In-hospital MACE Research Articles

Impact of the Stress Hyperglycemia Ratio on Heart Failure and Atherosclerotic Cardiovascular Events After Acute Myocardial Infarction.

An acute hyperglycemic status is reportedly associated with poor prognosis in patients with acute cardiovascular diseases. Although the stress hyperglycemia ratio (SHR) is used to evaluate the hyperglycemic condition on admission, relationships between SHR and clinical outcomes, particularly heart failure (HF), remain uncertain in acute myocardial infarction (AMI). This retrospective multicenter study included 2,386 patients with AMI undergoing percutaneous coronary intervention. SHR was calculated using blood glucose and HbA1c levels. Co-primary endpoints included HF-related events (death, worsening HF, and hospitalization for HF) and major adverse cardiovascular events (MACE; death, recurrent AMI, and ischemic stroke) during the index hospitalization and after discharge. The mean (±SD) SHR was 1.30±0.51; HF events and MACE occurred in 680 (28.5%) and 233 (9.8%) patients during hospitalization, respectively. SHR was independently associated with in-hospital HF events and MACE. Of 2,017 patients who survived to discharge, 195 (9.7%) and 214 (10.6%) experienced HF events and MACE, respectively, over a median follow-up of 536 days. The risk of HF events was higher in patients with a high (>1.45) SHR than in those with SHR ≤1.45; there was no significant difference in MACE rates after discharge between these 2 groups. In AMI patients, SHR was predictive of in-hospital outcomes, including HF events and MACE, whereas after discharge a higher SHR was associated with higher HF risks, but not MACE.

Features and Limitations of Robotically Assisted Percutaneous Coronary Intervention (R-PCI): A Systematic Review of R-PCI.

Background: Ischaemic heart disease is one of the major drivers of cardiovascular death in Europe. Since the first percutaneous coronary intervention (PCI) in 1977, developments and innovations in cardiology have made PCI the treatment of choice for stenotic coronary artery disease. To address the occupational hazards related to chronic exposure to radiation and wear and tear from heavy lead-based radioprotective aprons, the concept of robotically assisted PCI (R-PCI) was introduced in 2005. Aim: To explore the features and limitations of R-PCI, we first discuss the concept and evolution of R-PCI platforms and then systematically review the available clinical data. Methods: A systematic review has been performed across the Pubmed, Embase and Cochrane databases in order to assess the efficacy and safety of R-PCI. Secondary endpoints, such as operator and patient exposure to radiation, contrast volume used and procedural time, were assessed when available. Results: In selected patients, R-PCI provides high technical and clinical success rates, ranging from 81 to 98.8% and from 93.3 to 100%, respectively. In-hospital and 1-year MACE rates ranged from 0 to 10.4% and 4.8 to 10.5%, respectively. R-PCI is able to significantly reduce the operator's exposure to radiation. Further research analysing the patient's and cath lab staff's exposure to radiation is needed. Therapy escalation with R-PCI seems to be limited to complex lesions. R-PCI procedures add approximately 10 min to the procedural time. Conclusions: The efficacy and safety of R-PCI have been proven, and R-PCI is able to significantly reduce occupational hazards for the first operator. The lack of adoption in the community of interventional cardiologists may be explained by the fact that current generations of R-PCI platforms are limited by their incompatibility with advanced interventional devices and techniques needed for escalation in complex interventions.

Percutaneous coronary interventions for aneurysmatic right coronary artery in acute coronary syndrome: RIGHTMARE registry outcomes

BackgroundThe optimal strategy during percutaneous coronary intervention (PCI) of aneurysmatic right coronary artery (ARCA) remains uncertain and has never been tested in the acute setting. ObjectivesTo compare the in-hospital and long-term outcomes of immediate and staged PCI strategies for ARCA as culprit lesions during acute coronary syndrome (ACS). MethodsAmong 102.376 PCIs performed in 18 European centers, a total of 85 patients presenting with acute coronary syndrome undergoing ARCA PCI were finally included in the analysis. PCI strategy (stenting performed during the immediate vs staged procedure) and pharmacological approach adopted were collected. The primary outcome was procedural success (technical success without in-hospital MACE). ResultsThe primary outcome occurred in 48.2 % of cases, with no significant differences observed between the immediate and staged PCI groups (50.9 % vs 43.3 %, p = 0.504). Patients in the staged-PCI group had a significantly higher rate of intravenous anticoagulant use (83.3 % vs 48.1 %, p = 0.002), BARC type 3 and 5 bleedings (12.9 % vs 1.9 %, p = 0.037), and longer in-hospital stay (7.40 ± 5.11 vs 9.5 ± 5.25 days, p = 0.049). After multivariate analysis, no independent predictors for procedural success were found in either group. Target lesion failure occurred in 24.1 % of cases without differences between groups at a median follow-up of three years. ConclusionsAmong patients undergoing ARCA PCI in the setting of ACS, immediate or staged PCI were associated with similar in-hospital and long-term outcomes. However, staged PCI was associated with a higher risk of major bleeding events and longer length of stay compared to immediate PCI strategy.

Ticagrelor versus Clopidogrel in Prevention of No Reflow after 1ry PCI in Diabetic Patients with STEMI

Abstract Background Adequacy of coronary flow can be judged upon using several methods like TIMI Grade and myocardial blush grade. No-reflow phenomenon, defined as incomplete reperfusion at the microvascular level despite adequate patency of the occluded artery, remains an important limitation of primary percutaneous intervention in STEMI patients nowadays. We aim in this study to investigate the relationship between the antiplatelet loading dose whether to be Ticagrelor or Clopidogrel and post intervention coronary flow, bleeding risk in these patients. Aim of the Work To compare between the effects of preoperative loading dose of Ticagrelor and clopidogrel in Diabetic STEMI patients undergoing primary percutaneous coronary intervention regarding prevention of no reflow, Instent thrombosis and short term bleeding risk. Myocardial reperfusion was judged upon using TIMI Grade and myocardial blush grade. Patients and Methods a single center prospective randomized controlled trial based at the coronary care units in Ain shams university hospitals. The study included Three hundred Diabetic patients presenting to Ain shams university hospitals diagnosed with STEMI in the ER fulfilling the inclusion criteria were randomized to receive Ticagrelor (150 patients) or receiving clopidogrel (150 patients) Results As regard TIMI flow there was statistically highly significant highly significant difference between two studied groups with P value 0.000 where in group A 64 % of patients developed TIMI III flow, 22.7 % with TIMI II flow, 12.7% with TIMI I and 0.7% with TIMI 0 While in group B 86% of patients developed TIMI III flow, 9.3% of them developed TIMI II, 3.3 % developed TIMI I flow and 1.3 % developed TIMI 0. As regard MBG there was statistically highly significant difference between two groups with P value 0.00 where in group A where percentage of patients with MBG grades 0,1,2 and 3 were 4%, 16 %,18 % and 62 % respectively while in group B percentage of patients with MBG grades 0,1,2 and 3 were 1.3 %, 3.3 %, 9.3 % and 86 % respectively. As regard echo EF, there was statistically significant difference between two groups with P value 0.036 where mean EF in patients with group A was 40.50 ± 7.93 while the mean EF in patients with group B was 42.55 ± 8.88 . Conclusion Ticagrelor loading before primary PCI resulted in improved post-procedural TIMI flow. It also increased the post-procedural MBG. This resulted in a significant increase in the number of patients having more post-procedural Ejection fraction as measured by modified Simpson’s method. However, it did not decrease incidence of in-hospital MACE. Also there was no significant increase in risk of major nor minor bleeding in both young and elderly patients.

Ticagrelor versus Clopidogrel in Prevention of No Reflow after 1ry PCI in Diabetic Patients with STEMI

Abstract Background Adequacy of coronary flow can be judged upon using several methods like TIMI Grade and myocardial blush grade. No-reflow phenomenon, defined as incomplete reperfusion at the microvascular level despite adequate patency of the occluded artery, remains an important limitation of primary percutaneous intervention in STEMI patients nowadays. We aim in this study to investigate the relationship between the antiplatelet loading dose whether to be Ticagrelor or Clopidogrel and post intervention coronary flow, bleeding risk in these patients. Aim of the Work To compare between the effects of preoperative loading dose of Ticagrelor and clopidogrel in Diabetic STEMI patients undergoing primary percutaneous coronary intervention regarding prevention of no reflow, Instent thrombosis and short term bleeding risk. Myocardial reperfusion was judged upon using TIMI Grade and myocardial blush grade. Patients and Methods a single center prospective randomized controlled trial based at the coronary care units in Ain shams university hospitals. The study included Three hundred Diabetic patients presenting to Ain shams university hospitals diagnosed with STEMI in the ER fulfilling the inclusion criteria were randomized to receive Ticagrelor (150 patients) or receiving clopidogrel (150 patients) Results As regard TIMI flow there was statistically highly significant highly significant difference between two studied groups with P value 0.000 where in group A 64 % of patients developed TIMI III flow, 22.7 % with TIMI II flow, 12.7% with TIMI I and 0.7% with TIMI 0 While in group B 86% of patients developed TIMI III flow, 9.3% of them developed TIMI II, 3.3 % developed TIMI I flow and 1.3 % developed TIMI 0. As regard MBG there was statistically highly significant difference between two groups with P value 0.00 where in group A where percentage of patients with MBG grades 0,1,2 and 3 were 4%, 16 %,18 % and 62 % respectively while in group B percentage of patients with MBG grades 0,1,2 and 3 were 1.3 %, 3.3 %, 9.3 % and 86 % respectively. As regard echo EF, there was statistically significant difference between two groups with P value 0.036 where mean EF in patients with group A was 40.50 ± 7.93 while the mean EF in patients with group B was 42.55 ± 8.88 . Conclusion Ticagrelor loading before primary PCI resulted in improved post-procedural TIMI flow. It also increased the post-procedural MBG. This resulted in a significant increase in the number of patients having more post-procedural Ejection fraction as measured by modified Simpson’s method. However, it did not decrease incidence of in-hospital MACE. Also there was no significant increase in risk of major nor minor bleeding in both young and elderly patients.

Predictive value of triglyceride glucose index combined with neutrophil-to-lymphocyte ratio for major adverse cardiac events after PCI for acute ST-segment elevation myocardial infarction

Acute ST-segment elevation myocardial infarction (STEMI) is a severe cardiovascular disease that poses a significant threat to the life and health of patients. This study aimed to investigate the predictive value of triglyceride glucose index (TyG) combined with neutrophil-to-lymphocyte ratio (NLR) for in-hospital cardiac adverse event (MACE) after PCI in STEMI patients. From October 2019 to June 2023, 398 STEMI patients underwent emergency PCI in the Second People's Hospital of Hefei. Stepwise regression backward method and multivariate logistic regression analysis were used to screen the independent risk factors of MACE in STEMI patients. To construct the prediction model of in-hospital MACE after PCI in STEMI patients: Grace score model is the old model (model A); TyG combined with NLR model (model B); Grace score combined with TyG and NLR model is the new model (model C). We assessed the clinical usefulness of the predictive model by comparing Integrated Discrimination Improvement (IDI), Net Reclassification Index (NRI), Receiver Operating Characteristic Curve (ROC), and Decision Curve Analysis (DCA). Stepwise regression and multivariate logistic regression analysis showed that TyG and NLR were independent risk factors for in-hospital MACE after PCI in STEMI patients. The constructed Model C was compared to Model A. Results showed NRI 0.5973; NRI + 0.3036, NRI − 0.2937, IDI 0.3583. These results show that the newly developed model C predicts the results better than model A, indicating that the model is more accurate. The ROC analysis results showed that the AUC of Model A for predicting MACE in STEMI was 0.749. Model B predicted MACE in STEMI with an AUC of 0.685. Model C predicted MACE in STEMI with an AUC of 0.839. For DCA, Model C has a better net return between threshold probability 0.1 and 0.78, which is better than Model A and Model B. In this study, by combining TyG, NLR, and Grace score, it was shown that TyG combined with NLR could reasonably predict the occurrence of MACE after PCI in STEMI patients and the clinical utility of the prediction model.

#1259 Relationship between renal dysfunction, non-obstructive ACS and in-hospital prognosis: findings from the CCC-ACS project

Abstract Background and Aims Acute coronary syndrome (ACS) is an acute and critical condition of coronary heart disease (CHD) with high mortality and poor prognosis. The prevalence of non-obstructive ACS is about 5% ∼ 15%. Among patients with non-obstructive ACS, which patients are more prone to poor prognosis is a concern. Chronic kidney disease (CKD) is an important risk factor for cardiovascular disease, and due to its special pathophysiological mechanism, non-obstructive ACS may not be uncommon in CKD patients. Therefore, the aim of this study was to investigate the relationship between renal function, the occurrence and prognosis of non-obstructive ACS. Method Improving Care for Cardiovascular Disease in China - Acute Coronary Syndrome (CCC-ACS), a hospital-based medical quality improvement project, is a hospital-based medical quality improvement project to improve the compliance of ACS guidelines in China and improve the prognosis of patients. It was jointly sponsored by the American Heart Association (AHA) and the Chinese Society of Cardiology (CSC) in 2014, with 240 hospitals participating, representing different levels of ACS management in Chinese hospitals. We analyzed patients who underwent coronary angiography from November 2014 to July 2019 in CCC-ACS. Patients were divided into eGFR <60 ml/min·1.73 m² and eGFR≥60 ml/min·1.73 m² groups according to estimated glomerular filtration rate (eGFR) calculated by the EPI formula. According to the results of coronary angiography, the patients were divided into obstructive ACS group and non-obstructive ACS group (obstructive ACS group was defined as at least one coronary artery stenosis ≥ 50%; the others were non-obstructive ACS group). Outcome was defined as in-hospital all-cause mortality and in-hospital MACEs. Results A total of 77 586 patients were included, including 2 292 patients (3.0%) with non-obstructive ACS and 75 294 patients (97.0%) with obstructive ACS. After adjusting for confounding factors using a multivariate logistic regression model, patients with eGFR<60 ml/min·1.73 m² had an approximately 20% increased risk of non-obstructive ACS compared with patients with eGFR≥60 ml/min·1.73 m². The comparison of in-hospital outcomes between the patients with non-obstructive ACS and obstructive ACS is shown in Fig. 1. In-hospital outcomes showed that although the obstructive ACS group had a worse in-hospital prognosis than the non-obstructive ACS group, and the eGFR<60 ml/min·1.73 m² group had a worse in-hospital prognosis than the eGFR≥60 ml/min·1.73 m² group, further grouping of patients showed that the non-obstructive ACS group with eGFR<60 ml/min·1.73 m² had a worse prognosis than the obstructive ACS group with eGFR≥60 ml/min·1.73 m². Confounding factors adjusted for non-obstructive ACS showed that lower eGFR was associated with a higher risk of in-hospital MACEs. After analyzing the in-hospital medication and discharge medication of patients, it was found that the standardized cardiovascular drug therapy was inadequate in patients with non-obstructive ACS. Conclusion Patients with non-obstructive ACS have worse renal function than patients with obstructive ACS, and the proportion of patients with eGFR<60 ml/min·1.73 m² is higher. In patients with non-obstructive ACS, the risk of in-hospital MACEs significantly increased as eGFR decreased. This suggests that we may consider giving standardized cardiovascular drug therapy to patients with non-obstructive ACS, especially those with non-obstructive ACS combined with abnormal renal function, in order to improve the prognosis of patients. This needs to be confirmed by more randomized controlled trial results.

Association between the triglyceride-glucose index and in-hospital major adverse cardiovascular events in patients with acute coronary syndrome: results from the Improving Care for Cardiovascular Disease in China (CCC)-Acute Coronary Syndrome project

ObjectiveAlthough the TyG index is a reliable predictor of insulin resistance (IR) and cardiovascular disease, its effectiveness in predicting major adverse cardiac events in hospitalized acute coronary syndrome (ACS) patients has not been validated in large-scale studies. In this study, we aimed to explore the association between the TyG index and the occurrence of MACEs during hospitalization.MethodsWe recruited ACS patients from the CCC-ACS (Improving Cardiovascular Care in China-ACS) database and calculated the TyG index using the formula ln(fasting triglyceride [mg/dL] × fasting glucose [mg/dL]/2). These patients were classified into four groups based on quartiles of the TyG index. The primary endpoint was the occurrence of MACEs during hospitalization, encompassing all-cause mortality, cardiac arrest, myocardial infarction (MI), and stroke. We performed Cox proportional hazards regression analysis to clarify the correlation between the TyG index and the risk of in-hospital MACEs among patients diagnosed with ACS. Additionally, we explored this relationship across various subgroups.ResultsA total of 101,113 patients were ultimately included, and 2759 in-hospital MACEs were recorded, with 1554 (49.1%) cases of all-cause mortality, 601 (21.8%) cases of cardiac arrest, 251 (9.1%) cases of MI, and 353 (12.8%) cases of stroke. After adjusting for confounders, patients in TyG index quartile groups 3 and 4 showed increased risks of in-hospital MACEs compared to those in quartile group 1 [HR = 1.253, 95% CI 1.121–1.400 and HR = 1.604, 95% CI 1.437–1.791, respectively; p value for trend < 0.001], especially in patients with STEMI or renal insufficiency. Moreover, we found interactions between the TyG index and age, sex, diabetes status, renal insufficiency status, and previous PCI (all p values for interactions < 0.05).ConclusionsIn patients with ACS, the TyG index was an independent predictor of in-hospital MACEs. Special vigilance should be exercised in females, elderly individuals, and patients with renal insufficiency.

Patients with alcohol abuse have higher risks of complications after coronary artery bypass grafting: A population-based study of National Inpatient Sample from 2015 to 2020

BackgroundAlcohol abuse (AA) has s high prevalence, affecting 10 to 15 million Americans. While AA was demonstrated to negatively impact cardiovascular health, limited evidence from existing studies presents conflicting findings regarding the effects of AA on coronary artery bypass grafting (CABG) outcomes. This study aimed to compare the in-hospital outcomes after CABG between AA and non-AA patients. MethodsPatients who underwent CABG were identified in National Inpatient Sample from Q4 2015–2020. Exclusion criteria included age<18 years and concomitant procedures. A 1:3 propensity-score matching was used to address differences in demographics, socioeconomic status, primary payer status, hospital characteristics, comorbidities, and transfer/admission status between AA and non-AA patients. In-hospital outcomes after CABG were examined. ResultsThere were 5694 (3.39%) AA patients who underwent CABG. After matching, 17,315 from 162,488 non-AA patients were matched to all AA patients. AA and non-AA patients had comparable mortality (1.64% vs 1.55%, p = 0.67) and MACE (2.46% vs 2.56%, p = 0.73). However, AA patients had higher cardiogenic shock (8.31% vs 7.43%, p = 0.03), mechanical ventilation (11.51% vs 7.96%, p < 0.01), hemorrhage/hematoma (57.49% vs 54.75%, p < 0.01), superficial (0.99% vs 0.61%, p < 0.01) and deep wound complications (0.37% vs 0.18%, p = 0.02), reopen surgery for bleeding control (0.92% vs 0.63%, p = 0.03), transfer out (21.00% vs 16.38%, p < 0.01), longer time from admission to operation (p < 0.01), longer length of stay (p < 0.01), and higher hospital charge (p < 0.01). ConclusionWhile AA was not found to be linked with in-hospital mortality or MACE after CABG, it was independently associated with postoperative complications. These findings could enhance preoperative risk stratification for AA patients and inform postoperative management following CABG.

The impact of the COVID-19 pandemic on cardiovascular disease in the cardiovascular center of Kermanshah, in the west of Iran

BackgroundCardiovascular diseases (CVD) are known as the most common cause of mortality worldwide. Hence, exploring the impact of COVID-19 pandemic on CVD and its risk factors. This study aimed to explore clinical and echocardiographic characteristics and cardiac manifestations in COVID-19 patients. MethodsThis cross-sectional study was conducted on 386 patients with COVID-19 admitted to Imam Ali Hospital, the largest specialized cardiology hospital in western Iran. The checklist included information about age, gender, hypertension, BMI, diabetes, chronic renal disease, cigarette smoking, echocardiography and ECG findings, in-hospital MACE, venous and arterial thrombotic events. To analyze the data, SPSS23, paired-samples t-test, chi-square test and logistic regression analysis were used. ResultsOur findings showed 57 % of patients were male and 43 % were female. The paients' average age was 64.61 ± 14.21 years. Moreover, 25.9 % of patients had diabetes, 27.7 % had blood pressure, 11.7 % were cigarette smokers and 11.1 % had hyperlipidemia. The main electrocardiographic abnormalities were ST-T changes in 1.31 % of the patients, sinus tachycardia in 16.3 % and atrial fibrillation in 11.1 % of patients. Mild to moderate pericardial effusion was observed in 8.1 % and pleural effusion in 9.1 % of the sample. Common cardiac complications were ACS in 52.9 %, DHF in 24.4 %, and CHB in 4.4 % of patients. 19.4 % of patients died during hospitalization. Mild to moderate pericardial effusion (OR = 1.96, 95 % CI 1.18–2.14, P = 0.012) was an independent predictor of mortality in COVID-19 patients. ConclusionResults of the study showed it is essential to pay closer attention to elderly, diabetic and hypertensive patients, who are more prone to COVID-19 infection. Moreover, common cardiac complications were ACS and DHF, respectively.

Robotic-assisted percutaneous coronary intervention: experience in Switzerland.

Percutaneous coronary intervention (PCI) exposes operators to ionizing radiation. Robotic-assisted PCI (RA-PCI) is a novel technology that enables interventional cardiologists to operate coronary devices remotely from a radiation-shed cockpit. The aim of this study is to describe the experience and challenges during the initiation of a RA-PCI program and to report outcomes of the first 21 patients undergoing RA-PCI in Switzerland. All patients undergoing RA-PCI using the CorPath GRX Vascular Robotic System between 06/2021 and 12/2021 at Inselspital, Bern University Hospital were included in this retrospective registry study. Baseline, procedural and clinical follow-up data were prospectively assessed as part of the Cardiobase Bern PCI registry (NCT02241291). The two endpoints of interest were clinical success [defined as <30% residual diameter stenosis in the absence of in-hospital major adverse cardiovascular events (MACE: composite of death, periprocedural myocardial infarction, target-vessel revascularization, and stroke)] and robotic success (defined as clinical success and completion of RA-PCI without or with partial manual assistance). Additional outcome measures include clinical long-term outcomes at one year. Twenty-five lesions in 21 patients were treated with RA-PCI (age 62.4 ± 9.1 years, 24% female). Clinical success was achieved in 100%, and robotic success in 81% (17/21 procedures, including 4 procedures requiring partial manual assistance). Manual conversion (e.g. manual completion of the procedure) occurred in 19% (4 procedures). Reasons for manual assistance or conversion were poor guiding-catheter back-up or platform limitations (4), adverse events (2x transient slow-flow that was solved manually), safety decision (1x vasovagal reaction not related to robotic approach), and software error (1). No in-hospital MACE occurred. During 12 months of follow-up, one patient suffered a non-target-vessel myocardial infarction requiring repeat PCI. RA-PCI can safely be performed without clinically relevant robot-associated complications in selected patients with approximately 80% of procedures conducted without or with partial manual assistance.

Coronary microvascular dysfunction in Takotsubo syndrome: an analysis using angiography-derived index of microcirculatory resistance.

Coronary microvascular dysfunction (CMD) has been proposed as a crucial factor in the pathophysiology of Takotsubo syndrome (TTS). The angiography-derived index of microcirculatory resistance (caIMR) offers an alternative to conventional hyperemic wire-based IMR to assess CMD. We aimed to evaluate CMD's prevalence, transience, and impact on in-hospital outcomes in TTS. All three coronary arteries of 96 patients with TTS were assessed for their coronary angiography derived Index of microcirculatory Resistance (caIMR) and compared to non-obstructed vessels of matched patients with ST-elevation myocardial infarction. Further, the association between caIMR and the TTS-specific combined in-hospital endpoint of death, cardiac arrest, ventricular arrhythmogenic events and cardiogenic shock was investigated. Elevated IMR was present in all TTS patients, with significantly elevated caIMR values in all coronary arteries compared to controls. CaIMR did not differ between apical and midventricular TTS types. CaIMR normalized in TTS patients with follow-up angiographies performed at a median of 28months (median caIMR at event vs follow-up: LAD 34.8 [29.9-41.1] vs 20.3 [16.0-25.3], p < 0.001; LCX: 38.7 [32.9-50.1] vs 23.7 [19.4-30.5], p < 0.001; RCA: 31.7 [25.0-39.1] vs 19.6 [17.1-24.0], p < 0.001). The extent of caIMR elevation significantly correlated with the combined in-hospital endpoint (p = 0.036). TTS patients had evidence of elevated caIMR in at least one coronary artery with a trend towards higher LAD caIMR in apical type TTS and normalization after recovery. Furthermore, extent of caIMR elevation was associated with increased risk of in-hospital MACE of TTS patients.

Impact of Clostridioides difficile infection in heart failure hospitalizations: analysis from the national inpatient sample database

Abstract Background Congestive heart failure (CHF) patients are at greater risk of nosocomial infections such as Clostridioides difficile infection (CDI) due to higher comorbidities, readmission rates, and prolonged hospital stays. Further, hypovolemia and sympathetic drive may aggravate myocardial dysfunction due to demand mismatch and worsen clinical outcomes. Purpose To assess the impact of CDI in congestive heart failure (CHF) hospitalizations nationally in the US. Methods The National Inpatient Sample database from 2016 to 2019 was queried to identify patients with a primary diagnosis of CHF. Subsequently, the sample was stratified based on the presence of CDI as a secondary diagnosis. The adjusted odds ratios (aOR) of in-hospital outcomes were calculated using chi-square statistics in software STAT v.17. Results Of 1,270,414 weighted hospitalizations with CHF, 8275 were diagnosed with CDI (0.65%). On adjusted analysis, patients with CHF and CDI had significantly higher in-hospital mortality (aOR 3.58, 95% CI 3.28-4.51, p&amp;lt;0.001), cardiac arrest (aOR 3.89, 95% CI 2.79-5.41, p&amp;lt;0.001), AMI (aOR 1.37, 95% CI 1.08-, p=0.007), MCS (aOR 5.16, 95% CI 3.91-6.8, p&amp;lt;0.001), stroke (aOR 1.85, 95% CI 1.09-3.14, p=0.022) and MACE (aOR 2.54, 95% CI 2.21-2.91, p&amp;lt;0.001), (Figure 1). Additionally, HF patients with CDI are associated with longer lengths of stay (12±16 vs. 5±6 ) and adjusted total charge ($133,045±291,290 vs. $51,919±133,303) compared to HF patients without CDI (Table 1). Conclusions CDI in CHF hospitalizations have adverse in-hospital outcomes with higher rates of in-hospital mortality, AMI, stroke, and MACE. This highlights the importance of early detection and aggressive infection prevention strategies in this high-risk population.Figure 1Table 1

Calcified coronary left main disease treated with and without intravascular lithotripsy: a real word first description

Abstract Background Intravascular lithotripsy (IVL) is a promising balloon-based technique to treat calcified coronary lesions. The evidence of its use in LM disease is scarce and there are no studies reporting a comparison between IVL and conventional techniques for calcified lesions, especially in LM PCI that represented an exclusion criteria of the DISRUPT-CAD trials. Methods The aim of this study is to evaluate safety and efficacy of IVL to treat moderate-severe calcified LM disease from January 2018 to December 2022. We stratified our cohort into two groups 1) patients who underwent LM PCI with IVL treatment (bail-out or upfront) and 2) LM PCI with conventional techniques excluding IVL (cutting balloons, NC/OPN balloons, rotational atherectomy). Efficacy endpoint: device success and stent expansion evaluated either by intravascular imaging or angiographic criteria. Safety endpoint: peri-procedural complications (coronary dissection, perforation, no-slow flow, peri-procedural MI, pericardial effusion) and in hospital death or target vessel failure. Results 87 patients were enrolled, 43 (49.4%) underwent LM PCI with IVL (group A), while 44 (50.6%) were treated with conventional techniques (35 NC balloons, 7 RA, 2 cutting balloons). Intravascular imaging was performed in 69% of cases, the 2 groups were similar in terms of age (77.4±9.63, p=0.94), comorbidity, clinical presentation and angiographic characteristics. Both groups presented severe calcifications in terms of calcium length (11.9±10.3, p=0.87), arc (270° 144-350, p = 0.76, and thickness (1.3 ±0.7 p =0.99) assessed by intravascular imaging. IVUS calcium score was similar between 2 groups (1.53±0.7, p = 0.7). Target vessel was distal LM-proximal LAD in 56.6%. IVL most used balloon was 3.5mm (55%), followed by 4.00mm (38.2%). Impella CP was implanted to support 4 PCI and removed at the end of the procedure. Provisional stenting was performed in 55.1% of cases, while two-stents technique was used in 26.4% (mainly represented by DK-crush). Good stent expansion (&amp;gt;80%) was achieved in 85% of cases, with a certain prevalence for patients treated with IVL. Optimal stent expansion (&amp;gt;90%) was higher in patients treated with IVL (9 in group A vs 3 in group B), although it did not reach a statistically significative difference (p=0.06). No differences in terms of complications and peri-procedural myocardial infarction occurred between the two groups. Conclusions This is the first description of a comparison between IVL and conventional techniques in LM calcified PCI. IVL appeared to be safe and effective with good stent expansion and low rate of peri-procedural complications and in-hospital MACE. LM lesions treated with IVL appeared to reach greater stent expansion compared to other techniques, although it was not statistically significative. Certainly, further trials are warranted to establish longer term outcomes and the benefit of IVL over existing calcium-modification therapies.

Long-term outcomes of patients with late presentation STEMI undergoing percutaneous coronary revascularization

Abstract Background/Introduction Patients with late-presentation ST-segment myocardial infarction (STEMI) (12-48hr of symptom onset) tend to have worse clinical outcomes compared to early presenters (&amp;lt;12hr of symptom onset). The optimal management and decision for primary percutaneous coronary intervention (PCI) is limited by the current evidence, particularly in the modern revascularisation era. Purpose The aim of this study was to assess the short- and long-term clinical outcomes of primary PCI in patients with STEMI who present late following symptom onset (12-48hr) compared to those who present early (&amp;lt;12hr). Methods Data from 4265 consecutive patients undergoing PCI for STEMI within 48hr of presentation were analysed from the Melbourne Interventional Group registry between 2014 and 2020. Patients were categorised based upon symptom-to-door time (early &amp;lt;12hr vs late 12-48hr).. The primary endpoints were in-hospital, 30-day and long-term mortality. Secondary outcomes were major adverse cardiovascular events (MACE; composite of all-cause mortality, non-fatal myocardial infarction, non-fatal stroke or repeat revascularisation), procedural outcomes and medications at 30-day. Results 4044 patients were early presentation and 221 patients were late presentation. The median symptom-to-door time was 1.73hr (interquartile range (IQR) 1.2, 2.8) for early presenters and 14.8hr (IQR 13.2, 18.1) for late presenters. Late presenters were less likely to have out-of-hospital cardiac arrest and require inotropic support (all p&amp;lt;0.01). There was no significant difference in in-hospital mortality (6.5% vs 5.4%, p=0.53) and MACE (9.0% vs 7.7%, p=0.52), nor 30-day mortality (7.4% vs 7.3%, p=0.94) and MACE (11.1% vs 10.5%, p=0.77). Long-term mortality did not differ between early and late presenters with hazard ratio 1.17 (95% confidence interval 0.71-1.95, p=0.54). There was no difference in major bleeding at 30-days (p=0.42). Conclusions Primary PCI in patients following late presentation STEMI is not associated with worse short- or long-term clinical outcomes compared to those who present early . Further, randomised controlled trials in the modern revascularisation era are needed to guide clinical practice.

The framing of time-dependent machine learning models improves risk estimation among young individuals with acute coronary syndromes

Abstract Introduction Acute coronary syndrome (ACS) is a common cause of death in individuals older than 55 years. Although younger individuals are less frequently seen with ACS, this clinical event shows high recurrence rates and triggers considerable economic burden. Young individuals with ACS (yACS) are usually underrepresented and show idiosyncratic epidemiologic features compared to older subjects. These differences may justify why available risk prediction models usually penalize yACS with higher false positive rates compared to older subjects. We hypothesized that exploring temporal framing structures such as prediction time, observation windows and subgroup-specific prediction, could improve time-dependent prediction metrics. More specifically, we evaluated potential improvements in risk prediction quality among yACS by (i) developing models specifically in yACS versus a global cohort; (ii) splitting predictive rules into short- and long-term prediction windows [STWm and LTWm] versus a global follow-up model (GFm). Methods We included 6341 consecutive subjects with ACS (2242 with yACS) admitted into public hospitals in a large city in Brazil who undergone coronarography up to 48h after hospital admission from 2011 to 2020. The observation window in STWm and GFm included the first 48h upon hospital admission, and LTWm included all in-hospital information. yACS cohort was divided into train/validation-set (70%, n=1569) and test-set (30%, n=673); global cohort was divided in training/validation-set (70%, n=4439) and test-set including the 673 yACS subjects. Models were repeated over five cross-validation folds and then assessed in the test-set. C-statistics was the evaluation metric for STWm and time-dependent concordance (Ctd-index) for LTWm. STWm evaluated the occurrence of in-hospital cardiovascular deaths and recurrent ACS (MACE) and LTWm estimated events occurring post-discharge from index ACS hospitalization considering time-to-event with competing risks (MACE versus non-cardiovascular deaths). Results Among yACS and older subjects, respectively, in-hospital MACE occurred in 180 and 493 individuals, post-discharge MACE in 454 and 881; and post-discharge non-cardiovascular death in 47 and 285 after 6.67 years (95%CI 5.59-7.24) of follow-up. The best strategy was to design models specifically in yACS individuals combining STWm and LTWm. Among yACS subjects, STWm and LTWm yielded a C-statistics [0.921 (95%CI 0.889-0.953)] and Ctd-index [0.722 (95%CI 0.678-0.760)], respectively, while the best Ctd-index in GFm was 0.681 (95%CI 0.654-0.703). There was very low concordance among top predictors of MACE for prACS versus global cohort, as well as for STWm versus LTWm. Conclusions Predictive accuracy for adverse clinical events was optimized by using specific rules for yACS and splitting short-term and long-term prediction windows, leading to the detection of 80% of events, compared to 69% by using a rule designed for the global cohort.

Outcomes of chronic total occlusion percutaneous coronary intervention from the RAIAN (RAjaie - Iran) registry

ObjectiveWhile most of the evidence in CTO interventions emerge from Western and Japanese studies, few data have been published up today from the Middle East. Objective of this study was to evaluate technical success rates and clinical outcomes of an Iranian population undergoing CTO PCI in a tertiary referral hospital. Moreover, we sought to evaluate the efficacy of our CTO teaching program. MethodsThis is a retrospective single-center cohort study including 790 patients who underwent CTO PCI performed by operators with different volumes of CTOs PCI performed per year. According to PCI result, all patients have been divided into successful (n = 555, 70.3 %) and unsuccessful (n = 235, 29.7 %) groups. Study endpoints were Major Adverse Cardiovascular Events and Health Status Improvement evaluated using the Seattle Angina Questionnaire at one year. ResultsA global success rate of 70 % for antegrade and 80 % for retrograde approach was shown despite the lack of some CTO-dedicated devices. During the enrollment period, the success rate increased significantly among operators with a lower number of CTO procedures per year. One-year MACE rate was similar in both successful and unsuccessful groups (13.5 % in successful and 10.6 % in unsuccessful group, p = 0.173). One year patients’ health status improved significantly only in successful group. ConclusionsNo significant differences of in-hospital and one-year MACE were found between the successful and unsuccessful groups. Angina symptoms and quality of life significantly improved after successful CTO PCI. The RAIAN registry confirmed the importance of operator expertise for CTO PCI success.

Using machine learning to predict outcomes following open abdominal aortic aneurysm repair

ObjectivePrediction of outcomes following open abdominal aortic aneurysm (AAA) repair remains challenging with a lack of widely used tools to guide perioperative management. We developed machine learning (ML) algorithms that predict outcomes following open AAA repair. MethodsThe Vascular Quality Initiative (VQI) database was used to identify patients who underwent elective open AAA repair between 2003 and 2023. Input features included 52 preoperative demographic/clinical variables. All available preoperative variables from VQI were used to maximize predictive performance. The primary outcome was in-hospital major adverse cardiovascular event (MACE; composite of myocardial infarction, stroke, or death). Secondary outcomes were individual components of the primary outcome, other in-hospital complications, and 1-year mortality and any reintervention. We split our data into training (70%) and test (30%) sets. Using 10-fold cross-validation, six ML models were trained using preoperative features (Extreme Gradient Boosting [XGBoost], random forest, Naïve Bayes classifier, support vector machine, artificial neural network, and logistic regression). The primary model evaluation metric was area under the receiver operating characteristic curve (AUROC). Model robustness was evaluated with calibration plot and Brier score. The top 10 predictive features in our final model were determined based on variable importance scores. Performance was assessed on subgroups based on age, sex, race, ethnicity, rurality, median area deprivation index, proximal clamp site, prior aortic surgery, and concomitant procedures. ResultsOverall, 12,027 patients were included. The primary outcome of in-hospital MACE occurred in 630 patients (5.2%). Compared with patients without a primary outcome, those who developed in-hospital MACE were older with more comorbidities, demonstrated poorer functional status, had more complex aneurysms, and were more likely to require concomitant procedures. Our best performing prediction model for in-hospital MACE was XGBoost, achieving an AUROC of 0.93 (95% confidence interval, 0.92-0.94). Comparatively, logistic regression had an AUROC of 0.71 (95% confidence interval, 0.70-0.73). For secondary outcomes, XGBoost achieved AUROCs between 0.84 and 0.94. The calibration plot showed good agreement between predicted and observed event probabilities with a Brier score of 0.05. These findings highlight the excellent predictive performance of the XGBoost model. The top three predictive features in our algorithm for in-hospital MACE following open AAA repair were: (1) coronary artery disease; (2) American Society of Anesthesiologists classification; and (3) proximal clamp site. Model performance remained robust on all subgroup analyses. ConclusionsOpen AAA repair outcomes can be accurately predicted using preoperative data with our ML models, which perform better than logistic regression. Our automated algorithms can help guide risk-mitigation strategies for patients being considered for open AAA repair to improve outcomes.

Atrial fibrillation and chronic total occlusion percutaneous coronary intervention outcomes: insights from the Progress-CTO registry.

We examined the effect of atrial fibrillation on the outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). We examined the baseline characteristics and procedural outcomes of 9,166 CTO PCIs performed at 39 US and non-US centers between 2012 and 2023. Atrial fibrillation was present in 1122 (12%) patients. These patients were older and had a higher incidence of comorbidities, such as hypertension, dyslipidemia, heart failure, cerebrovascular disease, and peripheral arterial disease, lower left ventricular ejection fraction, and lower eGFR. Their CTOs were more likely to have moderate to severe calcification and longer lesion length. They also had higher mean J-CTO and PROGRESS-CTO complications (Acute MI, MACE, Mortality, Perforation, and Pericardiocentesis) scores. Patients with atrial fibrillation had higher prevalence of uncrossable and undilatable CTO lesions and required longer procedure (107 vs 119 min; P less than .001) and fluoroscopy (40 vs 43 min; P=.005) time. Technical success and MACE, including procedural/in-hospital bleeding, were similar in patients with and without atrial fibrillation. Although the crude incidence of MACE on follow-up (median 61 days) was significantly higher in patients with atrial fibrillation, the latter was not independently associated with adverse events on Cox proportional hazards analysis. Patients with atrial fibrillation undergoing CTO PCI are older, have more comorbidities, higher lesion complexity, and longer procedure time, but similar technical success and in-hospital MACE. They have higher MACE and mortality during follow-up, but the difference is not significant after adjusting for potential confounding variables.

Off-pump CABG surgery in left main coronary artery disease: a single-center prospective registry.

The treatment of left main (LM) coronary artery disease (CAD) requires complex decision-making. Patients with left main multi-vessel coronary artery disease (LM CAD) have concerns regarding incomplete revascularization and reduced survival with off-pump (OPCAB) when compared with on-pump (ONCAB) coronary bypass surgery. To evaluate outcomes among high-risk LM CAD patients undergoing OPCAB, we performed a registry-based prospective study. We performed 4868 coronary artery bypass graft (CABG) surgeries from Jan 2013 to Jun 2019 with 4662 (95.8%) OPCAB. In OPCAB cohort, we had 1323 patients (28.4%) with significant LM (> 50%) triple vessel CAD. Data regarding clinical features, extent of CAD, operative details, in-hospital outcomes, and 3-year follow-up were obtained. Descriptive statistics are reported. The study cohort (n = 1323) was aged 63 ± 9years with men 88.4%. Tobacco use was in 328 (24.8%), diabetes 598 (45.2%), previous myocardial infarction 463 (35.0%), previous coronary intervention 40 (3.0%), and congestive heart failure in 54 (4.1%). All patients had LM (100.0%) with triple vessel disease in 99.4% (LAD, left anterior descending 100.0%; LCX, left circumflex 99.4%; RCA, right coronary artery 78.7%). Vessels bypassed/patient were 2.7 ± 0.4 with 3.2 ± 0.7 total grafts and 2.1 ± 0.8 venous grafts. In total, 1278 (96.5%) patients received left internal mammary artery (LIMA), 63(4.7%) bilateral internal mammary artery (BIMA), and 74 (5.6%) radial artery grafts. There was no patient with conversion from OPCAB to ONCAB. In-hospital major adverse cardiovascular events (MACE: all-cause deaths, myocardial infarction, and stroke) were in 21 (1.6%). At 3-year follow-up (n = 1041), MACE rates were in 84 (8.1%) and cardiovascular deaths in 28 (2.7%). This study shows that off-pump CABG surgery is safe in patients with LM CAD. There is low in-hospital mortality and MACE and 3-year outcomes are similar to the published data of LM CAD patients who undergo on-pump CABG. The online version contains supplementary material available at 10.1007/s12055-023-01526-3.