmias, such as atrial fibrillation (AF) and flutter (AFL), particularly during pro-inflammatory states such as a COVID-19 infection. Amongst these patients, AF/AFL have been found to be markers of disease severity. Our aim was to evaluate AF/AFL as predictors of cardiovascular outcomes, and their synergistic relationship with atrial dilatation, in patients with COVID-19. Methods: We conducted a two-center retrospective study in patients hospitalized with COVID-19 from 2020 to 2021. Atrial enlargement was defined by 2D-guided linear measurement by echocardiography. The primary outcome of interest was to determine the association of MACE, defined as myocardial infarction, non-fatal stroke, cardiac arrest, and/or death, in patients who developed AF/AFL. The secondary outcome was to explore the synergistic risk of atrial enlargement and AF/AFL on MACE. Statistical analyses were performed using SAS 9.4. Results: From 488 patients, 68 (14%) developed AF/AFL. These patients were older (74±11 vs. 64±15 years), had higher rates of hypertension (79% vs. 64%), coronary artery disease (29% vs. 12%), and heart failure (28% vs 10%). There was a significant unadjusted effect of right atrial enlargement (OR 2.12, CI 1.15-3.91) and AF/AFL (OR 1.90, CI 1.14-3.19) on MACE, whereas the effect was not sustained for left atrial enlargement. Multivariable adjusted models showed that AF/AFL and right atrial enlargement had no longer a significant effect on MACE, and only age remained an independent significant predictor (OR 1.27, CI 1.09-1.47). Moreover, there was no joint effect of AF/AFL and right atrial enlargement on MACE when their interaction was accounted for. Conclusion: AF and AFL were not associated with a higher risk of MACE, nor was atrial enlargement shown to modify the relationship between AF/AFL and MACE in patients who were hospitalized with COVID-19. Age remains to be a predictor of poor outcomes. Studies with a larger sample size would be needed to determine if there’s a significant relationship.