Independent Predictors Of MACE Research Articles

Major Adverse Cardiac Events after first time elective isolated Coronary Artery

Abstract Background Major adverse cardiovascular events (MACE) are useful endpoints to evaluate cardiovascular outcomes. The aim of this study was to report our results in concordance with the expected improvement of records after using the online Research Electronic Data Capture (RedCap) software. Methods: We included patients who benefited from first time elective isolated coronary bypass grafting (CABG) at Ain-Shams university main hospital, in the period between April 2014 and April 2016; providing a minimum 2 years follow-up . Incidences, risk factors and independent predictors for MACE were calculated including; mortality, the occurrence or re-hospitalization for: heart failure, recurrence of angina or myocardial infarction (MI), cerebrovascular stroke (CVS), need of coronary angiography (CA), repeat percutaneous intervention (PTCA) or CABG. Results: 607 cases met our inclusion criteria and 105 patients (18.7%) developed 184 MACE, including 45 hospital mortalities (7.4%), 13 late mortalities (2.1%) and 126 non-fatal events recorded in 47 patients (7.7%); a majority (40 patients; 6.6%) had suffered from at least 3 non-fatal events. Two-years follow-up was complete for the 562 hospital survivors with a total of 1113 patient-years. The annualized incidence rates of ICU admission, repeated angina or MI, need for CA, PTCA, or CABG, development of CVS, heart failure, and late mortality were: 3.6%, 2.8%, 1.8%, 0.5%, 0.09%, 0.35%, 2% and 1.2% per patient-year; respectively. Independent predictors of hospital mortality were: advanced age at surgery (OR 1.06: 1-1.12; P = 0.049), female sex (OR 3.4: 1.3-8.9; P = 0.01), prolonged durations of: cardiopulmonary bypass CPB (OR 1.02: 1.01- 1.04; P < 0.001), mechanical ventilation (OR 1.07: 1.04- 1.09; P < 0.001) positive inotropic support (OR 1.03: 1.02- 1.05; P < 0.001) and ICU stay (OR 1.09: 1.07- 1.11; P < 0.001). Independent predictors of overall MACE were advanced age at surgery (OR 1.04: 1.01-1.07; P = 0.011), prolonged durations of: aortic cross clamp (OR 1.09: 1.04-1.11; P = 0.003), CPB (OR 1.06: 1.04-1.08; P < 0.001) and mechanical ventilation (OR 1.02: 1.01-1.03; P < 0.001). Conclusion: Our results suggested that more care should be given to females, elderly and to shorten and improve the quality of our operative times. The repetition of non-fatal MACE could be modified by closer observation of the patient, once developing his first event.

Relationship of systemic pentraxin-3 values with coronary plaque components on optical coherence tomography and post-percutaneous coronary intervention outcomes in patients with stable angina pectoris

Background and aimsElevated pentraxin-3 (PTX3) values are associated with vulnerable plaque existence and poor outcomes in acute coronary syndrome patients. The clinical significance of PTX3 values in stable angina pectoris (SAP) patients is, however, undetermined. We investigated the relationship of systemic PTX3 values and coronary plaque components and post-percutaneous coronary intervention (PCI) outcomes in SAP patients. MethodsWe included 93 consecutive de-novo lesions in 93 SAP patients with a normal pre-PCI high-sensitivity cardiac troponin-T (<0.014 ng/mL), undergoing pre- and post-PCI optical coherence tomography (OCT). Systemic PTX3 values were obtained immediately pre- and post-PCI, at 24-h and 9-month post-PCI. ResultsPeak post-PCI PTX3 values correlated with thinnest fibrous cap thickness (r = −0.23, p = 0.03) and lipid length (r = 0.24, p = 0.03), and were higher in patients with lesions having OCT-derived thin-cap fibroatheroma (6.67 (3.19–7.33) vs. 3.13 (2.34–4.11) ng/mL, p = 0.04) and post-stenting irregular tissue protrusion (4.76 (3.31–6.80) vs. 2.98 (2.23–4.06) ng/mL, p = 0.003) than in those without. At 9-month follow-up, cardiac event-free survival was poorer in patients with a peak post-PCI PTX3 value ≥ 4.08 ng/mL (upper tertile) (log-rank test χ2 = 9.0; p = 0.003). Multivariate Cox regression analysis showed a peak post-PCI PTX3 value ≥ 4.08 ng/mL as an independent predictor of MACE (hazard ratio, 3.915; 95% CI, 1.129–13.583; p = 0.03). ConclusionsPeak post-PCI PTX3 values correlated with pre-PCI plaque characteristics and post-PCI outcomes, providing a good prognostic factor of outcomes in SAP patients undergoing elective PCI.

Incidence of Adverse Events at 3 Months Versus at 12 Months After Dual Antiplatelet Therapy Cessation in Patients Treated With Thin Stents With Unprotected Left Main or Coronary Bifurcations

Incidence and predictors of adverse events after dual antiplatelet therapy (DAPT) cessation in patients treated with thin stents (<100 microns) in unprotected left main (ULM) or coronary bifurcation remain undefined. All consecutive patients presenting with a critical lesion of an ULM or involving a main coronary bifurcation who were treated with very thin strut stents were included. MACE (a composite end point of cardiovascular death, myocardial infarction [MI], target lesion revascularization [TLR], and stent thrombosis [ST]) was the primary endpoint, whereas target vessel revascularization (TVR) was the secondary endpoint, with particular attention to type and occurrence of ST and occurrence of ST, CV death, and MI during DAPT or after DAPT discontinuation. All analyses were performed according to length of DAPT dividing the patients in 3 groups: Short DAPT (3-months), intermediate DAPT (3 to 12 months), and long DAPT (12-months). A total of 117 patients were discharged with an indication for DAPT ≤3 months (median 1: 1 to 2.5), 200 for DAPT between 3 and 12 months (median 8: 7 to 10), and 1,958 with 12 months DAPT. After 12.8 months (8 to 20), MACE was significantly higher in the 3-month group compared with 3 to 12 and 12-month groups (9.4% vs 4.0% vs 7.2%, p ≤0.001), mainly driven by MI (4.4% vs 1.5% vs 3%, p ≤0.001) and overall ST (4.3% vs 1.5% vs 1.8%, p ≤0.001). Independent predictors of MACE were low GFR and a 2 stent strategy. Independent predictors of ST were DAPT duration <3 months and the use of a 2-stent strategy. In conclusion, even stents with very thin strut when implanted in real-life ULM or coronary bifurcation patients discharged with short DAPT have a relevant risk of ST, which remains high although not significant after DAPT cessation.

P4634Acute-phase high platelet reactivity with prasugrel loading is correlated with clinical outcomes during hospitalization in acute coronary syndrome

Abstract Background/Introduction Although high platelet reactivity (HPR) seems to be associated with adverse cardiovascular events after percutaneous coronary intervention (PCI), the relationship between post-procedure HPR with prasugrel loading and clinical outcomes in acute coronary syndrome (ACS) is still unclear. Moreover, factors contributing to HPR in ACS with prasugrel loading are also unknown. Purpose This study aimed to assess the impact of post-procedure HPR with prasugrel loading on clinical outcomes in ACS during hospitalization, as well as to define appropriate cut-off values and identify factors contributing to HPR. Methods We performed a single-centre, retrospective observational study that enrolled 132 patients who underwent emergent PCI for ACS with prasugrel loading. The P2Y12 reaction unit (PRU) value was measured immediately after PCI with the VerifyNowR System. The primary endpoint was major adverse cardiac events (MACE, defined as the composite of death, myocardial infarction, stroke, heart failure, ventricular arrhythmia needing defibrillation). Results Mean patient age (standard deviation) was 70.7 (±12.5) years, 76% were male, and average time from prasugrel intake to PRU calculation was 101 (±48.8) min. During a mean hospital stay of 15.4 (±8.0) days, there were 22 (16%) MACE events and 6 (4%) deaths. The post-procedure PRU value was 241±66. HPR was significantly higher in MACE group than non-MACE group [287 (±55) vs 232 (±64), p&lt;0.001]. The ROC curve analysis of PRU for discriminating significant in-hospital MACE showed a cut off value of 293 (sensitivity: 64%, specificity: 84% [AUC=0.764, p&lt;0.0001]). Thus, 33 patients (25%) were found to have HPR (PRU&gt;293) immediately after emergent PCI. Kaplan-Meier curve analysis showed MACE events occurred more frequently in the HPR group than in the non-HPR group (42% vs 8%, log rank p&lt;0.001). Multiple Cox regression analysis showed that peak creatine phosphokinase &gt;3,000 U/L and HPR were independent predictors of MACE in patients with ACS who underwent PCI (OR 4.96, 95% CI 1.86–13.26, p=0.001, and OR 7.52, 95% CI 2.73–20.7, p&lt;0.0001, respectively). HPR was significantly correlated with age, female sex, and reference lumen short diameter (pre-dilation) used in PCI. Conclusion HPR was significantly associated with adverse event during hospitalization in ACS patients. Female patients with large culprit lesion diameter were more likely to have HPR. Appropriate cut-off value of HPR in this study was 293. HPR in early-phase of ACS with prasugrel loading is a useful predictor of adverse events during hospitalization.

P1485Left atrial reservoir function is associated with major adverse cardiac events in patients undergoing transarterial valve implantation for isolated severe aortic stenosis

Abstract Background Left atrial (LA) reservoir function as measured by LA global longitudinal strain (LAGS) is an independent predictor of left ventricular (LV) performance and has prognostic value. Purpose To evaluate by speckle tracking echocardiography (STE), LAGS and other myocardial deformation indices changes after transarterial valve implantation (TAVI) for severe isolated aortic stenosis (AS) in relation to the outcome measures. Methods Of 995 pts who underwent TAVI at our Institution between 2017–18, 120 (age = 82.8±7.7 years, 74% female, AVAi = 0.37±0.09 cm2/m2, LVEF = 61.6±11.3%, no &gt; than 2+ mitral or aortic regurgitation, all in NSR) underwent 2-D echocardiography and STE, pre (21±34 days) and post (16±27 days) TAVI. LAGS was measured at QRS onset, and LV global longitudinal strain (LVGS) and RV free wall strain were recorded. The velocity index = peak vel LVOT/AV. Phillips IE 33 scanners (frame rates 60–80 Hz) were used and one observer analyzed data on QLAB software. The median follow-up was 208 days (range 20–763). The outcome variable was a composite of death, atrial fibrillation and hospitalization for heart failure (MACE). Univariate and multivariable logistic regression were used to determine independent predictors of LA, LV and RV free wall global strain changes (covariates; age, sex, BSA, LVEF, systolic blood pressure, LA volume index) and, separately, for predictors of MACE (covariates; age, sex, AVA index, LVEF and E/e'). Intra- and interclass correlation coefficients (ICC) were calculated. Results The intra- and inter-observer ICC was 0.70–0.90 and 0.90–0.95, respectively. In the absence of LA volume change, LAGS improved post TAVI in 54% of pts. Overall, mean change was 2.2±11.6% (95% CI; 0.05, 4.3) and it was significantly associated in multivariable analysis with RV free wall strain (OR=2.7, 95% CI; 1.2, 6), velocity index (OR=0.4, 95% CI; 0.2, 1), LVEF (OR= 0.3, 95% CI; 0.2, 0.8) and LVGS (OR=3.8, 95% CI; 1.4, 10), yielding together an AUC of 0.90. LVGS improved in 64% of pts by −2.8±7.5%, (95% CI: −4.2, −1.5) and the velocity index independently predicted the LVGS change (OR = 0.6; 95% CI: 0.4, 0.9). The other deformation indices did not significantly change. At follow-up, there were 6 hospitalizations for heart failure, 5 atrial fibrillation events and 6 deaths. At multivariable logistic regression analysis, post TAVI LAGS was the only variable independently predicting MACE (OR (in units of 1%) = 0.90, 95% CI; 0.82, 0.98), estimating that a 1% increase in post-LAGS decreases the likelihood of MACE by 10%. Conclusions 1. There was no relationship between LA systolic volume and LAGS change after TAVI. 2. Within a month after the procedure, LAGS improves in less than half of pts and is directly associated with both ventricles systolic function and AS severity. 3. At a median of 9 months after TAVI, post procedural LAGS is an independent predictor of MACE and could be used in the risk stratification of such pts.

4939Clinical significance of global strain estimated by 3D speckle tracking acutely after onset of ST-elevation myocardial infarction on prediction of long term prognosis

Abstract Background Three-dimensional (3D) speckle tracking echocardiography (STE) is a novel method for assessing cardiac function because of free form out-of-plane motion effects. Aim To explore the role of 3D-STE for prediction of the long term prognosis in patients with a first-time ST elevation acute myocardial infarction (STEMI). Methods A total of 238 patients (mean age 64.6 years) with a first-time STEMI treated with reperfusion therapy were enrolled in our study. Twenty four hours after admission, standard 2D echocardiography and 3D full volume imaging were obtained and strain parameters (GLS: global longitudinal strain, GCS: global circumferential strain) were calculated using 4D LV analysis. Infarct size was measured with single-photon emission computed tomography imaging 7 to 14 days after onset. We followed them for median 94 months (inter quartile range: 69–109 months). The primary end point was the major adverse cardiac and cerebrovascular events (MACE: cardiac death, non-fatal MI, heart failure requiring intravenous diuretics administration and stroke). The patients with persistent chronic atrial fibrillation, poor image quality, emergency bypass surgery were excluded. Results During follow up periods, 78 patients experienced MACE (26 cardiac death, 48 heart failure, 29 non-fatal MI, 5 stroke) and 48 patients died (22 non-cardiac death). In multivariate analysis, 3D-GLS was the strongest predictor for MACE. Kaplan-Meier Curve demonstrated that 3D-GLS &gt;−11.4 was the independent predictor for MACE (Log-rank χ2=73.818, p&lt;0.0001). When combined with 3D-GCS &gt;−19.2, the patients with higher value both of 3D-GLS and 3D-GCS were extremely high risk. The figure shows the Kaplan-Meier curve according to the 4 groups based on the cut-off values determinded by ROC curves. Conclusions Global strain estimated by 3D-STE immediately onset of STEMI was useful tool for the prediction of long term prognosis. Acknowledgement/Funding None

P1831Prediction of cardiovascular events by atheromatous plaques detected by non-obstructive general angioscopy: two-year results of EAST-NOGA Registry

Abstract Background Non-obstructive general angioscopy (NOGA) has revealed the intimal damages or atheromatous plaques as well as its spontaneous rupture of the aorta. Recent study revealed that plaque debris or different size of cholesterol crystals were detected in the blood above the spontaneous ruptured aortic plaque observed by NOGA and these plaque materials might cause the peripheral organ damages as the embolic source. These various morphological changes may cause the acute aortic events or atheroembolic events on the peripheral organs, such as brain, kidney, peripheral artery and so on. Purpose EAST-NOGA (Evaluation of AtheroSclerotic and rupture events by Non-Obstructive General Angioscopy) is a multi-center prospective observational study to assess the relationship between the findings of NOGA and future cardiovascular events. Methods Five hundred and seventy-seven patients with atherosclerotic cardiovascular disease who underwent NOGA study. The major cerebrocardiovascular events including cardiovascular death, non-fatal myocardial infarction, non-fatal cerebral infarction, and acute aortic syndrome were accumulated during the 2-year follow-up after NOGA study. Results The median number of aortic atheromatous plaques was 6 [IQR: 3–12]. A total of 514 patients were followed up (89.1%). The mean follow-up duration was 757±120 days. Major adverse cardiovascular events developed in 23 (4.5%) during 2 years follow-up. Patients with MACE and cerebral infarction, had significantly greater number of aortic atheromatous plaques (11 [5–19] vs. 6 [3–11], p&lt;0.001, 12 [4–20] vs. 6 [3–12], p=0.014, respectively). In a univariate analysis, the number of aortic atheromatous plaques and ruptured plaque were significant predictors of MACE (HR: 1.09 95% confidence interval 1.05–1.14, p&lt;0.001) and (HR: 1.12, 95% confidence interval 1.02–1.23, p=0.02). In a multivariate logistic analysis, the number of aortic atheromatous plaques is one of the independent predictors of MACE (HR 1.05, 95% confidence interval 1.00–1.10, p=0.032). Conclusion The number of atheromatous plaques identified by NOGA has a significant relation to the onset of cerebral infarction, which suggest the atheromatous plaque were vulnerable and ruptured spontaneously, then cause the aortogenic cerebral infarction. The NOGA study would be useful for predicting the futured atheroembolic events. Acknowledgement/Funding None

P1758The novel small leucin-rich repeat protein podocan is an independent predictor of major adverse cardiac events in patients with angiographically-defined coronary artery disease

Abstract Background Smooth muscle cell (SMC) function determines the clinical course of vascular disease via fibrous cap stability. Podocan is an inhibitor of SMC function and is circulating in peripheral blood rendering it a candidate biomarker to predict MACE in patients with Coronary Artery Disease (CAD). Purpose We designed a prospective cohort study assessing the predictive value of Podocan for cardiovascular outcome (MI, CVA or death) in patients with CAD. Methods 308 patients with angiographic evidence of CAD were enrolled. At index cardiac catheterization Syntax Score was calculated. For patient baseline characteristics see Table. Podocan and CRP-1 were measured using a human Podocan and CRP-1 ELISA. The Kaplan-Meier method was used to construct survival curves, which were compared using the log-rank test. Cox proportional hazard modeling was used for all univariate/multivariate analyses. Statistical analysis was performed using STATA. Results Podocan was detected in 212 patients (69%) with a detection threshold of 0.01 ng/ml. The median Podocan level observed was 1.4±8.2 ng/ml. 96 patients did not have a detectable Podocan level. Mean CRP-1 was 0.117±0.15 mg/ml. Mean Syntax Score was 12±9. Podocan did not correlate with CRP-1. There was also no association between Podocan and Syntax Score, age, BMI, smoking, LDL, and HDL, HgbA1c, LVEF and GFR. At the univariate level, presence of Podocan was associated with an increased rate of MACE (17% Podocan present vs. 7% Podocan absent, p=0.02). Kaplan-Meier survival analysis showed higher event free survival in patients with no detectable Podocan vs. detectable Podocan level (Figure). In a limited multivariate Cox proportional Hazard analysis, Podocan remained an independent predictor of MACE (HR: 2.5; P=0.042) in addition to diabetes, and LV ejection fraction. Baseline Characteristics Total (N=308) Chronic ischemic heart disease (N=273) Acute coronary syndrome (N=35) Age (Year) 66.5±9.5 67±9 61±11 Female (Sex) 106 (33%) 90 (31%) 16 (46%) Hypertension 282 (89%) 244 (89%) 26 (74%) Diabetes 142 (44%) 124 (45%) 11 (31%) Hyperlipidemia 269 (87%) 243 (89%) 26 (74%) CRP (mg/dL) 0.11±0.14 0.10±0.13 0.18±0.19 LVEF (%) 49±10 49±10 48±9.5 CRP, C-reactive protein; LVEF, Left ventricular ejection fraction. Kaplan Meier Survival Curves by Podocan Conclusion Podocan is a novel biomarker independently predicting MACE in secondary prevention of CAD warranting to be further studied in a Multicenter Clinical Trial.

Prognostic implication of three-vessel contrast-flow quantitative flow ratio in patients with stable coronary artery disease.

Contrast-flow quantitative flow ratio (cQFR) is a novel index of the functional severity of coronary stenosis, which can be calculated from three-dimensional quantitative coronary angiography. Previous studies have shown a high correlation between cQFR and fractional flow reserve. This study sought to investigate the prognostic value of the sum of cQFR in three vessels (3V-cQFR) in patients with stable coronary artery disease (CAD). A total of 549 patients who underwent invasive coronary angiography and cQFR measurements in three vessels were analysed in the present study. Median cQFR of all cQFR-assessed vessels and 3V-cQFR of each patient were 0.94 (0.85-0.98) and 2.75 (2.62-2.87), respectively. During a median follow-up of 2.2 years, 57 patients experienced MACE. 3V-cQFR could provide prognostic information in the total cohort and among those without undergoing revascularisation as well. In a multivariate analysis, 3V-cQFR, high-sensitivity cardiac troponin-I and previous MI remained as independent predictors for MACE, and conventional angiographic scores did not. 3V-cQFR could discriminate the risk for MACE in patients with stable CAD. 3V-cQFR calculated from routine invasive angiograms was feasible, and the prognostic implication could be more powerful than that of conventional angiographic scores.

Early cardiac complications after bariatric surgery: does the type of procedure matter?

BackgroundMajor adverse cardiac events (MACE) can be a cause of postoperative mortality. This is specifically important in bariatric surgery due to obesity-related cardiovascular risk factors. ObjectiveTo assess postoperative cardiac adverse events after bariatric surgery and its independent predictors. SettingA retrospective analysis of 2011–2015 Healthcare Cost and Utilization Project-National Inpatient Sample. MethodsData on patients who underwent laparoscopic sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) were retrieved. MACE was identified as a composite variable including myocardial infarction, acute ischemic heart disease without myocardial infarction, and acute heart failure. Dysrhythmia (excluding premature beats) was identified as a separate outcome. Multivariate regression analysis for MACE was performed using demographic factors, co-morbidities, and type of surgery. ResultsThe analysis included 108,432 patients (SG: 54.6%, RYGB: 45.4%). MACE was found in 116 patients (.1%), and dysrhythmia occurred in 3670 patients (3.4%). Median length of stay in patients with MACE was 4.5 versus 2 days in others (P < .001). There were 43 deaths overall, and 31 were in patients with MACE or dysrhythmia (P < .001). Age ≥ 50 years, male sex, congestive heart failure, chronic pulmonary disease, ischemic heart disease, history of pulmonary emboli, and fluid or electrolyte disorders were independent predictors of MACE based on multivariate analysis. Type of surgery (SG versus RYGB) was not an independent predictor for MACE (odds ratio 1.41, 95% confidence interval: .77–2.55). ConclusionsWhile cardiac complications are rare after bariatric surgery, their occurrence is associated with increased length of stay, hospital charges, and mortality. Older age, male sex, cardiopulmonary co-morbidities, and fluid or electrolyte disorders are predictive of MACE. RYGB does not increase the risk of MACE compared with SG.

Myocardial infarction with non-obstructive coronary arteries (MINOCA) in Chinese patients: Clinical features, treatment and 1 year follow-up

BackgroundMyocardial infarction with non-obstructive coronary arteries (MINOCA) is characterised by clinical evidence of myocardial infarction with normal or near-normal coronary arteries on angiography (stenosis<50%). We investigated clinical features among Chinese MINOCA patients and one-year follow-up on medication management and cardiovascular events. MethodsThe data of 2029 patients with acute myocardial infarction were consecutively collected. MINOCA patients were identified with coronary angiography (<50% stenosis). Clinical features, medication management and cardiovascular events were assessed. ResultsOne hundred and twenty-eight patients (6.3%) were diagnosed as MINOCA. Compared with the myocardial infarction with obstructive coronary arteries (MI-CAD) patients, the prevalence of traditional risk factors of CAD was lower in MINOCA patients. The levels of TG, LDL-C, cTnT, CK-MB and myoglobin in the MINOCA group were significantly lower, whereas LVEF was higher. MINOCA patients are less likely to receive secondary prevention medication for MI, and use of all recommended drugs decreased at one-year follow-up. MACE in the MINOCA group was lower. After adjusting related risk factors, logistic analysis showed MINOCA was independently associated with lower risk of MACE. Independent predictors for MACE in MINOCA patients were older age (≥60 years), females, atrial fibrillation and reduced LVEF. ConclusionCompared with MI-CAD, MINOCA was accompanied by fewer traditional risk factors of CAD, less likely to be discharged upon secondary prevention medication of MI and the occurrence of MACE during 1 year follow-up was lower. Older age (≥60 years), females, atrial fibrillation and reduced LVEF were independent risk factors for MACE in MINOCA patients within one year.

Serum Vaspin as a Predictor of Adverse Cardiac Events in Acute Myocardial Infarction.

BackgroundThe involvement of vaspin (visceral adipose tissue–derived serpin) in the development of atherosclerotic cardiovascular diseases has been documented. This study was designed to explore the prognostic value of serum vaspin in patients with acute myocardial infarction (AMI).Methods and ResultsWe included 1036 AMI patients in a cohort study and determined the association between serum vaspin and major adverse cardiac events (MACE) using Cox regression analysis. The receiver operating characteristic curve indicated that serum vaspin could significantly differentiate patients with MACE, and the optimal cutoff value was 0.62 ng/mL. The Kaplan–Meier survival curve showed that patients with lower vaspin levels had higher incidence of MACE. Multivariate Cox regression analysis revealed that low vaspin was an independent predictor of MACE (hazard ratio: 0.74; 95% CI, 0.48–0.96; P=0.029), together with age; previous histories of AMI, heart failure, hypertension, and diabetes mellitus; Killip class; revascularization; CRP (C‐reactive protein); and NT‐proBNP (N‐terminal pro–B‐type natriuretic peptide). Integrated discrimination and net reclassification improvements for MACE were significantly improved by addition of vaspin to the model of traditional risk factors. Moreover, low vaspin was a valuable predictor of heart failure hospitalization (hazard ratio: 0.58; 95% CI, 0.37–0.89; P=0.005) and recurrent AMI (hazard ratio: 0.72; 95% CI, 0.53–0.95; P=0.036) after adjustment for conventional cardiovascular risk factors.ConclusionsOur study suggests that serum vaspin is a significant prognostic marker of MACE in AMI patients.

Long-term outcomes in surgically ineligible patients managed with percutaneous coronary revascularization or medical therapy.

The objective of the study was to report clinical outcomes of patients unsuitable for surgical coronary revascularization (CABG) treated with percutaneous revascularization (PCI) or medical therapy alone (MT). The decision to revascularize patients referred for CABG but who are unsuitable should be made at Heart Team meetings. The clinical outcomes in this important patient subset are not known, and while cases are considered individually, these decisions are not guided by robust data. Clinical data were analyzed for patients referred to the Heart Team for consideration of CABG over a 4-year period in a UK tertiary referral center. Outcome data for those managed with urgent PCI or MT were considered over a further 3-year period. 133 patients were treated with PCI and 117 with MT. MACE at 30days were no different between groups (MT 10.3% versus PCI 12.2%); however, at 1year MACE were higher in the MT group (MT 39.3% versus PCI 26.7%, P < 0.01). Log rank for MACE-free survival to 1 and 3years was significantly lower in the MT group [HR 1.77 (0.60-1.11); P < 0.001]. Residual SYNTAX was an independent predictor of death. MT [OR 1.75 (1.03-2.99); P = 0.04] and a residual SYNTAX score [OR 6.45 (2.53-16.45); P < 0.001] were independent predictors of MACE at 1year in the whole group. Our data reveal better outcomes in patients treated with PCI over MT at 1-3years in CABG-ineligible patients. Patients without complete revascularization have worse outcomes.

Major adverse cardiac events after first time elective isolated coronary artery bypass grafting: A retrospective cohort study

BackgroundMajor adverse cardiovascular events (MACE) are useful endpoints to evaluate cardiovascular outcomes after coronary artery bypass grafting (CABG). The aim of this study was to evaluate our results in concordance with the expected improvement of records with the use of the online Research Electronic Data Capture (REDCap) software. MethodsThis is a retrospective cohort study with two years follow-up of patients who benefited from first time elective isolated CABG at Ain-Shams University Main Hospital, in the period between April 2014 and April 2016. Incidence, risk factors and independent predictors for MACE were calculated including; mortality, the occurrence or re-hospitalization for: heart failure, recurrence of angina or myocardial infarction (MI), cerebrovascular stroke (CVS), need of coronary angiography (CA), repeat percutaneous intervention (PTCA) or CABG. Results607 cases met our inclusion criteria and 105 patients (18.7%) developed 184 MACE, including 45 hospital mortalities (7.4%), 13 late mortalities (2.1%) and 126 non-fatal events recorded in 47 patients (7.7%); forty patients (6.6%) had at least 3 non-fatal events. Two-years follow-up was complete for the 562 hospital survivors with a total of 1113 patient-years. The annualized incidence rates of ICU admission, repeated angina or MI, need for CA, PTCA, or CABG, development of CVS, heart failure, and late mortality were: 3.6%, 2.8%, 1.8%, 0.5%, 0.09%, 0.35%, 2% and 1.2% per patient-year; respectively.Independent predictors of hospital mortality were: older age at surgery (OR 1.06: 1–1.12; P = 0.049), female sex (OR 3.4: 1.3–8.9; P = 0.01), prolonged durations of: cardiopulmonary bypass (CPB) (OR 1.02: 1.01–1.04; P < 0.001), mechanical ventilation (OR 1.07: 1.04–1.09; P < 0.001) positive inotropic support (OR 1.03: 1.02–1.05; P < 0.001) and ICU stay (OR 1.09: 1.07–1.11; P < 0.001). Independent predictors of overall MACE was older age at surgery (OR 1.04: 1.01–1.07; P = 0.011), prolonged durations of: aortic cross clamp (OR 1.09: 1.04–1.11; P = 0.003), CPB (OR 1.06: 1.04–1.08; P < 0.001) and mechanical ventilation (OR 1.02: 1.01–1.03; P < 0.001). ConclusionsOur results suggested that more care should be given to females, elderly and to shorten and improve the quality of our operative time. The repetition of non-fatal MACE could be modified by closer observation of the patient, once developing his first event.

Safety of intermediate left main stenosis revascularization deferral based on fractional flow reserve and intravascular ultrasound: A systematic review and meta-regression including 908 deferred left main stenosis from 12 studies

BackgroundCurrent guidelines recommend intravascular ultrasound (IVUS) or fractional flow reserve (FFR) to decide upon ambiguous left main (LM) disease. However, no study has compared the safety of LM revascularization deferral based on FFR or IVUS. MethodsMEDLINE/PubMed was systematically screened for studies reporting on deferred treatment of angiographically ambiguous LM based upon FFR or IVUS evaluation. Baseline, angiographic and outcome data were appraised and pooled separately for each strategy according to random-effect models with inverse-variance weighting. ResultsA total of 908 LM stenoses from 7 FFR and 5 IVUS studies were included with median follow-up of 29.0 and 31.5 months respectively. Per year of follow-up occurrence of overall MACE were 5.1% in FFR group and 6.4% in IVUS group while death, myocardial infarction, LM revascularization were respectively 2.6%, 1.5% and 1.8% vs. 3.0%, 0.5% and 2.2%. Meta-regression analysis suggested the influence of a distal LM stenosis on MACE in FFR group (β = 0.06, p = 0.01) and age in IVUS group (β = 0.4, p = 0.001). In individual studies several independent predictors of MACE were identified including use of lower doses of intracoronary adenosine (OR 1.39, p = 0.04) in FFR group and plaque burden (OR 1.34, p = 0.025), number of other diseased vessels (OR 1.39, p = 0.04) and any untreated stenosis (OR 3.80; p = 0.037) in IVUS- studies. ConclusionsDeferring LM intermediate stenosis on the basis of FFR or IVUS showed an acceptable and similar risk of events in a mid-term follow-up. Conversely, several different variables related to each technique showed an interaction on outcome.

Percutaneous Coronary Intervention in Octogenarian Patients. Long-term Results and Predictors of Poor Outcome

Background: Coronary percutaneous intervention in octogenarian patients is growing due to the rise in life expectancy. However, this population is underrepresented in randomized trials due to its high risk. Objectives: The aim of this study was to evaluate short and long-term outcomes of coronary percutaneous intervention in octogenarian patients, and to identify independent predictors of adverse outcome. Methods: This was a retrospective study including consecutive patients undergoing percutaneous coronary intervention at a general hospital from June 2011 to September 2013. Octogenarian patients (age ≥80 years) were compared with younger patients. Medical history, procedure characteristics and clinical outcomes were evaluated. Major adverse cardiovascular events (MACE consisting of death, myocardial infarction or stroke) were evaluated at 1 month, and 1 and 3 years. Multivariate analysis was performed to assess independent predictors of adverse outcome. Results: A total of 1,030 patients (20.2% octogenarians) were included in the study. Mean age of octogenarian patients was 83 years (IQR 81-86). This population had more cardiovascular risk factors and comorbidities. No differences were observed in procedure success and number of implanted stents. The rate of MACE was significantly higher in octogenarian patients at 1 month (14.4% vs. 4.9%; p<0.001), 1 year (23.9% vs. 8.5%; p<0.001) and 3 years (p<0.0001), due to increased mortality, without differences in myocardial infarction (4.8% vs. 3.8%), stroke (1.7% vs. 1.6%), or procedural complications. Independent predictors of mortality in octogenarian patients were kidney failure, chronic obstructive pulmonary disease and ventricular dysfunction. Age ≥80 years was an independent predictor of MACE in the overall population. Conclusions: Technical success was acceptable in octogenarian patients undergoing percutaneous coronary intervention, but octogenarian patients showed increased early and long-term mortality that appears to be independent of the procedure. Kidney failure, chronic obstructive pulmonary disease and ventricular function impairment were independent predictors of adverse outcome in these patients.

Predictive value of metabolic syndrome definitions in patients with myocardial infarction with ST segment elevation – are they all the same?

Objectives: We sought to determine the predictive power of metabolic syndrome (MS) definitions on the prognosis in patients with myocardial infarction with ST-segment elevation (STEMI).Methods: We prospectively included 507 patients with STEMI who were admitted for primary percutaneous coronary intervention and could be identified for MS using the AHA-NHLBI, NCEP-ATP III and IDF definitions. After applying these criteria, we divided the group in patients with MS and without MS; we compared baseline characteristics, clinical findings and outcomes among these patients.Results: The prevalence of MS was lowest with the NCEP-ATP III definition (37.87%), followed by the AHA-NHLBI definition (42.80%) and highest when using the IDF definition (44.38%). During follow-up, the occurrence of new myocardial infarction and new revascularization was significantly higher in patients with MS. Only in a group of patients with MS according to the NCEP-ATP III definition, a higher number of strokes were recorded. Multivariate analysis shows that MS according to the NCEP-ATP III definition was an independent predictor for MACE (OR 1.830, 95% CI 1.238–2.704, p = .002) but not for mortality.Conclusion: Metabolic syndrome according to the NCEP-ATP III definition was associated with increased risk of the development of new cardiovascular events among the patients with STEMI.

Clinical implications of three-vessel fractional flow reserve measurement in patients with coronary artery disease.

There are limited data on the clinical implications of total physiologic atherosclerotic burden assessed by invasive physiologic studies in patients with coronary artery disease. We investigated the prognostic implications of total physiologic atherosclerotic burden assessed by total sum of fractional flow reserve (FFR) in three vessels (3V-FFR). A total of 1136 patients underwent FFR measurement in three vessels (3V FFR-FRIENDS study, NCT01621438). The patients were classified into high and low 3V-FFR groups according to the median value of 3V-FFR (2.72). The primary endpoint was major adverse cardiac events (MACE, a composite of cardiac death, myocardial infarction and ischaemia-driven revascularization) at 2 years. Mean angiographic percent diameter stenosis and FFR were 43.7 ± 19.3% and 0.90 ± 0.08, respectively. There was a negative correlation between 3V-FFR and estimated 2-year MACE rate (P < 0.001). The patients in low 3V-FFR group showed a higher risk of 2-year MACE than those in the high 3V-FFR group [(7.1% vs. 3.8%, hazard ratio (HR) 2.205, 95% confidence interval (CI) 1.201-4.048, P = 0.011]. The higher 2-year MACE rate was mainly driven by the higher rate of ischaemia-driven revascularization in the low 3V-FFR group (6.2% vs. 2.7%, HR 2.568, 95% CI 1.283-5.140, P = 0.008). In a multivariable adjusted model, low 3V-FFR was an independent predictor of MACE (HR 2.031, 95% CI 1.078-3.830, P = 0.029). Patients with high total physiologic atherosclerotic burden assessed by 3V-FFR showed higher risk of 2-year clinical events than those with low total physiologic atherosclerotic burden. The difference was mainly driven by ischaemia-driven revascularization for both functionally significant and insignificant lesions at baseline. Three-vessel FFR might be used as a prognostic indicator in patients with coronary artery disease. 3V FFR-FRIENDS study (https://clinicaltrials.gov/ct2/show/NCT01621438, NCT01621438).

Predictors of major adverse cardiac events following elective stenting of large coronary arteries

ObjectiveDiameter of the affected coronary artery is an important predictor of restenosis and need for revascularization. In the present study, we investigated the frequency and potential risk factors for major adverse cardiac events following elective percutaneous coronary intervention (PCI) and stenting of large coronary arteries. MethodsWe reviewed the data of elective candidates of PCI on a large coronary artery who presented to our center. Demographic, clinical, angiographic and follow-up data of the eligible patients were retrieved from our databank. The study characteristics were then compared between the patients with and without MACE in order to find out the probable risk factors for MACE in patients with large stent diameter. ResultsData of 3043 patients who underwent single vessel elective PCI with a stent diameter of ≥3.5mm was reviewed. During a median follow up period of 14 months, 64 (2.1%) patients had MACE. TVR was the most common type of MACE that was observed in 29 patients, while 5 patients had cardiac death. Higher serum levels of creatinine, history of cerebrovascular accident (CVA), and use of a drug eluting stent (DES) were significantly associated with MACE. In the multivariate model, history of CVA (odds ratio=5.23, P=0.030) and use of DES (odds ratio=0.048, P=0.011) were the independent predictors of MACE in patients underwent large coronary artery stenting. ConclusionThis study showed that prior CVA and the use of BMS were the potential risk factors for MACE in patients who were stented on their large coronary arteries.

Prognostic impact of residual SYNTAX score in patients with ST-elevation myocardial infarction and multivessel disease: Analysis of an 8-year all-comers registry

BackgroundThe residual SYNTAX score (rSS) was designed and validated to quantify the burden of residual coronary artery disease after percutaneous coronary intervention (PCI). The aim of this study was to assess the prognostic impact of rSS in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease undergoing primary-PCI. MethodsThis retrospective cohort study included 1499 consecutive patients with STEMI who underwent primary-PCI between January 2008 and December 2015. After exclusion criteria, the multivessel disease cohort (n=535) was divided into three groups, according to rSS: complete revascularization (rSS=0; n=198), reasonable incomplete revascularization (0<rSS<8; n=238) and incomplete revascularization (rSS≥8; n=99). ResultsIn-hospital mortality was significantly lower in patients with complete and reasonable incomplete revascularization, when compared to those with incomplete revascularization (1.5% vs. 1.7% vs. 9.0%, p<0.001). During follow-up (median 2.4years), rSS was positively correlated with MACE (25.3% for rSS=0 vs. 31.1% for 0<rSS<8 vs. 47.0% for rSS≥8, p=0.001) and all-cause mortality (5.1% vs. 10.5% vs. 19.2%, p=0.001). The rSS was also an independent predictor of MACE (when compared with complete revascularization, odds ratio [OR] was 1.5 for reasonable incomplete and 1.8 for incomplete revascularization) and all-cause mortality during follow-up (OR 2.9 for reasonable incomplete and 3.9 for incomplete revascularization), adding prognostic value over control variables and GRACE. ConclusionsIn a real-world cohort of patients with STEMI and multivessel disease who underwent PCI, the rSS added important prognostic information over control variables and GRACE, being an independent predictor of MACE and all-cause mortality during follow-up.