History Of Myocardial Infarction Research Articles

Uveitis as a Predictor for Myocardial Infarction in Patients with Behçet's Disease, Multi Centric Cohort Study from Aseer Region, Saudi Arabia

Introduction: Behçet's disease (BD) is a chronic, multisystem inflammatory disorder characterized by a diverse array of clinical manifestations, including recurrent oral and genital ulcers, ocular inflammation, skin lesions, and joint problems. Its presentation varies, requiring tailored diagnosis and management. Methods: Retrospective cohort study, though review of medical charts and data for patients who meet the diagnostic criteria for BD actively receiving care in rheumatology clinics. The primary objective was to investigate the correlation between uveitis and Myocardial infarction in this population. Results: This study included a total of 111 patients. Approximately 33% of the patients exhibited positive CRP levels. Approximately 10% (11 patients) of the subjects were diagnosed with uveitis. Notably, the majority of individuals with uveitis were males. Three patients with uveitis had arthritis, none of whom presented with gastrointestinal tract (GIT) Complaints. Remarkably, none of the patients diagnosed with uveitis had a documented history of myocardial infarction (MI). Conclusion: In our cohort, those with a history of MI did not have a documented history of uveitis. Larger, prospective studies are needed to evaluate the associations between MI and uveitis in a BD population.

Telomere length across the spectrum of metabolic health – an analysis from the LIPIDOGEN2015 study

IntroductionBackground: Telomere length is a cellular aging marker and correlates with various cardiovascular disease (CVD) risk factors. The current study assessed the association between obesity, metabolic syndrome (MetS), and telomere length.Material and methodsMaterial and methods: The LIPIDOGRAM&LIPIDOGEN2015 study was conducted in primary care in 2015-2016. Recruited patients to the LIPIDOGEN2015 cohort (n=1788) were a random subset of patients of the LIPIDOGRAM2015 (n=13,724) study. For the aims of this analysis, the recruited patients were divided into four groups based on the presence of MetS: healthy slim (HS), metabolically healthy obese (MHO), non-obese with MetS (NOMS), and metabolically unhealthy obese (MUO). Relative telomere length (RTL) was measured using quantitative polymerase chain reaction (qPCR).ResultsResults: 1516 patients (85%; females - 59.7%, mean age- 50.3 years) were included for final analyses. An increase in body mass index (BMI), waist circumference, prevalence of diabetes mellitus, hypertension, dyslipidemia, and history of myocardial infarction moving from HS to MUO were observed. MUO group exhibited the highest triglycerides and lowest high-density lipoprotein (HDL-C) levels. Univariable regression analyses indicated that NOMS (p=0.038) and MUO (p=0.003) were associated with significantly decreased RTL. After adjustment for age, gender, education, smoking, place of residence, and myocardial infarction, the association was no longer statistically significant.ConclusionsConclusions: Despite the lack of statistical significance in the multivariate analysis, the univariate results suggest that both MUO and NOMS phenotypes contribute to the shortening of telomere length. These results may also indicate that MetS, irrespectively on obesity occurrence, is responsible for the shortened lifespan.

Phosphocreatine in the treatment of chronic heart failure: Case report

Currently, there is a steady increase in the prevalence of chronic heart failure (CHF), as well as a high mortality rate associated with this condition, despite the implementation of rational pharmacotherapy. The use of quadrotherapy in clinical practice for the treatment of CHF contributes to the blocking of neurohumoral regulation by inhibiting the renin-angiotensin-aldosterone and sympathoadrenal systems, which leads to decrease in preand afterload and, respectively, to delayed and partial reverse remodeling of the heart chambers. However, these drugs don’t affect the energy metabolism of cardiomyocytes, which is still impaired in patients at the preclinical stage of CHF. In this regard, an important task of practical healthcare is the search for new schemes of a pathogenetic therapy of CHF. One of the promising directions is an adjuvant therapy, which is represented by phosphocreatine, a drug with a cardioprotective effect, proven in a large number of studies, which ensures the maintenance of myocardial energy metabolism. The use of phosphocreatin prevents further deterioration of the contractile function of the heart in patients with CHF, reduces the degree of damage to the cell membrane, improves microcirculation, and also has antiarrhythmic activity, which is especially significant in patients with a history of myocardial infarction. The drug not only improves the quality of life of patients by reducing the severity of symptoms, but also has been proven to increase myocardial contractility and reduce mortality. The purpose of the clinical case report is the description of adjuvant therapy results in a patient with CHF after using all pharmacotherapy reserves. The clinical case demonstrates the effectiveness of CHF treatment with phosphocreatine, confirmed by data from clinical, laboratory and instrumental examinations.

Phosphocreatine in the treatment of chronic heart failure: Case report

Currently, there is a steady increase in the prevalence of chronic heart failure (CHF), as well as a high mortality rate associated with this condition, despite the implementation of rational pharmacotherapy. The use of quadrotherapy in clinical practice for the treatment of CHF contributes to the blocking of neurohumoral regulation by inhibiting the renin-angiotensin-aldosterone and sympathoadrenal systems, which leads to decrease in preand afterload and, respectively, to delayed and partial reverse remodeling of the heart chambers. However, these drugs don’t affect the energy metabolism of cardiomyocytes, which is still impaired in patients at the preclinical stage of CHF. In this regard, an important task of practical healthcare is the search for new schemes of a pathogenetic therapy of CHF. One of the promising directions is an adjuvant therapy, which is represented by phosphocreatine, a drug with a cardioprotective effect, proven in a large number of studies, which ensures the maintenance of myocardial energy metabolism. The use of phosphocreatin prevents further deterioration of the contractile function of the heart in patients with CHF, reduces the degree of damage to the cell membrane, improves microcirculation, and also has antiarrhythmic activity, which is especially significant in patients with a history of myocardial infarction. The drug not only improves the quality of life of patients by reducing the severity of symptoms, but also has been proven to increase myocardial contractility and reduce mortality. The purpose of the clinical case report is the description of adjuvant therapy results in a patient with CHF after using all pharmacotherapy reserves. The clinical case demonstrates the effectiveness of CHF treatment with phosphocreatine, confirmed by data from clinical, laboratory and instrumental examinations.

PHARMACOLOGICAL STRATEGIES TO PREVENT CARDIOVASCULAR EVENTS IN HIGH-RISK PATIENTS

INTRODUCTION: Cardiovascular diseases (CVDs) remain the leading cause of global mortality, and high-risk patients, such as those with a history of myocardial infarction, diabetes, uncontrolled hypertension, or severe dyslipidemia, are especially vulnerable to adverse cardiovascular events. Pharmacological strategies aimed at preventing these events in high-risk patients are essential to reduce morbidity and mortality associated with CVDs. These strategies include the use of antiplatelet agents, statins, angiotensin-converting enzyme inhibitors (ACEIs), and beta-blockers, which have shown efficacy in the secondary prevention of events such as myocardial infarction and stroke. OBJECTIVES: Given the importance of this topic, this study aims to explore the most effective pharmacological strategies to prevent cardiovascular events in patients considered at high risk. The study aims to elucidate the main drugs used, their mechanisms of action, as well as the relevance of their clinical application for the reduction of fatal and non-fatal cardiovascular events in these patients. METHODOLOGY: The study was developed based on an integrative literature review, based on searches in the Virtual Health Library (VHL), PubMed and SciELO databases. The search terms used included: “Cardiovascular prevention”, “High-risk patients”, and “Pharmacological strategies”. Articles published in the last five years were selected to ensure the relevance and timeliness of the information. RESULTS: Pharmacological strategies to prevent cardiovascular events in high-risk patients include the use of antiplatelet agents such as aspirin, which reduces platelet aggregation and prevents arterial thrombosis. Statins, which reduce LDL cholesterol levels, have been shown to significantly reduce the risk of myocardial infarction and stroke. In addition, ACE inhibitors and beta-blockers have shown benefits in patients with heart failure and hypertension, reducing cardiovascular mortality. Individualizing treatment, considering the comorbidities and characteristics of each patient, is essential to optimize clinical results. CONCLUSION: Pharmacological strategies play a crucial role in the prevention of cardiovascular events in high-risk patients. The combination of medications such as antiplatelet agents, statins, ACE inhibitors and beta-blockers, when applied individually and according to clinical guidelines, can significantly reduce the incidence of serious cardiovascular events. Awareness of the importance of the correct use of these therapies and adherence to treatment are essential to improve the quality of life and increase the longevity of patients.

Patient characteristics and mortality trends among octogenarians with heart failure over two decades - a Danish nationwide study

Abstract Background Mortality rates among octogenarians with heart failure (HF) have changed little despite significant advancements in care over recent decades. Investigating the factors contributing to this trend may offer valuable insights for devising targeted management strategies for the oldest HF patients. Purpose We aimed to examine different patient characteristics associated with mortality among octogenarians with HF over the past 20 years. Methods From nationwide Danish healthcare registries, we included all patients with new-onset HF between 2001-2020 who were ≥ 80 years old at the time of diagnosis. The patients were categorized into 5-year calendar periods depending on the time of their diagnosis, the first period being between 2001-2005 and the last 2016-2020. The Kaplan-Meier estimator was used to assess the mortality risk. Mortality rates were examined with multivariable Cox regression models, comparing the first (reference) and the last calendar period and adjusting for predefined covariables. Results We included 47,754 octogenarian patients with new-onset HF, of whom 13,293 (51%) were diagnosed between 2001-2005 and 12,813 (49%) between 2016-2020. The distribution of males and females changed between the two calendar periods, with 5696 (43%) males in the first period and 6631 (52%) in the last period. The 3-year absolute mortality risk decreased by 8% [95% CI, 7.9-8.0] from 2001-2005 (64% [95% CI, 63.9-64.7]) to 2016-2020 (56% [95% CI, 55.3-56.7]) (p-value <0.001) (Figure 1). After adjustment for covariables, patients diagnosed in the last period exhibited a mortality hazard ratio (HR) of 0.94 [CI 95% 0.90-0.99] (p-value 0.02) compared to those diagnosed in the first period. An interaction was observed between the first and the last calendar periods among patients with a history of myocardial infarction and those aged <85 years. The survival rates improved over time for patients with a history of myocardial infarction (HR 0.80 [95% CI, 0.72-0.90], p-value for interaction<0.001), as well as for those aged between 80 and 85 years (HR 0.86 [95% CI, 0.80-0.91], p-value for interaction<0.001) (Figure 2). Conclusion Over two decades the mortality risk among octogenarians with HF has improved slightly, however it remains high. Patients with a history of myocardial infarction and those aged 80 to 85 years emerge as subgroups experiencing the most improved survival rates over time.3-year mortality riskMortality rates in selected subgroups

The effect of Trimetazidine on the left ventricular global longitudinal strain assessed by cardiac magnetic resonance in stable angina patients with previous myocardial infarction and left ventricular

Abstract Introduction Trimetazidine (TMZ) is an anti-ischemic metabolic agent that is indicated in adults as add-on therapy for the symptomatic treatment of patients with stable angina pectoris (SA). Global left ventricular (LV) systolic function is an important predictor of outcomes in patients after myocardial infarction (MI). Cardiac magnetic resonance (CMR) imaging has now evolved into a major tool for the evaluation of patients with LV dysfunction, providing precise measurements of ejection fraction (EF) and viability assessment but also now allowing assessment of global longitudinal strain (GLS) from standard cine CMR images. We hypothesized that the use of TMZ 80 mg as an anti-ischemic agent in patients with SA, history of MI, reduced EF and in the presence of viable myocardium may produce an early modification of GLS. Methods TRIM-AZ - was a non-interventional, prospective Azerbaijan study to analyze the capacity of short-term therapy with TMZ 80 mg on LV GLS evaluated by CMR in patients with previous MI. Patients with a confirmed diagnosis of heart failure (HF) with impaired LV systolic function and SA in the presence of viable myocardium were included. The treatment of all patients was optimized according to the latest ESC guidelines before entry in the study. Patients were randomized into two groups, one received TMZ 80 mg on top of guidelines directed medical therapies, and the other was the control group. A CMR as well as a transthoracic echography were performed for all patients at the inclusion visit and 8 weeks later. Results 52 patients were included in the study, 30 patients in the TMZ group and 22 in the control group,. At baseline, the mean age was 62±7 years , 63% were smokers, 60% hypertensive, 60% diabetics, 48% had a family history of MI, 12% had typical symptoms of SA while 88% had atypical form (e.g. like shortness of breath). All patients received baseline therapy with ARNI/ACE-i, SGLT2 inhibitors, beta-blockers, MRA, ASA, and statin. 8 weeks after the initiation of TMZ, there were no significant changes in LVEF assessed both by Echo and CMR (29,8%±3,2% vs 30,1%±3,5% by echo in TMZ group; 31,3%±2,7% vs 31,6%±2,7% by echo in the control group; 25,9%±3,1% vs 26,9±4,1% by CMR in TMZ group; 26,9%±2,1% vs 30,1%±2,3% by CMR in the control group), however GLS was significantly improved in TMZ group (-9,9%±1,1% to -12,7%±1,2%, p=0,00), but not in control group (-9,3%±1,3% vs -10,3%±1,4% p=0,3). No adverse event related to TMZ use was reported during the study. Conclusion These findings suggest that the use of trimetazidine in patients with stable angina , previous MI and heart failure in the presence of viable myocardium could improve the left ventricular global longitudinal strain assessed by CMR.

Temporal trends and prognostic significance of heart failure after acute myocardial infarction

Abstract Background There are limited and conflicting data regarding the incidence and prognostic impact of in-hospital heart failure (HF) complicating acute myocardial infarction (MI). The aim of this study was to examine temporal trends in the incidence and outcomes of systolic HF after acute MI in a large national cohort in South Korea. Methods The nationwide Korea Acute Myocardial Infarction Registry records baseline characteristics, treatments, and outcome of consecutive patients with acute MI admitted to hospitals capable of primary percutaneous coronary intervention (PCI) in South Korea. Systolic HF was defined as an ejection fraction ≤40% by echocardiography at admission. This study included 68,123 patients admitted for index acute MI between 2005 and 2020 (phase 1: 2005-2007, n=14,735; phase 2: 2008-2011, n=24,656; phase 3: 2012-2015, n=13,104; phase 4: 2016-2020, n=15,628). Results In all patients, the incidence of HF declined from 19.4% in phase 1 to 14.1% in phase 4 (p<0.001). This decrease was more pronounced in patients with ST-segment elevation MI (STEMI, from 20.9% to 15.8%) compared to those with non-ST-segment elevation MI (NSTEMI, from 17.9% to 12.3%). The use of PCI and of statins at discharge increased from 86% to 91.2% and from 75.1% to 92.2%, respectively (p<0.001 for all). Previous history of MI increased from 8.4% to 10.4% (p<0.001) whereas previous history of HF and stroke decreased from 6.3% to 1.3% and from 17.4% to 6.4%, respectively (p<0.001). The median symptom-to-door time decreased from 3.5 hours to 2.1 hours for STEMI and from 6.3 hours to 5.5 hours for NSTEMI (p<0.001). The median door-to-balloon time decreased from 107 min to 64 min for STEMI and from 26 hours to 14 hours for NSTEMI (p<0.001). The in-hospital and 12-month mortality rates for all patients decreased over the years from 5.0% to 3.3% and from 7.6% to 6.1%, respectively (p<0.001). However, in those who developed HF during the index MI, no significant declining trends were observed in in-hospital mortality (phase 1: 8.8%, phase 2: 7.95%, phase 3: 8.3%, phase 4: 7.3%, p=0.123) and 12-month mortality (phase 1: 15.4%, phase 2: 12.6%, phase 3: 19.4%, phase 4: 15.2%, p=0.270). Independent predictors of developing in-hospital HF were age >75 years, body mass index <18.5 kg/m2, symptom-to-door and door-to-balloon times, systolic blood pressure <100 mmHg at presentation, heart rate >90 min at presentation, presence of atrial fibrillation or diabetes, and previous history of MI, HF or stroke. Conclusions A marked reduction was found in the incidence of HF after acute MI between 2005 and 2020 in South Korea. However, in-hospital and 12-month mortality rates in HF patients remain unchanged, warranting intensive post-MI management with more aggressive efforts for secondary prevention.

Awareness of personal cardiovascular risk among the adults with an elevated body mass index in a very high-risk country

Abstract Background An elevated body mass index (BMI) is a risk factor for cardiovascular diseases (CVD). The awareness of personal cardiovascular risk (pCVR) may vary in different populations, thus influencing health behaviours and cardiovascular prevention. Purpose To analyse the awareness of pCVR among the adults with an elevated BMI, along with sociodemographic characteristics and cardiovascular risk factors (CRF) possibly associated with the lack of pCVR awareness in a very high-risk country. Methods The pilot study included a convenient sample of 1054 adults. Those with an elevated BMI (≥25 kg/m2) were divided into two groups depending on their awareness of pCVR. The groups were compared according to the sociodemographic characteristics (age, gender, and education) and CRF (BMI, hypertension, dyslipidaemia, diabetes mellitus, smoking, physical inactivity, feeling of frequent exposure to stress, previous myocardial infarction (MI), and family history for CVD). The data were collected by voluntary filling out a survey with multiple-choice questions from April 1st to June 30th, 2022. Results Out of the total number, about half of the participants had an elevated BMI (N=549, 52%). Most of them were aware of their pCVR (69% vs 31%, p<0.01). Those unaware of pCVR were younger (44±13 vs 51±14, p<0.05), mostly females (56% vs 47%, p<0.05), with high education (61% vs 51% with more than high school, p<0.05). The groups had similar average BMI (28±3 kg/m2 vs 29±3 kg/m2, p>0.05), but the participants unaware of pCVR were more frequently overweight than obese (82% vs 64% with BMI ≥25 kg/m2 and <30 kg/m2, p<0.01). They had significantly lower frequencies of hypertension (15% vs 53%, p<0.01), dyslipidaemia (23% vs 46%, p<0.01), diabetes mellitus (2% vs 14%, p<0.01), smoking (50% vs 59%, p<0.05), previous MI (3% vs 26%, p<0.01), and family history for CVD (62% vs 82%, p<0.01). However, the majority in both groups reported physical inactivity (60% vs 64%, p>0.05) and a feeling of frequent stress exposure (70% vs 71%, p>0.05). The participants unaware of pCVR less frequently had over three modifiable CRF (12% vs 37%, p<0.01). Conclusion Most of the adults with an elevated BMI in a very high-risk country are aware of pCVR, usually because of obesity, multiple additional modifiable CRF, previous MI, or family history of CVD. Still, a notable proportion of the adults with an elevated BMI in a very high-risk country is unaware of pCVR, which is associated with younger age, female gender, high education, overweight, fewer additional modifiable CRF, and the absence of previous MI or family history for CVD. This subpopulation should be considered as a target for timely health education to raise the awareness of pCVR. Increasing physical activity through motivational campaigns and developing programmes for stress relief would be important for CVD prevention among the adults with an elevated BMI, independently of pCVR awareness.

Residual post-infarct myocardial inflammation detected by 68Ga-DOTATATE PET/MRI predicts long-term adverse cardiac remodelling

Abstract Background Maladaptive inflammatory responses are associated with adverse cardiac remodelling after myocardial infarction (MI), but clinical methods for detecting residual myocardial inflammation post-MI are lacking. Purpose To investigate somatostatin receptor subtype 2 (SST2) positron emission tomography (PET)/magnetic resonance imaging (MRI) using 68Ga-DOTATATE after MI. Methods In a prospective observational cohort study, infarct-related myocardial inflammation detected by 68Ga-DOTATATE PET at 2wk and 3mo post-MI was compared with MRI characteristics including left ventricular (LV) volumetric changes at 1yr, as well circulating immune cell phenotyping and serum proteomic markers. Patients with a prior history of MI or heart failure were excluded. Histological SST2 expression was assessed in myocardial biopsies. Results 38 participants (mean age 60 [SD 9] years; 84% male) with recent MI were enrolled, of whom 58% had an ST-segment elevation MI. Mean peak Troponin I was 16,665 (range 408 to >25,000) ng/L and mean post-infarct LV ejection fraction was 51 (SD 9) %. 68Ga-DOTATATE maximum standardized uptake values (SUVmax) at 10 (SD 4) days accurately localised infarcted myocardial segments defined by late-gadolinium enhancement MRI (LGE; Fig. 1); were 14.2% higher in akinetic/hypokinetic vs. normo-kinetic segments (p<0.0001); and were correlated both with peak segmental strain (r=0.47, p=0.003) and segmental T1 values (r=0.51, p=0.02). Mean infarct SUVmax was 19.7% lower on repeat PET/MRI after a mean 102 (SD 22) days (p<0.0001), and this change was in keeping with parallel reductions in T2-weighted oedema signal on MRI and serum biomarkers of cardiac injury and systemic inflammation. Residual inflammation assessed by mean infarct SUVmax at 3mo was correlated with ΔLV indexed end-diastolic volume at 369 (SD 14) days, after adjustment for baseline infarct size and other clinical variables (p=0.038). The 3mo:2wk ratio of mean infarct SUVmax was an even stronger predictor of adverse myocardial remodelling (p=0.0025). Circulating SST2+ classical monocytes were correlated with infarct 68Ga-DOTATATE signal (r=0.47, p=0.02), and SST2 was co-expressed with CD68+ macrophages in inflamed myocardial specimens of patients with recent MI and ischaemic heart failure. After statistical feature selection and multiple comparisons adjustments, among the blood markers associated with 3mo:2wk infarct SUVmax was CCL25, a chemokine involved in macrophage recruitment which has been implicated in adverse cardiac remodelling. Conclusions Here, in the first prospective clinical study of serial SST2 PET/MRI after MI, we show that 68Ga-DOTATATE can identify and track resolving infarct-related myocardial inflammation. Moreover, residual inflammation detected by 68Ga-DOTATATE is associated with long-term adverse myocardial remodelling and could provide a potential future imaging biomarker to help stratify high-risk patients for emerging immunomodulatory therapies.Figure 1.68Ga-DOTATATE PET-MRI after MI

Association of weekday-to-weekend sleep duration pattern with myocardial infarction: analysis of the NHANES 2017- 2020

Abstract Background Short sleep is linked to increased acute myocardial infarction (MI) risk.However, the association of weekend-to-weekday sleep patterns with MI in a nationally representative population remains unknown. The goal is to investigate how weekday and weekend sleep durations affect myocardial infarction (MI) in the general population, and if longer weekend sleep can offset insufficient weekday sleep's effects. Methods A cross-sectional study utilized data from the 2017-2020 NHANES to examine the relationship between sleep patterns and MI. Participants self-reported their average sleep durations on weekdays (1) and weekends (2), along with the calculated weekend-to-weekday sleep duration ratio (SDR) (3). Logistic regression models, adjusting for various factors, including demographics and comorbidities, were employed to analyze the association. Those with SDR > 1 had more weekend sleep, while an SDR = 1 indicated equal sleep durations. Results The study involved 9,205 adult participants, with a mean ± SD age of 68.8 ± 10.8 years and 30.7% being female. Among them, 4.65% (428 patients) had a history of MI. The mean ± SD of weekday and weekend sleep hours was 7.6 ± 1.7 and 8.3 ± 1.8 hours, respectively. For weekday sleep duration, after univariate analysis, individuals compared to those in Q1 were statistically significant 0.72 times less likely in Q2 and 1.4 times more likely in Q4 to experience MI . While MI was 0.76 times less likely to occur among participants in Q3, it was not statistically significant (95% CI Q2: 0.54, 0.96; Q4: 1.05, 1.76; Q3:0.57, 1.00). After adjusting, participants only in Q3 were statistically significant 0.71 times less likely to develop MI.(Q3: 95% CI 0.51, 0.99). For weekend sleep duration, the univariate analysis showed that individuals in Q2, Q3, and Q4 were significantly less likely to experience MI (OR = 0.63, 0.67, and 0.69; 95% CIs: 0.48-0.82, 0.51-0.87, 0.53-0.90, respectively) After adjusting, only participants in Q2 were statistically significant less likely to develop MI (OR = 0.71; 95% CI 0.52 - 0.96). For the weekend-to-weekday sleep duration ratio (SDR), after univariate analysis, individuals were statistically significant 0.54 times less likely, and 1.5 times more likely to experience MI in those whose SDR is more than 1, and those whose SDR equals 1, respectively (95% CI SDR > 1: 1.14, 1.98; SDR = 1: 0.39, 0.72). After adjusting, participants with SDR more than 1 were statistically significant 0.69 times less likely to develop MI. Conclusions Moderate sleep durations on weekdays (in Q3), weekends (in Q2), along with SDR more than 1, were negatively linked with MI in a general population. This implies that sleep durations on both weekends and weekdays have comparable associations with MI. Additionally, full recovery sleep on weekends following sleep-deprived weekdays, might reduce MI risk. Further studies are needed to explore impact of weekend and weekday sleep patterns on MI.Histogram and Margins plotTable of Odd ratios

Score-2 in heavy smokers: are we underestimating the risk?

Abstract Background The shared diagnostic decision-making process in patients with atypical chest pain is challenging, especially when functional tests are negative. SCORE2 (1) can help in making decisions. In this score, the risk is assessed based on geographical origin, age, sex, current smoking, systolic blood pressure, cholesterol values. However, it does not take into account the quantity of cigarettes smoked but only the current binary value, yes or no. In our study we wanted to evaluate the impact of smoking on prognosis, considering the number of cigarettes smoked and in particular focusing on heavy smokers. Methods In the last 15 years we evaluated 3,588 outpatients aged >35 years (average 64±9, women 55%) for the presence of stable chest pain. We excluded 290 patients who had ECG changes compatible with recent ischemia, history of myocardial infarction or any other major cardiovascular event, evidence of heart failure, left ventricular dysfunction, or cardiomyopathies. In the other 3,298 cases we applied the traditional classification of typical, atypical angina and non-anginal pain. A functional test was performed in all patients. In 2,774 patients with atypical chest pain and negative functional test we evaluated the extent of cardiovascular risk based on SCORE2 and the number of cigarettes currently smoked. One year follow-up was carried out to evaluate vital status and any fatal and non-fatal cardiovascular events. Results Table 1 shows the events in patients classified according to the degree of cardiovascular risk of SCORE2 and in heavy smokers (≥ 20 cigarettes per day) aged <70 years as a cathegory in itself. In moderate smokers (<20 cigarettes/day) of any age, the risk was considered binary as in the conventional assessment. Tables 2 and 3 show the risk stratification in male and female patients. SCORE2 is unable to intercept the extremely high risk of heavy smokers aged <70 years. This happens both in males, considered at moderate risk in 76% of cases but with a rate of fatal events of 2.4% and as many non-fatal events, both in women with a risk considered moderate in 80% of cases but with a 12% rate of fatal events (as seen in Table 1). Conclusions SCORE2 does not consider the quantity of cigarettes smoked per day, so if we rely on it heavy smokers seem to have a moderate risk. On the contrary, based on our analysis, they all have an extremely high risk, regardless of other risk factors, and in any case higher than non-smoking or moderately smoking patients. Especially heavy smoking women aged <70 years with atypical chest pain and negative functional tests have an extreme risk of fatal cardiac events (12% at one year). Probably these patients (male and female), regardless of the outcome of functional tests, should be sent for an anatomical evaluation for the detection of high-risk stenosis, as well as firmly urged to improve lifestyles and treat risk factors .

Higher systolic blood pressure in left not right upper limb is associated with all-cause mortality risk in a community-based population

Abstract Background and Purpose Previous studies have shown that elevated inter-arm systolic blood pressure difference (SBPD) is a valuable indicator for assessing the risk of all-cause mortality. However, no research currently reports that the different impact of higher SBP in which upper limb on all-cause mortality risk. This study investigates which side of the upper limbs has a higher SBP that is more associated with all-cause mortality risk in a community population. Methods The subjects were from the a Atherosclerosis Cohort of the Department of Cardiology of our University First Hospital from 2012 to 2021, and those with missing data of brachial-ankle pulse wave velocity and a history of myocardial infarction or stroke in the baseline survey were excluded. The endpoint was defined as all-cause mortality. SBPD was defined as the difference between the systolic blood pressure of the right arm minus the systolic blood pressure of the left arm by the noninvasive arteriosclerosis detection device BP-203RPEIII (Omron, Japan). SBPD was categorized into four groups: 0-10 mmHg (right arm higher <10mmHg), ≥ 10 mmHg (right arm higher ≥ 10 mmHg ), -10 to < 0 mmHg (left arm higher ≤10 mmHg), and < -10 mmHg (left higher > 10mmHg). The relationship between SBPD and all-cause mortality risk was determined by multivariable Cox proportional hazards regression after adjusting for covariates (age, body mass index, gender, current smoking, current drinking, estimated glomerular filtration rate, diabetes, hypoglycemic treatment, total cholesterol, triglycerides, lipid-lowering treatment, and antihypertensive treatment). Results Totally, 8628 participants were included, with a mean age of 56.58 ± 8.97 years old, and 64.51% (5566) were female. Among them, 380 (4.40%) had an SBPD ≥ 10 mmHg, and 409 (4.74%) had an SBPD < -10 mmHg. During a median follow-up of 9.87 years, 442 cases of all-cause mortality (5.19%) occurred. The Kaplan-Meier curve suggested that the greater the difference in SBPD, the higher the cumulative risk of all-cause mortality. The Log-rank test showed a significant statistical difference (P= 0.0115). Compared to right arm higher <10mmHg group, the risk of all-cause mortality was not significantly elevated in right arm higher ≥ 10 mmHg (adjusted HR=1.17, 95% CI: 0.74-1.84, P=0.507) or left arm higher ≤10 mmHg group (adjusted HR=0.90, 95%CI: 0.74-1.11, P=0.329). However, the risk of all-cause mortality significantly increased by 59% in left higher > 10mmHg Group (adjusted HR=1.59, 95% CI: 1.10-2.30, P=0.013). The results remained significant after adjusting for peripheral right arm SBP (adjusted HR=1.56, 95% CI: 1.08-2.24, P=0.018). Conclusion This study found that a higher SBP in the left arm is associated with a higher risk of all-cause mortality in a Beijing community-based population, and they should be monitored and intervened more intensively.Hazard Ratios for all-cause mortalitySurvival curves for SBPD groups

Inflammation and cholesterol associated residual cardiovascular risk and its dependence on chronic kidney disease in statin treated patients with coronary artery disease

Abstract Background/Aim In statin-treated patients with chronic coronary syndrome (CCS) there is uncertainty about the relative contribution of inflammation and dyslipidaemia to residual cardiovascular risk, particularly in the presence of chronic kidney disease. We thus aimed to evaluate high sensitive C-reactive protein (hsCRP) and low density lipoprotein-cholesterol (LDL-C) as predictors of future events in these patients, stratified by estimated glomerular filtration rate (eGFR). Methods We identified patients with CCS on stable statin treatment from a contemporary all-comers cohort recruited at a large tertiary care center in Germany. We excluded patients with active malignancy, infectious disease or in a post-operative state. Cox regression for major adverse cardiovascular events (MACE, composite of cardiovascular death, myocardial infarction, stroke) and all-cause death was performed adjusting for age, sex, arterial hypertension, diabetes mellitus, active smoking, body mass index and change in the intensity of statin therapy at discharge, with log(hsCRP) or LDL-C as the exposure variables. Interaction with eGFR (< vs. ≥ 60 ml/min/1.73m²) was investigated. Results 937 patients with CCS (mean age 71.1 years, 78.7% male, median hsCRP 2.0 mg/L, median LDL-C 73.0 mg/dl, median eGFR 71.3 ml/min/1.73m²) were followed-up over 4 years, with 101 cases of MACE and 171 cases of all-cause death recorded. The hazard ratios (HR) for MACE per standard deviation (SD) increase were as follows: log(hsCRP) 1.08 (95% confidence interval (CI) 0.87, 1.34; p = 0.48), LDL-C 1.10 (95% CI 0.89, 1.35; p = 0.37). For all-cause death the HRs for log(hsCRP) and LDL-C were 1.60 (95% CI 1.36, 1.88; p <0.001) and 0.88 (95% CI 0.74, 1.04; p = 0.14), respectively. Kaplan-Meier curves stratifying the cohort by median values of LDL-C and hsCRP consistently demonstrated a significantly higher risk of death in the subgroups with elevated hsCRP (Figure 1). Contrastingly for LDL-C, levels below (vs. above) the median were associated with a higher mortality rate. This is in part a reflection of a higher prevalence of high-intensity statin therapy in this subgroup (21.0 vs. 14.2%, p = 0.0081), in turn a reflection of greater severity of coronary artery disease (history of myocardial infarction 43.9 vs. 31.9%, p <0.001). Further confounding by unadjusted for diseases with a catabolic metabolism is possible. Interaction analysis with eGFR revealed that log(hsCRP) was predictive of all-cause mortality both in the presence and absence of chronic kidney disease, whilst lower LDL-C values were found to be predictive only at eGFR <60 ml/min/1.73m² (Table 1). Conclusion Residual inflammation as measured by hsCRP predicts all-cause mortality in statin-treated patients with CCS in this contemporary all-comers cohort, both in the presence and absence of chronic kidney disease. The predictive utility of LDL-C is limited, likely due to confounding e.g. by the intensity of lipid lowering medication.Kaplan-Meier curves (all-cause death)Interaction analysis with eGFR

The trajectory of self-care over a 12-month period in patients with heart failure, comparing those with consistently good and poor self-care

Abstract Background Self-care behaviour plays a pivotal role in enhancing the quality of life for patients with heart failure (HF) and reducing mortality and morbidity rates, but many patients struggle with suboptimal self-care behaviours. It is crucial to understand the factors influencing long-term self-care management. Purpose To assess the trajectory of self-care over a 12-month period and assess differences between patients who have constantly good self-care over a 12-month period compared to constantly poor self-care. Method This study use data from a randomised controlled intervention study, called the HF-Wii study. We included patients who had complete data on self-care during on baseline, 3, 6 and 12 months. Self-care was measured with the European Heart Failure Self-care Behaviour scale (EHFSBs). A threshold score of equal or higher than 70 was used to define self-care behaviour as good and a score lower than 70 as poor self-care. Based on literature, the following characteristics (collected from questionnaires and medical records at baseline) were considered in the analysis: age, sex, marital status, education, history of myocardial infarction, duration of HF, New York Heart Association (NYHA) functional class, LVEF, comorbidity. Other factors assessed were Health-related Quality of Life (HrQoL, Minnesota living with HF questionnaire), depressive symptoms (Hospital Anxiety and Depression scale), cognition (Montreal Cognitive Assessment), sleep (Minimal Insomnia Symptom Scale) and level of HF knowledge (Dutch HF knowledge scale). Logistic regression was performed with backwards elimination of the factors considered associated with the differences between patients who have constantly good self-care at baseline, 3, 6 and 12 months compared to constantly poor self-care. Results In total, 407 patients were included in this study. At baseline, the mean self-care was 65±21, with 41% of the patients (n=245) performing good self-care. In total, 126 patients had a constantly good self-care over 12 month (31%), 120 patients had a constantly bad self-care over 12 months (30%) and 161 (39%) fluctuated in their self-care (Figure). In the multivariate analysis, patients that had continuously good self-care over 12-months were of older age (68±10 vs. 64±12, odds ratio (OR) 1.061, P-value<0.001), had higher HF knowledge (score 13±2 vs. 12±2, OR 1.439, P-value<0.001) and had higher HrQoL (score 28±20 vs 36±22, OR 0.984, P-value=0.022). compared to patients with consistently poor self-care. The variance was explained by 20%. Conclusion Younger patients with HF tend to struggle with consistent self-care over a year, underscoring the necessity for tailored interventions for this group. Conversely, patients with greater HF knowledge and higher HrQoL maintained good self-care habits.

The prognostic role of left atrial mechanics but not left ventricular function in functional mitral regurgitation

Abstract Introduction When atrial dilatation or ventricular dysfunction underline the development of functional mitral regurgitation (FMR), FMR has been categorized into ventricular and atrial type. Due to limited evidence of surgical correction, majority of patients with FMR were left untreated. We therefore investigated the clinical outcomes related to different phenotypes of FMR and the prognostic factors. Methods Subjects with severe or moderate to severe FMR, diagnosed by transthoracic echocardiography were eligible for this analysis. Three phenotypes of FMR, including atrial, ischemic and ventricular FMR were then classified. The left atrial (LA) strain and left ventricular (LV) global longitudinal strain (GLS) were measured. The study population were followed for a year. Results A total of 298 subjects (mean age 72.3 ± 14.0 years; 68% male) were enrolled, including 165 subjects of ischemic-type FMR (iFMR), 77 subjects of non-ischemic ventricular-type FMR (vFMR), and 56 subjects of atrial-type FMR (aFMR). The baseline characteristics, including age, gender, demography, and morbidities were similar between three groups, but aFMR group had higher LA reservoir strain and better LV GLS. During a mean follow-up duration of 283 days, there were 50 (17%) cases died within the first year. The Kaplan Meier curve analysis showed similar survival rate between three phenotypes of FMR. Body mass index (BMI), systolic blood pressure, diastolic blood pressure, history of myocardial infarction (MI), RV dysfunction, and a lower LA reservoir strain, but not LV GLS were crudely related to one-year mortality. In the multivariable Cox proportional regression analysis, LA reservoir strain was independently predictive of mortality (Hazard ratio for 1% increase and 95% confidence intervals: 0.943, 0.895-0.994). Conclusions Patients with aFMR also have despaired clinical outcomes as patients with vFMR or iFMR. LA reservoir function but not LV systolic function was predictive of worse clinical outcomes. The results may encourage the transcatheter therapy, approved for ventricular-type FMR, for the treatment of aFMR.Kaplan Meier curve analysisMultivariable CPH regression model

Atrial and ventricular mitral regurgitation in the general population

Abstract Background Functional mitral valve regurgitation (FMR) is the result of two concurrent pathomechanisms: (1) the dilatation of mitral valve annulus (atrial) or (2) remodelling of the left ventricle (ventricular) in the absence of relevant leaflet degeneration¹. Even though FMR has been reported to be the most common cause of relevant MR², there is no general accepted definition of the two subtypes, nor are there population-based data regarding their prevalence, distribution and risk profiles¹. Purpose We aimed to evaluate the prevalence of FMR and to provide an in-depth characterisation of the subtypes aFMR and vFMR in the general population. Methods The study included the first 10,000 participants of the population-based Hamburg City Health Study enrolled between 2016 and 2019. Of these, 8.543 echocardiographic samples were available for analysis. Mitral valve was assessed by two independent investigators. Isolated degenerative MRs as determined by valve mobility (prolapse or restrictive) were excluded. FMR was classified as ventricular when fulfilling one of the following criteria: history of myocardial infarction or coronary artery disease, left ventricular ejection fraction (LVEF) ≤ 40%, restrictive leaflet, tenting area ≥ 150 mm² or coaptation depth ≥ 10 mm. All FMR with LVEF > 55% were classified as atrial. Results After excluding the samples with an insufficient image quality or missing data and re-assessment by the second investigator, 216 of 282 participants with a relevant MR (i.e. moderate or severe) remained (2,6% of the total cohort, see figure 1). In the next step, 153 participants were classified as pure FMR (68.9%), the remaining were mainly functional with minor degenerative features. A total of 31 (14.4%) MRs were classified as vFMR, the remaining 185 participants had an aFMR. Female gender was significantly more common in the aFMR cohort. The remaining demographic variables (age, body mass index) as well as established cardiovascular risk factors (i.e., diabetes, smoking, hypertension) were comparable between the vFMR and aFMR cohort. However, vFMR patients had significantly higher levels of NT-proBNP or NHYA state and presented more frequently with an atrial fibrillation (see figure 2). LVEF and LV stroke volume, TAPSE, left atrial ejection fraction and E/A ratio as a parameter of diastolic dysfunction were lower in the vFMR cohort whereas tenting area and left atrial endsystolic volume was significantly increased. Conclusion In our population-based study, aFMR was found to be the predominant subtype of FMR. The established cardiovascular risk factors were comparable in the vFMR and aFMR cohort. Echocardiographic variables differed significantly and indicate more advanced heart failure and LV remodelling in the vFMR cohort. Further categorization of FMR, in particular regarding the prognostic impact and long-term outcomes, is strongly warranted to allow a clinically relevant definition of aFMR and vFMR.Figure 1:Overview of sample sizeFigure 2:Baseline characteristics

Differences in left ventricular contraction in left bundle branch block with preserved and reduced ejection fraction: an evaluation using 2-dimensional speckle tracking echocardiography

Abstract Background Left ventricular (LV) contraction in left bundle branch block (LBBB) is characterized by early septal contraction and delayed contraction of the lateral wall, but the process may differ depending on myocardial contractility in addition to the degree of conduction block. Purpose This study aimed to evaluate LV contraction in patients with LBBB by analysis of longitudinal strain (LS) and to compare it between patients with preserved LV ejection fraction (pEF: EF>50%) and reduced LV EF (rEF: EF<40%). Methods We studied 87 patients with LBBB. Fifty had pEF (EF 59±7%) with a mean QRS duration of 144±12ms, and 38 had rEF (EF: 29±4%) with a mean QRS duration of 147±12ms (p=0.32 vs. pEF). We also studied 43 patients without conduction block (Narrow-QRS; pEF, n=23; rEF, n=20). Patients with a heart rate less than 60 or greater than 80 beats/min during echocardiography or with a history of myocardial infarction were excluded. Three standard apical images were recorded, and the LS of one heartbeat starting at the beginning of the QRS was evaluated in 18 LV segments. When the strain waveform showed a negative peak during the pre-ejection period, it was identified as early systolic contraction (ESC), and the first negative peak that appeared after aortic valve opening (AVO) was identified as late systolic contraction (LSC). The time from the beginning of QRS to the peak of the LSC (Q-Peak) and the strain value at the end of the QRS were measured in each segment. Results In patients with LBBB, the septum contracted early, and ESC was seen mainly in the early contracted area. The lateral wall contraction was delayed, and the difference between the maximum and minimum Q-Peak was greater than the Narrow-QRS in the same EF category. Patients with rEF and LBBB had a larger number of segments with ESC and a smaller minimum Q-Peak than those with pEF. The difference between the maximum and minimum Q-Peak was greater for patients with rEF than for patients with pEF. Conclusions Although patients with LBBB had significant dyssynchrony due to conduction block even those with pEF, LV contractile properties were altered in patients with rEF and associated with further increased dyssynchrony.

Beta-blocker use and outcomes in patients with heart failure and mildly reduced and preserved ejection fraction

Abstract Background Concerns have been raised about the appropriateness of use and safety of beta-blockers (BBs) in patients with heart failure and mildly reduced (HFmrEF) and preserved ejection fraction (HFpEF). However, randomized trial evidence is still lacking. Purpose To perform an observational analysis of the association between BB use and clinical outcomes in a large dataset of patients with HFmrEF and HFpEF. Methods We pooled individual patient data from four large HFmrEF/HFpEF trials (I-Preserve, TOPCAT, PARAGON-HF, and DELIVER). The associations between baseline BB use and outcomes were analyzed. The primary outcome was the composite of cardiovascular death or HF hospitalization. Results Among the 16,951 patients included, the mean left ventricular ejection fraction (LVEF) was 56.8%, and 13,400 (79.1%) had HFpEF (LVEF ≥50%). Overall, 12,812 patients (75.6%) received a BB. The median bisoprolol-equivalent dose of BB was 5.0 (Q1-Q3: 2.5-5.0) mg with BB continuation rates of 95.1% at 1 year and 93.1% at 2 years (in patients who survived more than 1 and 2 years, respectively). Overall, the hazard ratio (HR) for the primary outcome did not differ between BB users and non-users (HR: 0.98 [95% CI: 0.91-1.05]) but among patients with HFmrEF, BB users had a lower HR (0.84 [95% CI 0.71-0.98]), whereas in HFpEF the HR was similar BB users and non-users (0.99 [95% CI 0.92-1.08]). However, after comprehensive adjustment for known prognostic variables, including NT-proBNP, BB use was associated with a better outcome in the overall cohort (HR 0.81 [0.74-0.88]), and this association was maintained across the range of LVEF (Figure 1). In subgroup analyses, the risk of the primary outcome was similar in BB users and non-users with or without a history of myocardial infarction, with or without a history of hypertension, or with or without a baseline heart rate <70 bpm. By contrast, a better outcome with BB use was seen in patients with atrial fibrillation compared to those without atrial fibrillation (Figure 2). Conclusions Although this is an observational analysis of non-randomized treatment, there was no suggestion that BB use was associated with worse HF outcomes even after extensive adjustment for other prognostic variables. Figure Legends Figure 1. Association between beta-blocker use and outcomes across the range of LVEF. Risk in beta-blocker users versus non-users is shown as an adjusted continuous hazard ratio Figure 2. Association between beta-blocker use and non-use in the overall population and clinically relevant patient subgroups, shown as an adjusted hazard ratio (HR). The outcome analyzed was the composite of CV death or HF hospitalization (primary outcome)Figure 1Figure 2

Incremental role of Cardio-Ankle Vascular Index in predicting ischemic threshold in patients with suspected coronary artery disease

Abstract Background The Cardio-Ankle Vascular Index (CAVI) quantifies arterial stiffness and has emerged as a potential biomarker for cardiovascular disease and its associated risk factors. This study explores the prognostic utility of CAVI in predicting myocardial ischemia in patients with suspected coronary artery disease (CAD). Additionally, it examines the relationship between global longitudinal strain (GLS) and the wall motion score index (WMSI) during both rest and stress echocardiography. Methods We conducted a retrospective analysis of patients with suspected CAD who underwent CAVI measurement and stress echocardiography within a three-month window. Coronary angiography was utilized to evaluate anatomical stenosis (>50%). We used multivariate analysis to identify predictors of the ischemic threshold. Results In our cohort of 127 patients (average age 61.4 ± 9.1, 78% male), the prevalence of hypertension, dyslipidemia, and diabetes was 76%, 68% and 47% of patients, respectively. Prior coronary intervention and a history of myocardial infarction were showed significant prevalence at 33% and 9%, respectively. CAD distribution included absence in 15%, left main (LM) disease in 8%, proximal left anterior descending (LAD) artery disease in 38%, mid-to-distal LAD disease in 50%, left circumflex artery disease in 46%, and right coronary artery disease in 57%. A robust correlation between GLS and WMSI was observed both at rest and during peak stress (r=0.68 and r=0.57, p<0.001, respectively). High CAVI (≥8.5), resting GLS in the LAD(<-15.5%), and peak GLS during stress (<-15.3%) emerged as significant ischemic threshold predictors in multivariate analysis (AUC = 0.82, p<0.0001). Conclusion The correlation between WMSI and GLS provides valuable insights into cardiac mechanics. These findings underscore the clinical relevance of incorporating CAVI, GLS, and WMSI into routine assessments for patients with suspected CAD to enhance prognostic stratification.ROC for final predictive model