Increase In Major Adverse Cardiac Events Research Articles

Abstract 18876: Safety and Efficacy of Coronary CT Angiography in Acute Chest Pain. A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Background: Coronary computed tomography angiography (CCTA) allows direct visualization of coronary arteries. As a result of the high accuracy, CCTA has been proposed as an initial step in patients presenting to the emergency department (ED) with acute chest pain to rule out obstructive coronary artery disease (CAD). The effect of the initial CCTA strategy on downstream testing with coronary angiogram and coronary revascularization is yet to be delineated. Objective: To investigate the safety and efficacy of CCTA in patients presenting to the ED with acute chest pain compared to standard of care (SoC). Method: We searched PubMed, Cochrane CENTRAL Register, and ClinicalTrials.gov (inception through July 1st, 2023) for randomized clinical trials evaluating the outcomes of CCTA in acute chest pain. We used a random-effect model to calculate risk ratio (RR) with a 95% confidence interval (CI). The endpoints were all-cause mortality, major adverse cardiac events (MACE), rates of coronary angiography, and length of stay (LOS). Results: A total of 17 studies comprising 9237 patients were included in the analysis. Compared to SoC, the CCTA group had a shorter length of hospitalization (RR -0.3; 95%CI -0.64- -0.13; P = 0.0005). There was no significant difference in all-cause mortality or MACE (RR 0.8; 95%CI 0.45- 1.5; P = 0.52) and (RR -1.00; 95%CI 0.76- 1.3; P = 0.98), respectively. Rates of coronary angiography did not differ between the two groups (RR 0.93; 95%CI 0.61- 1.41; P = 0.96). Conclusion: CCTA is a reliable non-invasive imaging modality that can play a significant role in evaluating acute chest pain in the emergency department and is associated with a decrease in the length of stay without an increase in MACE. There was no increase in downstream coronary angiogram or coronary revascularization in the CCTA group.

Elevated HsCRP in Chronic Obstructive Pulmonary Disease: A Prospective Study of Long-Term Outcomes After Percutaneous Coronary Intervention.

ObjectiveAnti-inflammatory therapies are reported to have additional benefits beyond lipid control for patients with cardiovascular disease. However, no study has focused on the relationship between inflammation status and long-term outcomes for chronic obstructive pulmonary disease (COPD) patients, after percutaneous coronary intervention (PCI).Methods277 COPD-PCI patients were divided into two groups according to hsCRP status upon admission. Major adverse cardiac events (MACE) in high hsCRP patients were compared to patients with low hsCRP. Restricted cubic spline (RCS) analysis was performed using MACE hazard ratios (HR) to investigate interrelations with hsCRP, as a continuous variable.ResultsPatients in the high hsCRP group incurred more inflammation activation, in terms of higher white blood cell counts, neutrophil, lymphocytes, and had higher smoking rates, compared to those with lower hsCRPs. A significant increase in MACEs was observed in hsCRP high group, compared to the low hsCRP group (HR: 2.47, 95% CI: 1.22–5.00; p = 0.012). RCS curves suggest that HRs rise beyond 1.0, after the 0.24 juncture for Lg HsCRP (base 10 logarithm with hsCRP), HR per SD: 1.19 (95% CI: 0.96–1.48). Further subgroup analysis implies that elevated hsCRP is associated with a higher risk of MACEs across the sub-groups tested.ConclusionHsCRP could be a useful indicator for COPD-CAD patient prognosis, after PCI. This is because hsCRP highlights inflammation activation. More multi-center research, designed for COPD-CAD patients should be conducted to more accurately determine the cut-off value for hsCRP.

The prognostic value of regadenoson SPECT myocardial perfusion imaging: The largest cohort to date

BackgroundData on the prognostic value of regadenoson SPECT myocardial perfusion imaging (MPI) is limited and based on small cohorts. Methods and ResultsWe conducted a single-center, retrospective cohort study of 10,275 consecutive patients who underwent regadenoson SPECT-MPI. Among the study subjects, 28.7% had abnormal MPI and 25.5% had myocardial ischemia. Patients were followed for a mean of 2.4 ± 2.2 years for major adverse cardiac events (MACE), defined as cardiac death or myocardial infarction. There was a significant stepwise increase in MACE with an increasing burden of perfusion abnormality (P < .001) and myocardial ischemia (P < .001). Abnormal MPI (adjusted HR 1.52; 95% CI 1.21 to 1.91) and myocardial ischemia (adjusted HR 1.53; 95% CI 1.25 to 1.89) were associated with MACE, independent of and incremental to clinical covariates and left ventricular ejection fraction (LVEF). Moreover, post-stress LVEF, LVEF reserve, and left ventricular end-diastolic volume added significant prognostic information. Transient ischemic dilation ≥ 1.31 did not provide incremental prognostic value (adjusted HR 1.02; P = .906). ConclusionIn the largest cohort to date, we demonstrated that the presence and severity of perfusion abnormality and myocardial ischemia on regadenoson stress SPECT-MPI are associated with an independent increase in MACE.

Impact of Perioperative Blood Transfusion in Anemic Patients Undergoing Infra Inguinal Bypass

Patients who present with lower extremity ischemia are frequently anemic and the optimal transfusion threshold for this cohort remains controversial. We sought to evaluate the impact of blood transfusion on postoperative major adverse cardiac events (MACE), including myocardial infarction, dysrhythmia, stroke, congestive heart failure, and 30-day mortality for these patients. All consecutive patients who underwent infra-inguinal bypass at our institution from 2011 to 2020 were included. Perioperative red blood cell transfusion was the primary exposure, and the primary outcome was MACE. Univariate and multivariable analyses were performed to assess the impact of patient and procedural variables, including red blood cell transfusion, stratified by hemoglobin (Hgb) nadir: <7, 7-8, and >8 g/dL. Of the 287 patients reviewed for analysis, 146 (50.9%) had a perioperative transfusion (mean: 1.6 ± 3 units). Patients who received a transfusion had a mean nadir Hgb of 8.3 ± 1.0 g/dL, compared to 10.1 ± 1.7 g/dL without a transfusion. The overall incidence of MACE was 15.7% (45 of 287 patients). Univariate analysis demonstrated that MACE was associated with blood transfusion (P=0.009), lower Hgb nadir (P=0.02), and higher blood loss (P=0.003). On multivariate analysis, transfusion was independently associated with MACE for patients with a Hgb nadir >8 g/dL (OR: 3.09; P=0.006), but not for patients with Hgb nadir 7-8 g/dL (OR: 0.818; P=0.77). Additionally, patients with MACE had significantly longer length of hospital stay than for patients without (13 vs. 7.7 days, P=0.001). For patients undergoing infra-inguinal bypass, receiving a red blood cell transfusion with a Hgb nadir >8 g/dL was associated with a 3-fold increase in MACE, with nearly twice the length of stay. For patients with a Hgb 7-8 g/dL, transfusion did not increase or reduce the incidence of MACE. These findings suggest no benefit of blood transfusion for patients with Hgb nadir >7 g/dL and harm for Hgb >8 g/dL, however causation cannot be proven due to the retrospective nature of the study and randomized studies are needed to confirm or refute these findings.

Effect of Perioperative Blood Transfusion in Anemic Patients Undergoing Infrainguinal Bypass

Patients who present with lower extremity ischemia are frequently anemic, and the optimal transfusion threshold for this cohort has remained controversial. We sought to evaluate the effect of blood transfusion on major adverse cardiac events (MACE), including myocardial infarction, dysrhythmia, stroke, congestive heart failure, and 30-day mortality for these patients. All consecutive patients who had undergone infrainguinal bypass at our institution from 2011 to 2020 were included. The primary outcome was MACE, and blood transfusion was the primary exposure. Univariate and multivariable analyses were performed to assess the effects of patient and procedural variables, including red blood cell transfusion, stratified by hemoglobin (Hb) nadir (<7, 7-8, >8 g/dL). Of the 287 patients reviewed for analysis, 146 (50.9%) had required transfusion (mean, 1.6 ± 3 U). The patients who had received a transfusion had had a mean nadir Hb of 8.3 ± 1.0 g/dL compared with 10.1 ± 1.7 g/dL for those without transfusion. The overall incidence of MACE was 15.7% (45 of 287 patients). Univariate analysis demonstrated that MACE was associated with blood transfusion (P = .009), lower Hb nadir (P = .02), higher blood loss (P = .003), higher baseline creatinine (P = .02), previous coronary revascularization (P = .002), nonambulatory status (P = .03), American Society of Anesthesiologists classification 4 or 5 (P < .0001), and preoperative P2Y12 antagonist therapy (P = .049). Transfusion was independently associated with MACE for patients with a Hb nadir >8 (odds ratio [OR], 3.09; P = .006) but not for patients with a Hb nadir of 7 to 8 (OR, 0.818; P = .77). The effect in the Hb nadir <7 group was inconclusive (Fig). The only other variables independently associated with MACE were previous coronary revascularization (OR, 2.58; P = .01) and higher blood loss (OR, 1.05; P = .02). The hospital length of stay for patients with MACE was significantly longer than that for patients without MACE (14.8 vs 8.2 days; P < .001). For patients undergoing infrainguinal bypass, receiving a transfusion with a Hb nadir >8 was associated with a threefold increase in MACE, with a length of stay twice as long. For patients with a Hb of 7 to 8, transfusion did not increase or reduce the incidence of MACE. These findings suggest no benefit of blood transfusions for patients with a Hb nadir >7 and harm for those with a Hb nadir >8.

Poor glycemic control is associated with significant increase in major limb amputation and adverse events in the 30-day postoperative period after infrainguinal bypass

ObjectiveUnderstanding modifiable risk factors to improve surgical outcomes is increasingly important in value-based health care. There is an established association between peripheral artery disease (PAD), diabetes, and limb loss, but less is known about expected outcomes after revascularization relative to the degree of glycemic control. The purpose of this study was to determine the association between hemoglobin A1c (HbA1c) management in diabetics and surgical outcomes after open infrainguinal bypass. MethodsThe Vascular Quality Initiative infrainguinal bypass module was used to identify adult patients (≥18 years) with a history of diabetes who underwent bypass for PAD between 2011 and 2018. Exclusion criteria included missing or illogical HbA1c values and if the indication for the limb treated was not PAD. Patients were categorized by preoperative HbA1c levels as low severity/controlled (<7.0%), high severity (7.0%-10.0%), and very high severity (>10.0%). Primary outcomes were 30-day incidence of major adverse cardiac events (MACEs), major adverse limb events (MALEs), ipsilateral amputation, and 1-year all-cause mortality. Thirty-day outcomes were calculated using multivariable regression to compute odds ratios; hazard ratios were calculated for all-cause mortality. All analyses were adjusted for demographics, comorbidities, and clinical characteristics. ResultsThe final sample included 30,813 operations (27,988 unique patients): 17,517 (57%) nondiabetic patients, 5194 patients with low-severity/controlled diabetes, and 8102 (26%) patients with poorly controlled diabetes, including 5531 (70%) treated with insulin. There were 6439 (21%) patients with high-severity HbA1c values and 1663 (5%) patients with very-high-severity HbA1c values. Those with a very high HbA1c level were more likely to be nonwhite, insulin dependent, and active smokers. Compared with nondiabetics, patients with very-high-severity HbA1c had an 81% increase in MACEs and 31% increase in MALEs, whereas patients with high-severity HbA1c only had a 49% increase in MACEs and a 12% increase in MALEs. Each one-step increase in severity category (eg, low to high to very high) was associated with an average 29% increase in the odds of MACEs and an 8% increase in the odds of MALEs. ConclusionsUncontrolled diabetes with an HbA1c value >10.0% was associated with significantly worse 30-day surgical outcomes. Patients with incrementally better glycemic control (HbA1c level of 7.0%-10.0%) did not suffer the same rate of complications, suggesting that preoperative attempts at improving diabetes management even slightly could lead to improved surgical outcomes in open infrainguinal bypass patients.

Global Longitudinal Strain and Cardiac Events in Patients With Immune Checkpoint Inhibitor-Related Myocarditis

BackgroundThere is a need for improved methods for detection and risk stratification of myocarditis associated with immune checkpoint inhibitors (ICIs). Global longitudinal strain (GLS) is a sensitive marker of cardiac toxicity among patients receiving standard chemotherapy. There are no data on the use of GLS in ICI myocarditis. ObjectivesThis study sought to evaluate the role of GLS and assess its association with cardiac events among patients with ICI myocarditis. MethodsThis study retrospectively compared echocardiographic GLS by speckle tracking at presentation with ICI myocarditis (cases, n = 101) to that from patients receiving an ICI who did not develop myocarditis (control subjects, n = 92). Where available, GLS was also measured pre-ICI in both groups. Major adverse cardiac events (MACE) were defined as a composite of cardiogenic shock, arrest, complete heart block, and cardiac death. ResultsCases and control subjects were similar in age, sex, and cancer type. At presentation with myocarditis, 61 cases (60%) had a normal ejection fraction (EF). Pre-ICI, GLS was similar between cases and control subjects (20.3 ± 2.6% vs. 20.6 ± 2.0%; p = 0.60). There was no change in GLS among control subjects on an ICI without myocarditis (pre-ICI vs. on ICI, 20.6 ± 2.0% vs. 20.5 ± 1.9%; p = 0.41); in contrast, among cases, GLS decreased to 14.1 ± 2.8% (p < 0.001). The GLS at presentation with myocarditis was lower among cases presenting with either a reduced (12.3 ± 2.7%) or preserved EF (15.3 ± 2.0%; p < 0.001). Over a median follow-up of 162 days, 51 (51%) experienced MACE. The risk of MACE was higher with a lower GLS among patients with either a reduced or preserved EF. After adjustment for EF, each percent reduction in GLS was associated with a 1.5-fold increase in MACE among patients with a reduced EF (hazard ratio: 1.5; 95% confidence interval: 1.2 to 1.8) and a 4.4-fold increase with a preserved EF (hazard ratio: 4.4; 95% confidence interval: 2.4 to 7.8). ConclusionsGLS decreases with ICI myocarditis and, compared with control subjects, was lower among cases presenting with either a preserved or reduced EF. Lower GLS was strongly associated with MACE in ICI myocarditis presenting with either a preserved or reduced EF.

Abstract 226: Predicting Major Adverse Cardiac Events Using HEART Score in the Elderly

Background: The HEART score was developed to predict major adverse cardiac events (MACE) within 6 weeks in patients evaluated for chest pain. In the established score, age is scored as &lt;45 years old (y/o) = 0 points, 45-64 y/o = 1 point, and &gt;65 y/o = 2 points. The average age of patients in the original study by Backus et al was 61.2 y/o. Our aim is to evaluate the prognostic value of the HEART score in patients &gt;65 y/o. We hypothesized that elderly patients are at increased risk of MACE unaccounted for by the established age scoring system. Methods: We retrospectively reviewed 668 emergency room visits for chest pain (excluding STEMI) between 2016 to 2018 at a single tertiary, urban medical center. HEART scores were calculated based on presenting data. The primary outcome was MACE (MI, PCI, CABG, or death) within 6 weeks. Patients &gt;65 y/o were stratified to 65-74 y/o, 75-84 y/o, and &gt;85 y/o. Primary outcomes were compared between these age groups. Differences in HEART scores between age groups were controlled by comparing patients within the same HEART score brackets (4-6, 7-8, 9-10). Chi squared analysis was used to determine statistically significant differences in MACE (p&lt;0.01). Results: The average age was 60.2 y/o and average HEART score 5.56. There was statistically significant increase in MACE between &lt;45 y/o (18.5%), 45-64 y/o (36.6%), and &gt;65 y/o (47.4%), as outlined by the established HEART score (p&lt;0.01). However, when comparing 65-74 y/o (45.7%), 75-84 y/o (48.8%) and &gt;85 y/o (48.8%), increasing age did not correlate with increasing rate of MACE (p=0.90). When controlled for differences in HEART scores, there was again no statistically significant increase rates of MACE between 65-74 y/o, 75-84y/o, and &gt;85 y/o across all HEART score brackets (4-6, 7-8, 9-10). Conclusion: In patients &gt;65 y/o, increasing age did not correlate with increasing rate of MACE refuting our hypothesis. This represents that the other components of the HEART score have greater impact on prognosis than age in this elderly patient population. Our findings support the current age stratification of the established HEART score and show that even in the very elderly, the HEART score adequately accounts for age as a contributor to MACE.

The HAS-Choice study: Utilizing the HEART score, an ADP, and shared decision-making to decrease admissions in chest pain patients

ObjectiveThe HAS-Choice pathway utilizes the HEART Score, an accelerated diagnostic protocol (ADP), and shared decision-making using a visual aid in the evaluation of chest pain patients. We seek to determine if our intervention can improve resource utilization in a community emergency department (ED) setting while maintaining safe patient care. MethodsThis was a single-center prospective cohort study with historical that included ED patients ≥21years old presenting with a primary complaint of chest pain in two time periods. The primary outcome was patient disposition. Secondary outcomes focused on 30-day ED bounce back and major adverse cardiac events (MACE). We used multivariate logistic regression to estimate the odds ratio (OR) and its 95% confidence interval (CI). ResultsIn the pre-implementation period, the unadjusted disposition to inpatient, observation and discharge was 6.5%, 49.1% and 44.4%, respectively, whereas in the post period, the disposition was 4.8%, 41.5% and 53.7%, respectively (chi-square p<0.001). The adjusted odds of a patient being discharged was 40% higher (OR=1.40; 95% CI, 1.30, 1.51; p<0.001) in the post-implementation period. The adjusted odds of patient admission was 30% lower (OR=0.70; 95% CI, 0.60, 0.82; p<0.001) in the post-implementation period. The odds of 30-day ED bounce back did not statistically differ between the two periods. MACE rates were <1% in both periods, with a significant decrease in mortality in the post-implementation period. ConclusionOur study suggests that implementation of a shared decision-making tool that integrates an ADP and the HEART score can safely decrease hospital admissions without an increase in MACE.

Utility of Physician Selection of Cardiac Tests in a Chest Pain Unit to Exclude Acute Coronary Syndrome Among Patients Without a History of Coronary Artery Disease

There are few data on the utility of physician selection of cardiac tests, including no-test, in a chest pain unit (CPU) to rule out acute coronary syndrome in low-risk patients without a history of coronary artery disease. We analyzed consecutive low-risk patients admitted to our CPU between 2012 and 2014 and determined the proportion of patients selected for testing, the type of initial cardiac test selected, and the incidence of major adverse cardiac events (MACEs) at 30 days and 6 months. The study group comprised 619 patients: mean age 57 years (27 to 92), 332 women (54%), and 360 (58%) with multiple cardiac risk factors. Cardiac testing included 283 no-test (46%); 179 exercise treadmill (29%); 113 myocardial perfusion stress scintigraphy (18%); <10% each for exercise stress echocardiography and coronary angiography. Testing was negative in 296 (88%), nondiagnostic in 30 (9%), and positive in 10 patients (3%). There were no MACEs at 30 days in any patients, and at 6 months, MACEs were 5 (1.1%). Length of stay was less in no-test than in tested patients (5.4 hours vs 9.8 hours, p <0.0001), and there was no difference in incidence of MACE at 6 months in no-test vs tested patients (2 MACEs vs 3 MACEs). Physician selection of cardiac tests, including no-test, promptly identified patients at low risk of acute coronary syndrome who could be safely and rapidly discharged from the CPU. Exclusion of cardiac testing shortened length of stay and was not associated with increase in MACE at 6 months.

Near-infrared spectroscopy-derived lipid core burden index predicts adverse cardiovascular outcome in patients with coronary artery disease during long-term follow-up.

Near-infrared spectroscopy (NIRS) is able to quantify cholesterol within coronary arteries by the lipid core burden index (LCBI). We studied the prognostic value of NIRS-derived LCBI in patients with coronary artery disease (CAD) for adverse cardiac outcome during long-term follow-up. During 2009-2013, NIRS was performed in a non-culprit artery of 275 patients undergoing coronary angiography for acute coronary syndrome (ACS) or stable angina. LCBI was quantified by an independent corelab for the region of interest (LCBIROI) and the 4 and 10 mm long segment with the maximum LCBI (MaxLCBI4mm and MaxLCBI10mm). The primary endpoint was major adverse cardiac events (MACE), defined as the composite of all-cause death, non-fatal ACS, or unplanned revascularization. Hazard ratios (HR) were adjusted for age, gender, clinical risk factors, and segment plaque burden based on intravascular ultrasound. During a median follow-up of 4.1 years, 79 patients (28.7%) had MACE. There was a statistically significant and independent continuous relationship between higher MaxLCBI4mm values and a higher risk of MACE. Each 100 units increase of MaxLCBI4mm was associated with a 19% increase in MACE [hazard ratios (HR) 1.19, 95% confidence intervals (95% CI): 1.07-1.32, P = 0.001]. Continuous MaxLCBI4mm remained independently associated with MACE after exclusion of target lesion-related events (HR 1.21, 95% CI: 1.08-1.35), as well as after exclusion of adverse events related to the NIRS-imaged coronary segment (HR 1.19, 95% CI: 1.06-1.34). Results for MaxLCBI10mm were comparable. NIRS-derived LCBI is associated with adverse cardiac outcome in CAD patients during long-term follow-up independent of clinical risk factors and plaque burden.

Effect of Using the HEART Score in Patients With Chest Pain in the Emergency Department: A Stepped-Wedge, Cluster Randomized Trial.

The HEART (History, Electrocardiogram, Age, Risk factors, and initial Troponin) score is an easy-to-apply instrument to stratify patients with chest pain according to their short-term risk for major adverse cardiac events (MACEs), but its effect on daily practice is unknown. To measure the effect of use of the HEART score on patient outcomes and use of health care resources. Stepped-wedge, cluster randomized trial. (ClinicalTrials.gov: NCT01756846). Emergency departments in 9 Dutch hospitals. Unselected patients with chest pain presenting at emergency departments in 2013 and 2014. All hospitals started with usual care. Every 6 weeks, 1 hospital was randomly assigned to switch to "HEART care," during which physicians calculated the HEART score to guide patient management. For safety, a noninferiority margin of a 3.0% absolute increase in MACEs within 6 weeks was set. Other outcomes included use of health care resources, quality of life, and cost-effectiveness. A total of 3648 patients were included (1827 receiving usual care and 1821 receiving HEART care). Six-week incidence of MACEs during HEART care was 1.3% lower than during usual care (upper limit of the 1-sided 95% CI, 2.1% [within the noninferiority margin of 3.0%]). In low-risk patients, incidence of MACEs was 2.0% (95% CI, 1.2% to 3.3%). No statistically significant differences in early discharge, readmissions, recurrent emergency department visits, outpatient visits, or visits to general practitioners were observed. Physicians were hesitant to refrain from admission and diagnostic tests in patients classified as low risk by the HEART score. Using the HEART score during initial assessment of patients with chest pain is safe, but the effect on health care resources is limited, possibly due to nonadherence to management recommendations. Netherlands Organisation for Health Research and Development.

Trends in admissions for chest pain after the introduction of high-sensitivity cardiac troponin T

BackgroundThe aim was to describe temporal trends in admission rates for chest pain and patient outcomes after the clinical introduction of the high-sensitivity cardiac troponin T (hs-cTnT) assay. MethodsWe included all patients aged >25years presenting with chest pain to the emergency department (ED) at our hospital during 2011–2014. For each year, rates of admissions, coronary angiographies, and revascularizations were determined. After adjustment for confounders, hazard ratios (HR) with 95% confidence intervals (CI) were calculated for mortality or major adverse cardiac events (MACE) within 1year of the ED visit per year, using 2011 as referent. ResultsIn total, 15,472 chest pain patients were accountable for 18,237 visits to the ED. The chest pain admission rate in 2011 was 44%; 2012, 39%; 2013, 33%; and 2014, 28%, with an overall decrease in 36%. Coronary angiographies within 1year of the ED visit increased from 6.8% in 2011 to 9.6% in 2013, but the proportion of revascularizations was virtually unchanged. The risk of death within 1year of the visit increased by 51% (HR 1.51, 95% CI, 1.18–1.92) in 2014, compared with 2011. Only non-cardiovascular mortality was significantly increased (HR 1.85, 95% CI, 1.34–2.55), with no increase in MACE. ConclusionAdmissions for chest pain were reduced by 36% the first 4years of hs-cTnT use. We observed no increase in MACE, but all-cause mortality increased significantly for non-cardiovascular causes only which was paralleled by a significant increase in the use of coronary angiographies.

National Trends and In-Hospital Outcomes in Pregnant Women With Heart Disease in the United States

Investigation of trends and outcomes in heart disease (HD) and pregnancy has been limited. We chose to identify the prevalence, trends, and outcomes of pregnant women with different forms of HD in the United States. Healthcare Cost and Utilization Project's National Inpatient Sample was screened for hospital admissions for delivery in pregnant women with HD from 2003 to 2012. Maternal clinical characteristics and outcomes were identified in women with and without HD, and in HD subtypes: congenital (CHD), valvular HD, cardiomyopathy, and pulmonary hypertension (PH). Primary outcomes of interest were prevalence, trends, and major adverse cardiac events (MACEs), a composite of in-hospital death, acute myocardial infarction, heart failure, arrhythmia, cerebrovascular event, embolic events, or cardiac complications of anesthesia. We studied 81,295 patients with HD and 39,894,032 without. CHD was the most frequent type (41.8%, 33,982 of 81,295 patients), followed by valvular HD (30.9%, 25,138 of 81,295 patients), cardiomyopathy (20.8%, 16,926 of 81,295 patients), and PH (6.5%, 5,250 of 81,295 patients). MACE was highest among women with cardiomyopathy and lowest among women with CHD (44.0%, 7,449 of 16,926 vs 6.2%, 2,102 of 33,982; p <0.0001). PH patients had the highest in-hospital death, followed by cardiomyopathy patients (1.0%, 51 of 5,250 and 0.7%, 124 of 16,926, respectively). Pregnant women with HD significantly increased by 24.7%, related to increases in cardiomyopathy, CHD, and PH from 2003 to 2012. MACE significantly increased by 18.8%. In conclusion, pregnancy in women with HD is increasing, particularly for high risk conditions such as cardiomyopathy and PH. There is a significant and gradual increase in MACE for women with HD.

The REFLO-STEMI (REperfusion Facilitated by LOcal adjunctive therapy in ST-Elevation Myocardial Infarction) trial: a randomised controlled trial comparing intracoronary administration of adenosine or sodium nitroprusside with control for attenuation of microvascular obstruction during primary percutaneous coronary intervention

BackgroundMicrovascular obstruction (MVO) predicts short- and longer-term outcomes following primary percutaneous coronary intervention (PPCI) treatment of ST-elevation myocardial infarction (STEMI). The evidence base supporting the role of adenosine and sodium nitroprusside (SNP), the most evaluated adjunctive therapies aimed at attenuating MVO and infarct size, remains weak as the trials involved have had variable end points and used differing drug doses and modes of delivery.ObjectiveTo determine whether intracoronary administration of adenosine or SNP following thrombus aspiration reduces infarct size and/or MVO measured by cardiac magnetic resonance (CMR) imaging in patients undergoing PPCI within 6 hours of onset of STEMI.DesignMulticentre, prospective, parallel, randomised controlled and open-label trial with blinded end point analysis.SettingFour high-volume UK PPCI centres.ParticipantsPatients with STEMI undergoing PPCI with Thrombolysis in Myocardial Infarction (TIMI) flow grade 0/1 in the infarct-related artery and no significant bystander coronary artery disease on angiography.InterventionsParticipants were anticoagulated with bivalirudin and allocated by an automated 24-hour telephone randomisation service to one of three groups: (1) standard PPCI (control), (2) PPCI with adjunctive adenosine 1–2 mg or (3) PPCI with adjunctive SNP 250 µg. The study drugs were delivered intracoronary immediately following thrombus aspiration and again following successful stenting.Main outcome measuresThe primary outcome was infarct size (% total left ventricular end-diastolic mass; %LVM) measured by CMR imaging undertaken 48–96 hours post PPCI. Secondary outcome measures included MVO (hypoenhancement within the infarct core) on CMR imaging, electrocardiographic and angiographic markers of microvascular perfusion and major adverse cardiac events (MACEs) during a median of 6 months’ follow-up. The study aimed to recruit 240 patients (powered at 80% to detect a 5% absolute reduction in infarct size).ResultsThe trial completed recruitment in April 2014 having randomised 247 patients (standard PPCI group,n = 86; PPCI + adenosine group,n = 82; PPCI + SNP group,n = 79). In total, 79% of participants were male and the mean ± standard deviation age of participants was 59.3 ± 12.3 years. CMR imaging was completed in 197 (80%) patients (standard PPCI,n = 65; PPCI + adenosine,n = 63; PPCI + SNP,n = 69) for the primary outcome. There was no significant difference in infarct size [%LVM, median, interquartile range (IQR)] between the adenosine group (10.1, 4.7–16.2), the SNP group (10.0, 4.2–15.8) and the control group (8.3, 1.9–14.0) (p = 0.062 andp = 0.160 vs. control, respectively). MVO (%LVM, median, IQR) was similar across the groups [1.0, 0.0–3.7 (p = 0.205) and 0.6, 0.0–2.4 (p = 0.244) for adenosine and SNP, respectively, vs. 0.3, 0.0–2.8 for the control]. Using per-protocol analysis, infarct size (%LVM) was increased in adenosine-treated patients compared with control patients (12.0 vs. 8.3;p = 0.031). Increased left ventricular volume and reduced left ventricular ejection fraction were also observed in the adenosine arm. There was a significant increase in MACEs in patients undergoing adenosine-facilitated PPCI compared with control patients, driven by heart failure, at 30 days [hazard ratio (HR) 5.39, 95% confidence interval (CI) 1.18 to 24.60;p = 0.04] and 6 months (HR 6.53, 95% CI 1.46 to 29.2;p = 0.01) post randomisation.ConclusionsHigh-dose intracoronary adenosine and SNP during PPCI did not reduce infarct size or MVO measured by CMR imaging. Furthermore, adenosine may adversely affect mid-term clinical outcome and should not be used during PPCI to prevent reperfusion injury.Trial registrationClinicalTrials.gov NCT01747174 and EudraCT 2010–023211–34.FundingThis project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a MRC and NIHR partnership.

Abstract 11980: National Trends and In-hospital Outcomes During Delivery in Pregnant Women With Heart Disease in the US

Background: Investigation of trends and outcomes in heart disease (HD) and pregnancy has been limited. Objective: We chose to investigate the temporal trends and outcomes of pregnancy in women with HD in the US from 2003-2012. Methods: Healthcare Cost and Utilization Project’s National Inpatient Sample was screened for hospital admissions for delivery in pregnant women with HD from 2003-2012. Maternal clinical characteristics and outcomes were identified in women with and without HD, and in HD subtypes: congenital (CHD), valvular (VHD), cardiomyopathy (CDM), and pulmonary hypertension (PH). Primary outcomes of interest were prevalence, trends, and major adverse cardiac events (MACE), a composite of in-hospital death, acute myocardial infarction, heart failure, arrhythmia, cerebrovascular event, embolic events, or cardiac complications of anesthesia. Results: We studied 81,295 patients with HD and 39,894,032 without. CHD was the most frequent type (41.8%, 33,982 of 81,295), followed by VHD (30.9%, 25,138 of 81,295), CDM (20.8%, 16,926 of 81,295) and PH (6.5%, 5,250 of 81,295). MACE was highest among women with CDM and lowest in CHD (44.0%, 7,449 of 16,926 vs 6.2%, 2,102 of 33,982 p&lt;0.0001). PH patients had the highest in-hospital death, followed by CDM (1.0%, 51 of 5,250 and 0.7%, 124 of 16,926 respectively). Pregnant women with HD significantly increased by 24.7%, related to increases in CDM, CHD, and PH. MACE significantly increased by 18.8%. Conclusions: Pregnancy in women with heart disease is increasing, particularly for high risk conditions such as CDM and PH. There is a significant and gradual increase in MACE for women with heart disease.

Five-year outcomes of ST-elevation myocardial infarction versus non-ST-elevation acute coronary syndrome treated with biodegradable polymer-coated sirolimus-eluting stents: Insights from the CREATE trial

BackgroundLong-term outcome of drug-eluting stents (DES) for ST-elevation myocardial infarction (STEMI) versus non-ST-elevation acute coronary syndrome (NSTE-ACS) remains unclear. This study sought to compare the long-term outcomes of biodegradable polymer-coated DES in patients with STEMI versus NSTE-ACS. MethodsWe explored a post hoc analysis of the 5-year outcome of the CREATE trial in the subgroup of patients with STEMI (n=318) versus NSTE-ACS (n=1223) who were implanted with biodegradable polymer-coated DES. The primary outcome was the rate of major adverse cardiac events (MACE) at 5 years. Clopidogrel and aspirin for 6 months followed by chronic aspirin therapy were recommended. ResultsSTEMI patients showed a trend of increase in MACE (8.7% vs. 6.8%, log rank p=0.289) compared to NSTE-ACS patients at 5 years, and a greater risk of cardiac death (5.4% vs. 2.1%, log rank p=0.003), mainly driven by the higher cardiac death rate within the first month after stent placement (log rank p=0.003) and the last year of follow-up (log rank p=0.001). No significant difference in stent thrombosis was found between them (3.1% vs. 2.5%, log rank p=0.653). Prolonged clopidogrel therapy (>6 months) showed no effect on risk of MACE or stent thrombosis between the two groups (both p for interaction >0.1). ConclusionsSTEMI patients have a higher risk of cardiac mortality compared with NSTE-ACS patients after biodegradable polymer-coated DES placement, primarily attribute to more cardiac deaths that happened within the first month after the event and the last year of follow-up.

Usefulness of Beta2-Microglobulin as a Predictor of All-Cause and Nonculprit Lesion-Related Cardiovascular Events in Acute Coronary Syndromes (from the PROSPECT Study)

In the Providing Regional Observations to Study Predictors of Events in the Coronary Tree (PROSPECT) study, plaque burden, plaque composition, and minimal luminal area were associated with an increased risk of adverse cardiovascular events arising from untreated atherosclerotic lesions (vulnerable plaques) in patients with acute coronary syndromes (ACS). We sought to evaluate the utility of biomarker profiling and clinical risk factors to predict 3-year all-cause and nonculprit lesion-related major adverse cardiac events (MACEs). Of 697 patients who underwent successful percutaneous coronary intervention (PCI) for ACS, an array of 28 baseline biomarkers was analyzed. Median follow-up was 3.4years. Beta2-microglobulin displayed the strongest predictive power of all variables assessed for all-cause and nonculprit lesion-related MACE. In a classification and regression tree analysis, patients with beta2-microglobulin >1.92mg/L had an estimated 28.7% 3-year incidence of all-cause MACE; C-peptide <1.32ng/ml was associated with a further increase in MACE to 51.2%. In a classification and regression tree analysis for untreated nonculprit lesion-related MACE, beta2-microglobulin >1.92mg/L identified a cohort with a 3-year rate of 18.5%, and C-peptide <2.22ng/ml was associated with a further increase to 25.5%. By multivariable analysis, beta2-microglobulin was the strongest predictor of all-cause and nonculprit MACE during follow-up. High-density lipoprotein (HDL), transferrin, and history of angina pectoris were also independent predictors of all-cause MACE, and HDL was an independent predictor of nonculprit MACE. In conclusion, in the PROSPECT study, beta2-microglobulin strongly predicted all-cause and nonculprit lesion-related MACE within 3years after PCI in ACS. C-peptide and HDL provided further risk stratification to identify angiographically mild nonculprit lesions prone to future MACE.

0025 : Myocardial revascularization modalities in 200 patients with venous coronary artery bypass graft failure

The therapeutic management of bypass failure has been little studied. Compare prognosis and the occurrence of cardiovascular events at 2 years in patients with venous bypass graft failure by differentiating between three patient groups: medical therapy, percutaneous coronary intervention (PCI) in native vessels (native PCI), and PCI in coronary artery bypass grafts (PCI-CABG). Retrospective observational study in patients with bypass graft failure diagnosed between February 2009 and September 2013 at Poitiers University Hospital, France. Follow-up data at 1 year and at 2 years regarding major adverse cardiac events (MACEs), defined as death, acute coronary syndrome (ACS) or revascularization, were collected during patient visits to the department. From a series of 320 CABG patients examined using coronary angiography, all patients with bypass graft failure were included in the study (200 patients). Mean age was 69 years (+/- 11). Coronary angiography was performed a mean of 117 months after bypass surgery. Medical therapy alone was chosen in 88 patients, 75 patients underwent native PCI, and 37 patients underwent PCI-CABG. Patients in the PCI-CABG group were older (73.6 years; p = 0.027) and had significantly older bypass grafts (22% for a period of more than 10 years; p = 0.018), and their typical clinical presentation was one of ACS without ST-segment elevation (41%; p = 0.006). The groups were comparable in terms of hospital complications, except for vascular complications, which were more common in the PCI-CABG group (8%; p =0.01). At 1 year, no significant difference in terms of MACEs was found, but there was a trend towards an increase in ACS without ST-segment elevation (11%; p =0.06) in the PCI-CABG group, and towards an increase in ACS with STsegment elevation (7%; p = 0.06) in the medical therapy group. At 2 years, the medical therapy group stood out by virtue of a significant increase in MACEs compared with the other two groups (63%; p = 0.02). The native PCI group presented both fewer MACEs and fewer vascular complications. MACEs were common and more severe in the medical therapy group. When coronary lesions are amenable to PCI, PCI in native vessels should be proposed as first-line treatment. PCI of CABG is performed in a riskier setting and has poorer prognosis.

Circumferential strain predicts major adverse cardiac events independent of myocardial perfusion in asymptomatic aortic stenosis

Background Asymptomatic aortic stenosis (AS) remains a challenging clinical entity characterised by adverse left ventricular remodelling, microvascular dysfunction and sudden cardiac death. Previous studies have shown reduced myocardial strain in patients with asymptomatic aortic stenosis, however the relationship between impaired myocardial strain, ischaemia and major adverse cardiac events (MACE) remains poorly understood. We therefore assessed myocardial strain and myocardial perfusion reserve index (MPRI) in these patients and followed patients prospectively. Methods 96 consecutive patients (73 male) underwent CMR scanning on a 1.5T scanner with a 32-channel coil. Of these, 45 underwent adenosine stress perfusion scanning. The remaining 51 patients had medical contraindications for perfusion imaging or refused consent. LV mass and MPRI were analysed and late gadolinium enhancement imaging (LGE) was performed using standard protocols, and scored by two independent operators blinded to other CMR results. Patients were then followed prospectively for a mean of 1.5 ±0.8 years and the predictors of MACE determined. Results 19 of 96 patients suffered a MACE: 1 death, 12 valve replacements, 1 atrial fibrillation, 1 pacemaker insertion, and 4 unplanned hospitalisations with cardiac symptoms. Patients with MACE had significantly impaired mid ventricular peak systolic circumferential strain compared to those without MACE (-14.8±3% vs -17.9 ±3% respectively, p -16.5) was 37%, compared to 16 % in patients with strain 1.3 (3.0±0.6m/s); p=0.002). There was no correlation between reduced strain and reduction in MPRI, though numbers were more limited. There was also no significant difference in MPRI values between those with normal or reduced strain, and between those with/without MACE. Conclusions There is a 2.2-fold increase in MACE in patients with AS and reduced circumferential strain compared to those with normal myocardial strain. Myocardial perfusion reserve (a measure of microvascular dysfunction) was not related to strain or to MACE. Funding