Hospitalization For Revascularization Research Articles

Association of lipid target achievement and cardiovascular outcomes following statin initiation: a population-based cohort study

Abstract Introduction Non-high density lipoprotein cholesterol (non-HDL-C) is increasingly incorporated into clinical practice guidelines along with low density lipoprotein cholesterol (LDL-C) to guide lipid-lowering therapy decisions. We aimed to examine patterns of LDL-C and non-HDL-C levels after statin initiation for primary prevention of cardiovascular disease (CVD), and their association with incident CV events. Methods We conducted a population-based cohort study of Ontario, Canada residents age ≥66 years who initiated a statin for primary prevention between January 1, 2012 and December 31, 2019. For those surviving 1-year after statin initiation, we determined the proportion with a lipid panel in the 1-year period after a statin was started. For those with a lipid panel, we used the lipid panel closest to the end of the 1-year period to categorize individuals based on the LDL-C and non-HDL-C thresholds in the 2021 Canadian Cardiovascular Society dyslipidemia guidelines (Table 1). We stratified by diabetes/chronic kidney disease (CKD) status. We evaluated the association between LDL-C/non-HDL-C category and a composite of all-cause mortality or hospitalization for myocardial infarction, stroke or revascularization (primary outcome). We also investigated the association between each category and each component of the primary outcome. The index date was the 365 days after a statin was initiated and follow-up was until December 31, 2020. We used a cause-specific hazards model for analysis, adjusted for clinical and sociodemographic confounders. Results Our cohort comprised 173,127 people. In the 1-year period after statin initiation, 72% of people had a follow-up lipid panel performed. Median follow-up after that was 2.5 years. Compared with those meeting both LDL-C and non-HDL-C targets, being above both targets was associated with an increased rate of the primary outcome for people without diabetes/CKD (HR 1.10, 95% CI 1.05 to 1.15) and those with diabetes/CKD (HR 1.16, 95% CI 1.09 to 1.23). Being at LDL-C target but above non-HDL-C target was associated with an increased rate of the primary outcome for people with diabetes/CKD (HR 1.16, 95% CI 1.03 to 1.30) but not for those without diabetes/CKD (HR 1.05, 95% CI 0.93 to 1.17). Conclusions In this population-based cohort, having an LDL-C and non-HDL-C above guideline-recommended targets after statin initiation was associated with an increased rate of adverse outcomes. These findings support the residual risk associated with incompletely controlled LDL-C or non-HDL-C levels after initiating statin therapy for primary prevention.Primary outcome associationsComponents of primary outcome

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

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

Prognostic implications of obstructive sleep apnea in patients with unstable angina stratified by remnant cholesterol and triglyceride: a prospective cohort study

BackgroundThe prognostic significance of obstructive sleep apnea (OSA) in patients with unstable angina (UA) based on remnant cholesterol (RC) or triglyceride (TG) levels remains unclear. This study aims to evaluate the effects of the interaction between RC, TG, and OSA on cardiovascular outcomes in UA patients.MethodsIn this prospective cohort study, OSA was diagnosed when apnea-hypopnea index of ≥ 15 events/h. Patients with high RC (HRC, n = 370) or high TG (HTG, n = 362) included RC or TG in the highest tertile, and those in the middle and lowest tertiles were defined as normal RC (NRC, n = 736) or normal TG (NTG, n = 744). The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE), including cardiovascular death, myocardial infarction, ischemia stroke, ischemia-driven revascularization, or hospitalization for UA.ResultsA total of 1,106 eligible UA patients were enrolled, among which 560 (50.6%) had OSA. RC and TG levels were increased in OSA patients, but there was no difference in the prevalence of OSA between the NRC and HRC or NTG and HTG groups. During a median follow-up of 1.9 (1.1, 3.0) years, OSA was associated with an increased risk of MACCE occurrence compared to non-OSA in UA patients with HRC (adjusted HR 2.06; 95% CI 1.20–3.51, P = 0.008), but not in those with NRC (adjusted HR 1.21; 95% CI 0.84–1.75, P = 0.297). The incremental risk in HRC was attributable to higher rates of hospitalization for UA and ischemia-driven revascularization. Results for HTG and NTG were similar.ConclusionOSA was associated with a worse prognosis in UA patients with HRC or HTG, emphasizing the necessity of identifying OSA presence in this population.Trial registrationClinicaltrials.gov; No: NCT03362385.

Sudden cardiac death after early-onset myocardial infarction: a multicentre longitudinal cohort study with a 20-year follow-up.

Sudden cardiac death (SCD) is a serious consequence of a myocardial infarction (MI), but identifying patients at risk of developing SCD remains a major clinical challenge, especially in the case of juvenile MI. The aim of this study is to identify predictors of SCD after early-onset MI using long-term follow-up data relating to a large nationwide patient cohort. The Italian Genetic Study on Early-onset MI enrolled 2000 patients experiencing a first MI before the age of 45 years, who were followed up for a median of 19.9 years. Fine-Gray proportional hazard models were used to assess the associations between their clinical, demographic, and index event data and the occurrence of SCD. Sudden cardiac death occurred in 195 patients, who were more frequently males, were hypertensive and/or diabetic, had a history of previous thrombo-embolic events with a greater atherosclerotic burden, and had a lower left ventricular ejection fraction (LVEF) after the index event. A multivariable analysis showed that the independent predictors of SCD were diabetes, hypertension, previous thrombo-embolic events, a higher SYNTAX score, and a lower LVEF. There was no clear evidence of the clustering of SCD events during the follow-up. Sudden cardiac death was the first post-MI clinical event in 101 patients; the remaining 94 experienced SCD after a non-fatal MI or hospitalization for coronary revascularization. Sudden cardiac death frequently occurs during the 20 years after early-onset MI. The nature of the identified predictors and the absence of clustering suggest that the pathophysiological basis of SCD may be related to progressive coronary atherosclerosis.

Long-term outcomes after revascularization in chronic total and non-total occluded coronary arteries: A regionwide cohort study.

Understanding the prognostic impact of percutaneous coronary intervention (PCI) in chronic total occlusion (CTO) is crucial for patient management. Previous studies have primarily been studying prognostic impact of successful versus unsuccessful CTO PCI. This study investigated the prognostic impact of successful and unsuccessful percutaneous coronary intervention (PCI) of chronic total occluded coronary arteries (CTO) with non-CTO PCI as reference. Patients treated with PCI from 2009 to 2019 in the Central Region of Denmark were included in a population-based cohort study. We compared successful and unsuccessful CTO PCI with non-CTO PCI. Exclusion criteria was myocardial infarction within 30 days. Primary outcome was difference in a composite major adverse cardio- and cerebrovascular events (MACCE) encompassing all-cause death, any myocardial infarction, stroke, hospitalization for heart failure or revascularization tracked via nationwide registries. Of 21,141 screened patients, 10,638 were enrolled: 9,065 underwent non-CTO PCI, 1,300 had successful CTO PCI, and 273 had unsuccessful CTO PCI. Median follow-up time was 5.9 [3.5;9.0] years and 4,750 MACCEs were recorded. Compared to non-CTO PCI, the adjusted MACCE rate for successful CTO PCI was equivalent (Hazard Ratio (HR): 0.98, 95% Confidence Interval (CI): 0.90-1.07, p = 0.71). In contrast, unsuccessful CTO PCI was associated with a higher MACCE rate (HR: 1.22, 95% CI: 1.04-1.43, p<0.01). HR was adjusted for age, body-mass index, previous revascularization, smoking, kidney disease, two or three-vessel disease, left ventricular ejection fraction, diabetes and comorbidities. The pre-specified hypothesis was accepted. Successful CTO PCI was associated with equivalent long-term outcomes as non-CTO PCI, and unsuccessful CTO PCI was identified as a high-risk group associated to worse outcomes.

Association of global longitudinal strain by feature tracking cardiac magnetic resonance imaging with adverse outcomes among community-dwelling adults without cardiovascular disease: The Dallas Heart Study.

Left ventricular (LV) global longitudinal strain (GLS) may detect subtle abnormalities in myocardial contractility among individuals with normal LV ejection fraction (LVEF). However, the prognostic implications of GLS among healthy, community-dwelling adults is not well-established. Overall, 2234 community-dwelling adults (56% women, 47% Black) with LVEF ≥50% without a history of cardiovascular disease (CVD) from the Dallas Heart Study who underwent cardiac magnetic resonance (CMR) with GLS assessed by feature tracking CMR (FT-CMR) were included. The association of GLS with the risk of incident major adverse cardiovascular events (MACE; composite of incident myocardial infarction, incident heart failure [HF], hospitalization for atrial fibrillation, coronary revascularization, and all-cause death), and incident HF or death were assessed with adjusted Cox proportional hazards models. A total of 309 participants (13.8%) had MACE during a median follow-up duration of 17 years. Participants with the worst GLS (Q4) were more likely male and of the Black race with a history of tobacco use and diabetes with lower LVEF, higher LV end-diastolic volume, and higher LV mass index. Cumulative incidence of MACE was higher among participants with worse (Q4 vs. Q1) GLS (20.4% vs. 9.0%). In multivariable-adjusted Cox models that included clinical characteristics, cardiac biomarkers and baseline LVEF, worse GLS (Q4 vs. Q1) was associated with a significantly higher risk of MACE (hazard ratio [HR] 1.55, 95% confidence interval [CI] 1.07-2.24, p = 0.02) and incident HF or death (HR 1.57, 95% CI 1.03-2.38, p = 0.04). Impaired LV GLS assessed by FT-CMR among adults free of cardiovascular disease is associated with a higher risk of incident MACE and incident HF or death independent of cardiovascular risk factors, cardiac biomarkers and LVEF.

Prognostic value of stress perfusion cardiac magnetic resonance in patients with prediabetes and suspected coronary artery disease.

Stress perfusion cardiac magnetic resonance (CMR) is an accurate and comprehensive modality for evaluating patients with suspected coronary artery disease (CAD), but its prognostic value in prediabetic patients is uncertain. This retrospective study included 452 consecutive prediabetic patients without prior diagnoses of CAD who underwent adenosine stress perfusion CMR. The primary endpoint was major adverse cardiovascular events (MACE), defined as cardiovascular death, nonfatal myocardial infarction (MI), hospitalization for heart failure, ischemic stroke, and late coronary revascularization (>90 days post-CMR). The secondary endpoint was a composite of cardiovascular death, nonfatal MI, and hospitalization for heart failure. The mean age was 68±11 years (49% male). Over a median follow-up time of 8.1 (IQR 5.7, 10.4) years, 55 patients experienced MACE, and 24 met the secondary endpoint. Patients with inducible ischemia had significantly greater annualized event rates for MACE (5.7% vs. 0.7%, p<0.001) and for the secondary endpoint (2.0% vs. 0.3%, p<0.001) than those without ischemia. Multivariable analysis revealed inducible ischemia as a consistent predictor for MACE (HR 3.36, 95%CI 1.90-5.94, p<0.001) and for the secondary endpoint (HR 2.89, 95%CI 1.22-6.80, p = 0.01). Late gadolinium enhancement (LGE) was an independent predictor of the secondary endpoint (HR 3.56, 95%CI 1.25-10.13; p = 0.02). Incorporating inducible ischemia and LGE data significantly improved the model's ability to discriminate MACE risk (C-statistic increase from 0.77 to 0.83; net reclassification improvement 0.42; integrated discrimination improvement 0.05). Stress perfusion CMR offers substantial independent prognostic value and effectively aids in reclassifying cardiovascular risk among prediabetic patients with suspected CAD.

Systemic inflammatory disease in patients with spontaneous coronary artery dissection

Abstract Background Spontaneous coronary artery dissection (SCAD) is an increasingly recognised cause of non-atherosclerotic myocardial infarction (MI). Systemic inflammatory diseases are commonly associated with SCAD patients, but the link between inflammatory diseases and SCAD remains unclear. Purpose To determine the prevalence of systemic inflammatory disease (SID) and elevated inflammatory markers (EIM) at SCAD presentation. To compare long-term outcomes between SCAD patients with and without SID, and with and without EIM at presentation. Methods We reviewed patients enrolled in the Canadian SCAD Study who had laboratory measurements of inflammatory markers at presentation with SCAD. We compared the baseline demographics, presence of SID, presentation characteristics, and long-term outcomes between patients with and without SID, and between patients presenting with and without EIM at time of SCAD. SID was determined using past medical history and patient self-identification. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were used as inflammatory biomarkers. Major adverse cardiovascular events (MACE) were defined as the composite of all-cause mortality, stroke or transient ischemic attack, MI, hospitalization for heart failure and unplanned revascularization. Results Of 1307 patients with SCAD, 360 had inflammatory markers measured at presentation. Of these 360 patients, 150 (43.1%) had EIM at presentation, and 13 (3.6%) reported a history of SID. Mean age was 52.9±9.8 years for patients with EIM, vs. 50.8±10.9years for patients without EIM (p=0.06). Patients with EIM had significantly higher body mass index compared to those without EIM (35.5% vs 17.6%, p=0.001). Of the patients with reported SID, there was higher prevalence of diabetes and hypertension. There was no significant difference in mean inflammatory marker levels, ESR (13.4±15.6mm/h vs 13.7±13.2mm/h, p=0.965) and CRP (15.6± 23.1mg/L vs 11.9± 26.8mg/L, p=0.644) among SID vs. no SID patients at SCAD presentation. Overall mean follow-up was 3.7±1.9 years. There was no difference in in-hospital MACE and overall MACE between patients with EIM vs. no EIM, and between SID and no SID cohorts. There were also no significant difference in angiographic findings, fibromuscular dysplasia prevalence, proportion treated conservatively vs. with revascularization in these cohorts. Conclusion There was no significant difference between presentation, laboratory values, treatment, or outcomes between SCAD patients with or without SID, and between patients who present with and without EIM. This suggests that both active inflammation and history of inflammatory diseases do not contribute to SCAD or outcomes.Table 1.SCAD cohort demographics &amp; data

FRI117 Major Adverse Cardiovascular Events In Severe Insulin Resistance Syndromes: Lipodystrophy Compared To Pathogenic Variants Of The Insulin Receptor

Abstract Disclosure: M. Lightbourne: None. R.J. Brown: None. Patients with insulin resistance (IR) associated with obesity and/or type 2 diabetes have increased atherosclerotic cardiovascular disease (ASCVD) risk. Rare, syndromic forms of severe IR (SIR) exist, in which ASCVD risk is not established. SIR can be classified into post-receptor IR, where insulin signaling is increased in some signaling pathways, and decreased in others (i.e. lipodystrophy) or receptor IR, where all insulin signaling is blocked at the insulin receptor (i.e. insulin receptor pathogenic variants, INSR). These differences in insulin signaling associate with differences in ASCVD risk factors, i.e. dyslipidemia and uric acid (high in lipodystrophy, low in INSR), but the incidence of ASCVD in these population is unknown. We hypothesized that patients with post-receptor IR due to lipodystrophy would have more major adverse cardiovascular events (MACE) vs those with receptor IR due to INSR. This is a retrospective chart review of patients with lipodystrophy and INSR aged ≥18 years. Our primary outcome was incidence of MACE (composite of cardiovascular death, non-fatal myocardial infarction, ischemic stroke and hospitalization for unstable angina, heart failure or revascularization). Patients with INSR (n=24) were younger than those with lipodystrophy (n=241) (32 ± 12 vs 40 ± 15 years, p=0.02) at first MACE or last follow-up. 62% of patients with INSR were female vs 82% with lipodystrophy (p=0.02); 50% with INSR were white vs 75% with lipodystrophy (p=0.0098). Of patients with lipodystrophy, 153 had partial, 79 had generalized, and 9 had progeroid forms of lipodystrophy. Nine patients with INSR had homozygous or compound heterozygous variants and 15 had heterozygous variants. MACE occurred in 33 patients with lipodystrophy (5 generalized, 24 partial, 4 progeroid; age 42.6 ± 12.7 years) and in 0 patients with INSR with a Hazard Ratio of 2.9 (95% CI 0.6-14.5, P=0.2). In patients with lipodystrophy, 9 patients had cardiovascular deaths (mean age 32.4 ± 15.4 years, 3 with progeroid syndromes); 11 had non-fatal myocardial infarcts with 2 patients having recurrent events; 8 were hospitalized for strokes or transient ischemic attacks; 12 were hospitalized for coronary revascularization with 7 patients having recurrent events; 5 were hospitalized due to heart failure. In addition to MACE, 4 patients with lipodystrophy had peripheral revascularization or amputation vs 0 with INSR. MACE events did not occur in patients with INSR and were highly prevalent at a young age in patients with lipodystrophy, suggesting higher risk of MACE in lipodystrophy. There was no statistical difference for MACE events between the 2 groups; however, statistical power was limited by the small sample size and young age of patients INSR. These data suggest that contributions from both increased and decreased insulin signal transduction in patients with post-receptor IR may lead to increased ASCVD risk. Presentation: Friday, June 16, 2023

Association of prior outpatient diabetes screening with cardiovascular events and mortality among people with incident diabetes: a population-based cohort study

BackgroundOutcomes of diabetes screening in contemporary, multi-ethnic populations are unknown. We examined the association of prior outpatient diabetes screening with the risks of cardiovascular events and mortality in Ontario, Canada.MethodsWe conducted a population-based cohort study using administrative databases among adults aged ≥ 20 years with incident diabetes diagnosed during 2014–2016. The exposure was outpatient diabetes screening performed within 3 years prior to diabetes diagnosis. The co-primary outcomes were (1) a composite of all-cause mortality and hospitalization for myocardial infarction, stroke, coronary revascularization, and (2) all-cause mortality (followed up until 2018). We calculated standardized rates of each outcome and conducted cause-specific hazard modelling to determine the adjusted hazard ratio (HR) of the outcomes, adjusting for prespecified confounders and accounting for the competing risk of death.ResultsWe included 178,753 Ontarians with incident diabetes (70.2% previously screened). Individuals receiving prior screening were older (58.3 versus 53.4 years) and more likely to be women (49.6% versus 40.0%) than previously unscreened individuals. Individuals receiving prior screening had relatively lower standardized event rates than those without prior screening across all outcomes (composite: 12.8 versus 18.1, mortality: 8.2 versus 11.1 per 1000 patient-years). After multivariable adjustment, prior screening was associated with 34% and 32% lower risks of the composite (HR 0.66, 0.63–0.69) and mortality (0.68, 0.64–0.72) outcomes. Among those receiving prior screening, a result in the prediabetes range was associated with lower risks of the composite (0.82, 0.77–0.88) and mortality (0.71, 0.66–0.78) outcomes than a result in the normoglycemic range.ConclusionsPreviously screened individuals with diabetes had lower risks of cardiovascular events and mortality versus previously unscreened individuals. Better risk assessment tools are needed to support wider and more appropriate uptake of diabetes screening, especially among young adults.

Contemporary patterns of lipoprotein(a) testing and associated clinical care and outcomes

ObjectiveElevated lipoprotein(a) [Lp(a)] is associated with atherosclerotic cardiovascular disease, yet little is known about Lp(a) testing patterns in real-world practice. The objective of this analysis was to determine how Lp(a) testing is used in clinical practice in comparison with low density lipoprotein cholesterol (LDL-C) testing alone, and to determine whether elevated Lp(a) level is associated with subsequent initiation of lipid-lowering therapy (LLT) and incident cardiovascular (CV) events. MethodsThis is an observational cohort study, based on lab tests administered between Jan 1, 2015 and Dec 31, 2019. We used electronic health record (EHR) data from 11 United States health systems participating in the National Patient-Centered Clinical Research Network (PCORnet). We created two cohorts for comparison: 1) the Lp(a) cohort, of adults with an Lp(a) test and 2) the LDL-C cohort, of 4:1 date- and site-matched adults with an LDL-C test, but no Lp(a) test. The primary exposure was the presence of an Lp(a) or LDL-C test result. In the Lp(a) cohort, we used logistic regression to assess the relationship between Lp(a) results in mass units (< 50, 50-100, and > 100mg/dL) and molar units (<125, 125-250, > 250nmol/L) and initiation of LLT within 3 months. We used multivariable adjusted Cox proportional hazards regression to evaluate these Lp(a) levels and time to composite CV hospitalization, including hospitalization for myocardial infarction, revascularization and ischemic stroke. ResultsOverall, 20,551 patients had Lp(a) test results and 2,584,773 patients had LDL-C test results (82,204 included in the matched LDL-C cohort). Compared with the LDL-C cohort, the Lp(a) cohort more frequently had prevalent ASCVD (24.3% vs. 8.5%) and multiple prior CV events (8.6% vs. 2.6%). Elevated Lp(a) was associated with greater odds of subsequent LLT initiation. Elevated Lp(a) reported in mass units was also associated with subsequent composite CV hospitalization [aHR (95% CI): Lp(a) 50-100mg/dL 1.25 (1.02-1.53), p<0.03, Lp(a) > 100mg/dL 1.23 (1.08-1.40), p<0.01]. ConclusionLp(a) testing is relatively infrequent in health systems across the U.S. As new therapies for Lp(a) emerge, improved patient and provider education is needed to increase awareness of the utility of this risk marker.

Prognostic Implications of OSA in Acute Coronary Syndrome by Obesity Status

A close relationship exists between OSA and obesity. The impact of obesity on the prognostic significance of OSA in patients with acute coronary syndrome (ACS) remains unclear. Do the effects of OSA on subsequent cardiovascular events in patients with ACS vary with obesity status? This is a prospective cohort study. Patients 18 to 85 years of age who were hospitalized for ACS were consecutively enrolled and underwent portable sleep monitoring after clinical stabilization. OSA was defined as an apnea hypopnea index≥ 15 events/h. The primary end point was major adverse cardiovascular and cerebrovascular event (MACCE), including cardiovascular death, hospitalization for ACS, stroke, ischemia-driven revascularization, or hospitalization for heart failure. Among 1,920 patients enrolled (84.5%male; mean age ± SD, 56.4 ± 10.5 years), 1,013 (52.8%) had OSA, and 718 (37.4%) were obese (BMI≥ 28kg/m2). During 2.9 years (1.5, 3.6 years) follow-up, the incidence of MACCE was significantly higher in patients with obesity than in patients without obesity (hazard ratio [HR], 1.29; 95%CI, 1.06-1.58; P= .013). Although the prevalence of OSA was lower in patients without obesity than in those with obesity (43.9%vs67.5%; P< .001), OSA independently predicted the incidence of MACCE only in patients without obesity (adjusted HR, 1.34; 95%CI, 1.03-1.75; P= .03), but not in patients with obesity (adjusted HR, 1.10; 95%CI, 0.78-1.55; P= .58). No significant interaction between obesity and OSA was noted (P for interaction= .35). The incremental risk associated with OSA in patients without obesity might be explained by more hospitalization for ACS and ischemia-driven revascularization. For patients with ACS, OSA was independently associated with an increased risk of subsequent events, particularly among patients without obesity. These findings highlight the importance of identifying OSA in nonobese patients with ACS. ClinicalTrials.gov; No.: NCT03362385; URL: www. gov.

Complementary prognostic value of stress perfusion imaging and global coronary flow reserve derived from cardiovascular magnetic resonance: a long-term cohort study

BackgroundPhase-contrast cine cardiovascular magnetic resonance (CMR) quantifies global coronary flow reserve (CFR) by measuring blood flow in the coronary sinus (CS), allowing assessment of the entire coronary circulation. However, the complementary prognostic value of stress perfusion CMR and global CFR in long-term follow-up has yet to be investigated. This study aimed to investigate the complementary prognostic value of stress myocardial perfusion imaging and global CFR derived from CMR in patients with suspected or known coronary artery disease (CAD) during long-term follow-up. MethodsParticipants comprised 933 patients with suspected or known CAD who underwent comprehensive CMR. Major adverse cardiac events (MACE) comprised cardiac death, non-fatal myocardial infarction, unstable angina, hospitalization for heart failure, stroke, ventricular arrhythmia, and late revascularization. ResultsDuring follow-up (median, 5.3 years), there were 223 MACE. Kaplan–Meier curve analysis revealed a significant difference in event-free survival among tertile groups for global CFR (log-rank, p < 0.001) and between patients with and without ischemia (p < 0.001). The combination of stress perfusion CMR and global CFR enhanced risk stratification (p < 0.001 for overall), and prognoses were comparable between the subgroup with ischemia and no impaired CFR and the subgroup with no ischemia and impaired CFR (p = 0.731). Multivariate Cox proportional hazard regression analysis showed that impaired CFR remained a significant predictor for MACE (hazard ratio, 1.6; p = 0.002) when adjusted for coronary risk factors and CMR predictors, including ischemia. The addition of impaired CFR to coronary risk factors and ischemia significantly increased the global chi-square value from 88 to 109 (p < 0.001). Continuous net reclassification improvement and integrated discrimination with the addition of global CFR to coronary risk factors plus ischemia improved to 0.352 (p < 0.001) and 0.017 (p < 0.001), respectively. ConclusionsDuring long-term follow-up, stress perfusion CMR and global CFR derived from CS flow measurement provided complementary prognostic value for prediction of cardiovascular events. Microvascular dysfunction or diffuse atherosclerosis as shown by impaired global CFR may play a role as important as that of ischemia due to epicardial coronary stenosis in the risk stratification of CAD patients.

Effect of phosphodiesterase type 5 inhibitors on major adverse cardiovascular events and overall mortality in a large nationwide cohort of men with erectile dysfunction and cardiovascular risk factors: A retrospective, observational study based on healthcare claims and national death index data.

Treatment with phosphodiesterase type 5 inhibitors (PDE-5is) is effective in treating erectile dysfunction (ED). The objective of this study was to determine the effect of PDE-5is on the incidence of major adverse cardiovascular (CV) events (MACE; composite outcome of CV death, hospitalization for myocardial infarction, coronary revascularization, stroke, heart failure, and unstable angina pectoris) and overall mortality. A retrospective observational cohort study was conducted in a large US claims database in men with ≥1 diagnosis of ED without prior MACE within 1year, from January 1, 2006, to October 31, 2020. The exposed group had ≥1 claim for PDE-5i and the unexposed group had no claims for PDE-5i, and the groups were matched up to 1:4 on baseline risk variables. The primary outcome was MACE and the secondary outcomes were overall mortality and individual components of MACE, determined by multivariable Cox proportional hazard modeling. Matched plus multivariable analyses showed that MACE was lower by 13% in men exposed (n = 23 816) to PDE-5is (hazard ratio [HR] 0.87; 95% CI 0.79-0.95; P = .001) vs nonexposure (n = 48 682) over mean follow-up periods of 37 and 29months, respectively, with lower incidence of coronary revascularization (HR 0.85; 95% CI 0.73-0.98; P = .029), heart failure (HR 0.83; 95% CI 0.72-0.97; P = .016), unstable angina (HR 0.78; 95% CI 0.64-0.96; P = .021), and CV death (HR 0.61; 95% CI 0.41-0.90; P = .014) with PDE-5i exposure. Phosphodiesterase type 5 inhibitor-exposed men had a 25% lower incidence of overall mortality (HR 0.75; 95% CI 0.65-0.87; P < .001). Men without coronary artery disease (CAD) but with CV risk factors at baseline showed a similar pattern. In the main study cohort, men in the highest quartile of PDE-5i exposure had the lowest incidence of MACE (HR 0.45; 95% CI 0.37-0.54; P < .001) and overall mortality (HR 0.51; 95% CI 0.37-0.71; P < .001) vs the lowest exposure quartile. In a subgroup with baseline type 2 diabetes (n = 6503), PDE-5i exposure was associated with a lower MACE risk (HR 0.79; 95% CI 0.64-0.97; P = .022). PDE-5is may have cardioprotective effects. Strengths are the large numbers of participants and consistency of the data; limitations include the retrospective nature of the study and unknown confounders. In a large population of US men with ED, PDE-5i exposure was associated with lower incidence of MACE, CV death, and overall mortality risk compared to non-exposure. Risk reduction correlated with PDE-5i exposure level.

Peripheral arterial disease and multisite atherosclerosis in patients undergoing percutaneous coronary intervention.

Key Points Atherosclerosis is a systemic disease and frequently coronary artery disease is intertwined with peripheral arterial disease (PAD). This large study showed that PAD and its extension (multisite atherosclerosis) negatively affects the risk of in‐hospital mortality in patients with coronary artery disease undergoing PCI. PAD status and its extension in the principal vascular territories should be carefully assessed during hospitalization for coronary revascularization and should be regarded as important risk factors.

Effect of folic acid, vitamin B12, and B6 supplementation on the risk of cardiovascular and cerebrovascular diseases: An updated meta-analysis of randomized controlled trials

Abstract Background Numerous studies indicated that B vitamin supplementation can reduce cardiovascular risk; nonetheless, available proof reported from individual studies have not been consistent, so we performed an updated meta-analysis of randomized controlled trials (RCTs) to evaluate the relationship between B vitamin supplementation and cardiovascular outcomes. Materials and method Relevant studies published before May 2022 were searched from the electronic databases of PubMed, Embase, the Cochrane Library, Chinese Biology Medicine, and the Chinese National Knowledge Infrastructure. Outcomes included major adverse cardiovascular event (MACE), myocardial infarction (MI), stroke, hospitalization for unstable angina, revascularization, total mortality, and cardiovascular death. The strength of the association was examined by risk ratio (RR) with 95% confidence interval (95% CI). Results A total of 17 RCTs involving 31,085 subjects were included in the meta-analysis. The combined supplementation of B vitamins had no significant effect on MACE based on eight RCTs (RR = 0.98, 95% CI = 0.92–1.04), MI based on 13 RCTs (RR = 1.00, 95% CI = 0.92–1.09), and revascularization based on 12 RCTs (RR = 1.02, 95% CI = 0.95–1.10). Ten studies showed that the combined supplementation of B vitamins reduced the risk of stroke by 12% (RR = 0.88, 95% CI = 0.81–0.97). Eleven studies showed that the combined supplementation of B vitamins had no significant effect on the total mortality (RR = 0.99, 95% CI = 0.94–1.05), and nine studies showed that the combined B vitamins had no significant effect on cardiovascular death (RR = 0.96, 95% CI = 0.88–1.05). Besides, with the extension of follow-up duration and those with a history of cardio-cerebrovascular diseases, supplementation of B vitamins could reduce the risk of stroke. Conclusion The supplementation of folic acid, Vitamin B6, and B12 is associated with a reduction in stroke, but not in total mortality, cardiovascular death, MACE, and MI.

Insights from Egyptian ticagrelor study in patients who presented with acute coronary syndrome (ETS in ACS)

BackgroundDual antiplatelet therapy with aspirin and a thienopyridine is used to prevent thrombotic complications of acute coronary syndrome (ACS) and percutaneous coronary interventions (PCI). Ticagrelor is an oral, reversible inhibitor of the adenosine diphosphate receptor P2Y12 with a faster onset and more potent platelet inhibition than clopidogrel. A study was needed to evaluate the efficacy and safety of generic ticagrelor in Egyptian patients.ResultsThis multicenter study included 830 patients aged above 40 years and diagnosed with ACS, with or without ST segment elevation during the preceding 6 months. They received generic ticagrelor (Thrombolinta, Global Napi Pharmaceutical Company, Egypt) (180 mg loading dose, 90 mg twice daily thereafter), added to aspirin 75–100 mg daily. The mean age of our study population was 57.5 (8.3) years and 38.3% were females. Hypertension, diabetes mellitus, dyslipidemia and previous coronary revascularization were present in 70.7%, 59.2%, 80.7% and 31% of the patients, respectively, and 42.5% were current smokers. The qualifying event was unstable angina, non-ST segment elevation myocardial infarction and ST segment elevation myocardial infarction in 54%, 21.8% and 24.2% of the patients, respectively. At 6 months, the primary efficacy end point—a composite of cardiovascular death, myocardial infarction and stroke—occurred in 3.4% of patients, while the secondary efficacy endpoint—a composite of the primary efficacy endpoints with the addition of hospitalization for unstable angina and urgent revascularization—occurred in 15.3%. Cardiovascular death occurred in 1.2% of the patients, myocardial infarction in 0.8%, stroke in 1.3%, hospitalization for UA in 8.1% and urgent revascularization in 3.9%. TIMI major bleeding occurred in 1.2% of patients, intracranial hemorrhage in 0.2% and TIMI minor bleeding in 13.3%. No significant difference was found between patients who underwent PCI at baseline and those who were treated conservatively regarding the primary (14 patients in each group, P = 0.931) and secondary (62 vs. 65 patients, P = 0.946) efficacy endpoints.ConclusionsIn patients who had an ACS during the 6 months preceding enrollment, treatment with generic ticagrelor led to a low rate of cardiovascular death, myocardial infarction and stroke with a minor increase in the risk of major bleeding.

Prognostic Value of Aortic Stiffness using Cardiovascular Magnetic Resonance in The Elderly with Known or Suspected Coronary Artery Disease.

ResumoFundamento A rigidez aórtica é considerada um marcador de doença cardiovascular. A ressonância magnética cardiovascular (RMC) permite realizar uma avaliação abrangente da rigidez aórtica e da isquemia miocárdica em um único exame. Entretanto, dados prognósticos relacionados à rigidez aórtica em pacientes idosos permanecem limitados.Objetivo Determinar o valor prognóstico da rigidez aórtica usando a velocidade da onda de pulso (VOP) baseada em RMC em pacientes idosos com doença arterial coronariana (DAC).Métodos Foram cadastrados pacientes consecutivos com idade >70 com indicação para RMC com perfusão de estresse com adenosina incluindo VOP, entre 2010 e 2014. Os pacientes foram acompanhados para verificar a ocorrência de eventos cardíacos adversos maiores (MACE), incluindo mortalidade cardíaca, infarto do miocárdio não fatal, hospitalização por insuficiência cardíaca, revascularização tardia (>180 dias após a RMC), e acidente vascular isquêmico. Foram realizadas análises univariadas e multivariadas para determinar os preditores de MACE. Um p-valor <0,05 foi considerado estatisticamente significativo.Resultados A VOP média foi 13,98±9,00 m/s. Depois de um período mediano de acompanhamento de 59,6 meses em 263 pacientes (55% do sexo feminino, 77±5 anos), ocorreram 61 MACE. Pacientes com VOP elevada (>13,98 m/s) tiveram índices de MACE significativamente mais altos (FC 1,75; IC 95% 1,05-2,94; p=0,03) que os dos pacientes com VOP não elevada (<13,98 m/s). A análise multivariada demonstrou que pressão arterial diastólica, fração de ejeção ventricular esquerda (FEVE), isquemia miocárdica, e VOP elevada são preditores independentes de MACE (p<0,05 para todos). A VOP apresentou um valor prognóstico incremental em relação a dados clínicos, FEVE e isquemia (qui-quadrado global aumentado = 7,25, p=0,01).Conclusão A rigidez aórtica, usando-se a RMC, é um preditor independente forte de eventos cardiovasculares em pacientes idosos com suspeita de DAC ou DAC confirmada.

Glucose lowering does not necessarily reduce cardiovascular risk in type 2 diabetes.

Diabetes mellitus (DM) is a health condition characterized by glucose dysregulation and affects millions of people worldwide. The presentation of heart failure in diabetic cardiomyopathy extends over a wide phenotypic spectrum, commencing from asymptomatic, subclinical structural abnormalities to severely symptomatic biventricular dysfunction with increased mortality risk. Similarly, the spectrum of systolic dysfunction in diabetic-induced heart failure is diverse. DM leads also to cardiac electrical remodeling reacting on various targets. Dipeptidyl peptidase-4 (DPP-4) inhibitors reduce glucagon and blood glucose levels by raising levels of the endogenous hormones glucagon-like-peptide 1 and glucose-dependent insulinotropic peptide and constitute a safe and effective glucose lowering treatment option in patients with type 2 DM. Despite DPP-4 inhibitors’ efficacy regarding glycemic control, their effect on cardiovascular outcomes (myocardial infarction, stroke, hospitalization for heart failure, hospitalization for unstable angina, hospitalization for coronary revascularization, and cardiovascular death) in diabetic patients has been neutral. The potential correlation between atrial flutter and DPP-4 inhibitors administration needs further investigation.

Systemic Immune-Inflammation Index Predicts Major Cardiovascular Adverse Events in Patients with ST-Segment Elevated Myocardial Infarction.

ResumoFundamento O índice de inflamação imune sistêmica (SII, systemic immune-inflammation index) tem sido descrito como um novo marcador prognóstico em tumores e doenças cardiovasculares.Objetivos Investigar a associação entre eventos cardiovasculares adversos em pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCSST).Métodos Foi realizado um estudo observacional retrospectivo em 843 pacientes com IAMCSST. Os pacientes foram divididos em dois grupos segundo valores medianos de SII. A análise de regressão de Cox foi usada para detectar preditores independentes de eventos adversos cardiovasculares. A melhora na capacidade discriminatória pela adição do SII aos fatores de risco tradicionais – idade, hipertensão, diabetes mellitus, e sexo masculino para eventos adversos maiores foi calculada por estatística c, melhora da discriminação integrada (IDI), e melhora na reclassificação. Um valor de p bilateral <0,05 foi considerado estatisticamente significativo.Resultados O grupo com SII elevado apresentou idade mais avançada que o grupo com SII baixo (61,2±11,2 e 59,2±7,9, respectivamente, p=0,002). O grupo com SII elevado apresentou taxas mais altas de morte cardiovascular, infarto do miocárdio não fatal, acidente vascular cerebral não fatal, hospitalização por insuficiência cardíaca, revascularização, e eventos cardiovasculares adversos maiores que no grupo com SII baixo. O SII foi um preditor independente de todos os eventos mencionados. A adição do SII aos fatores de risco tradicionais melhorou sua capacidade discriminatória para eventos cardiovasculares. O SII foi superior à razão neutrófilo-linfócito e à razão plaqueta-linfócito para predizer eventos adversos cardiovasculares.Conclusão O SII foi um preditor independente de eventos adversos maiores em pacientes com IAMCSST e pode ser usado para melhorar a predição de eventos adversos risco, especialmente se combinado com fatores de risco tradicionais.