Index Event Research Articles

Abstract 4115139: The Clinic Ottakring – Lipid Registry: a Contemporary Single-Center Real-World Analysis from a Tertiary Hospital

In the real world only about 20 % of patients with ASCVD are at the target range, as shown by the SANTORINI trial (1). Therefore, there is still a great need for the improvement of lipid-lowering therapy (LLT). Our Lipid Registry was set up as a retrospective study including patients who visited our outpatients ward focusing on lipid-lowering therapy (LLT). The indications were: low-density lipoprotein cholesterol (LDL-c) > 130 mg/dL in LLT- naive patients with acute coronary syndrome (ACS), coronary artery disease (CAD) not on optimal LLT, familial hypercholesterolemia and LLT intolerance. We collected baseline characteristics as well as laboratory parameters of these patients during their visits. The dual LLT (high-potency statin and ezetimibe) was initiated in every patient during the hospitalization, if not contraindicated, as target variable we used non-HDL-C. In total 181 patients were included, of which 136 (75.1%) patients visited our clinic for control purposes. Patients who didn’t visit the clinic were predominantly men and had no or few pre-experiences with LLT. Fourty-one (36.9%) patients had a BMI>30, 126 (92.6%) of patients had CAD of which 85 (63%) had the diagnosis of a recent ACS. Arterial hypertension was present in 78.7% and diabetes mellitus type 2 in 23.5% of cases. At the 1 st visit to our LLT department 4-6 weeks after dismission from the hospital, 86 patients (61.9%) reached the recommended (ESC/EAS 2019) non-HDL-C goal. At the 2 nd visit (8-12 weeks after index hospitalization), 117 patients (86.2%) and at the 3 rd visit 120 patients (88.2%) reached their target. The analysis of patients initially presenting with ACS showed that 60 (69.8%) of them after 4-6 weeks and 77 (90.6%) patients after 8-12 weeks reached the recommended non-HDL-c goal. Among the study population 108 (79.4%) of patients, and 81 (95.3%) of ACS patients received dual LLT immediately during the index event. After the first visit, 31 (36.5%) of ACS patients needed the addition of the third lipid-lowering drug to achieve the recommended goal (see attached tables). Our strategy for managing hyperlipidemia in patients with a very-high cardiovascular risk showed high achievement of the non-HDL-C goal as recommended by the recent ESC guidelines in contrast to real-world data. We were able to demonstrate, that the strategy based on the idea to treat high-CV risk patients early and strong is the way to reach the treatment goal in a high percentage of patients (2).

Abstract 4136963: Long-term Effects of Continuous Positive Airway Pressure on Cardiovascular Outcomes after Acute Myocardial Infarction in Obstructive Sleep Apnea Patients

Background: There is increasing evidence of a strong association between obstructive sleep apnea (OSA) and ischemic heart disease. Previous studies have demonstrated OSA to be a significant predictor of incident CAD, while recent studies have confirmed individuals with OSA to have 3.9 times greater incidence of major adverse cardiac and cerebrovascular events (MACCE) at one year following acute myocardial infarction (AMI) than individuals without OSA. Whether treatment with continuous positive airway pressure (CPAP) after AMI in OSA patients reduces MACCE is not known. This study investigated the long-term cardiovascular outcomes associated with CPAP therapy after AMI in OSA patients, and is the first study to evaluate the effect of CPAP on secondary prevention after AMI. Methods: This retrospective study was conducted from 2015 to 2019 and included adults with AMI. Patients with at least moderate OSA (n=180) were followed for at least 1 year and categorized as either AMI and compliant to CPAP (54 patients) or AMI and non-compliant to CPAP (126 patients). We estimated the incidence of MACCE (early rehospitalization, re-catheterization, CABG, recurrent MI, CHF, arrhythmia, stroke, and death) in each group during follow-up from the index event. Continuous and categorical variables were analyzed for significance with Wilcoxon’s test and Fisher’s exact test respectively. Multivariate analyses were performed to adjust for confounders. Results: Most participants were male, the average age was 66 years old, and no significant demographic difference was identified between the two groups. Compared with non-compliant patients, CPAP-compliant patients exhibited significantly lower overall MACCE incidence (22.2% vs 40.5%, p=0.03) and repeat catheterization rate (1.9% vs 11.1%, p=0.04) after AMI. Conclusion: Long-term, compliant CPAP therapy, as compared with non-compliant CPAP therapy, significantly reduces recurrent cardiovascular events and provides effective secondary prevention after AMI in patients with at least moderate OSA.

SURG-11. COMPARATIVE RISK ANALYSIS OF DEVELOPMENT OF ANEMIA IN RADIOTHERAPY-TREATED VS. NON-TREATED MULTIPLE SCLEROSIS PATIENTS: A MULTICENTER RETROSPECTIVE COHORT STUDY

Abstract INTRODUCTION The use of RT in patients who are diagnosed with multiple sclerosis (MS) is controversial due to adverse effects such as inflammation. Simultaneously, the relationship between oncologic RT and worsening anemia is well established. However, there is not a clear understanding of the risk associated with undergoing RT due to their oncologic diagnosis in MS patients for developing anemia. OBJECTIVE This study aims to analyze the risk of developing anemia for patients with MS who have been treated with RT versus who have not. METHODS This retrospective study consists of analysis of the data acquired from TriNetX, a database that houses clinical data from 92 healthcare organizations. Cohort 1 included MS patients with history of RT, while cohort 2 included MS patients without any history of RT. The cohorts were propensity score matched for demographics such as age, sex, race, and ethnicity. All neoplasms were also matched to eliminate cancer as a confounding variable. The analysis included outcomes of interest, ICD-10 code D64 (Other anemia), up to 6 months after the first occurrence of the index event. RESULTS 4,844 patients were identified for each cohort post-propensity score matching. The mean age was 65.4 and 67.3 years old, and most patients were white at 76.3% and 77.0% for the MS with RT and without RT cohorts, respectively. Cohort 1 had 628 patients who developed anemia, while cohort 2 only had 511 patients. The odds ratio was 1.263 with 95% confidence interval of 1.116 to 1.430 showing the statistically significant difference between the cohorts. CONCLUSION This study demonstrates that there is a significant increase in the likelihood of developing broadly categorized anemia for multiple sclerosis patients with or without radiation therapy. Further study is warranted to understand other potential factors leading to an increased risk of developing anemia in the irradiated cohort.

Relative Benefit of Dual Versus Single Antiplatelet Therapy Among Patients With Atrial Fibrillation on Oral Anticoagulation According to Time After ACS and PCI: Insights From the AUGUSTUS Trial.

In the AUGUSTUS trial (An Open-Label, 2 x 2 Factorial, Randomized Controlled, Clinical Trial to Evaluate the Safety of Apixaban vs Vitamin K Antagonist and Aspirin vs Aspirin Placebo in Patients With Atrial Fibrillation and Acute Coronary Syndrome or Percutaneous Coronary Intervention), the combination of dual antiplatelet therapy plus oral anticoagulation increased the risk of bleeding without reducing ischemic events compared with a P2Y12 inhibitor plus oral anticoagulation among patients with atrial fibrillation and acute coronary syndrome or elective percutaneous coronary intervention. However, AUGUSTUS enrolled patients up to 14 days after acute coronary syndrome or percutaneous coronary intervention, and there may be a benefit to dual antiplatelet therapy plus oral anticoagulation early after an ischemic event. In this secondary analysis of AUGUSTUS, we divided patients into groups based on whether they were enrolled <6 days (early) or ≥6 days (later) after their index acute coronary syndrome or percutaneous coronary intervention, and tested the interaction between time from the index event to enrollment and randomized treatment (apixaban versus vitamin K antagonist and aspirin versus placebo) on 30-day and 6-month clinical outcomes using Cox proportional hazards models. Among 4605 patients enrolled in AUGUSTUS with data available on time from the index event to enrollment, the median time from the index event to enrollment was 6 (range, 0-14) days. There were no significant interactions between time from the index event and aspirin versus placebo on clinical outcomes at 30 days or 6 months, though patients with time from the index event <6 days had a nominally significant reduction in death or ischemic events at 30 days with aspirin (hazard ratio, 0.55 [95% CI, 0.30-0.99]), whereas patients with time from the index event ≥6 days did not (hazard ratio, 0.88 [95% CI, 0.54-1.43]; interaction P=0.23). There were no significant interactions between time from the index event and apixaban versus vitamin K antagonist on clinical outcomes. Among patients with atrial fibrillation with acute coronary syndrome or undergoing percutaneous coronary intervention, there was no difference in the relative benefit of apixaban versus vitamin K antagonist or aspirin versus placebo when patients were enrolled early versus later after their index event. URL: https://www.clinicaltrials.gov; Unique identifier: NCT02415400.

Utilization of Syndromic Vaginitis Diagnostic Testing Reduces 6-Month Follow-Up Outpatient Service Healthcare Costs—A Real-World Data Analysis

Background/Objectives: Vaginitis is a common infection among women of reproductive age. Although various diagnostic methodologies exist, diagnosis without the utilization of available diagnostic tests remains prevalent. This study aimed to assess downstream healthcare utilization and the cost of patients with and without diagnostic testing. Methods: This retrospective, observational study utilized the IQVIA PharMetrics® Plus database from July 2020 to October 2023. Patients with an index claim (ICD-10 code indicating vaginitis) were categorized into two cohorts: those who received a syndromic polymerase chain reaction (PCR) test and those who had no documented test on the index date or within two days. Total and service-specific healthcare resource utilization and costs were assessed for 6 months following the index event. This study was designed to inform how Syndromic Vaginitis PCR testing is used to make treatment decisions and to track outpatient and inpatient healthcare utilization for 6 months post index date represented by cost. Results: Patients who received a Syndromic Vaginitis PCR test had significantly fewer outpatient medical services in the 6 months following initial diagnosis compared to those who received no diagnostic test. This was largely attributed to a substantial decrease in other medical service visits, resulting in mean cost savings of USD 2067 (Syndromic PCR = USD 6675, SD = USD 17,187; No Test = USD 8742, SD = USD 29,894) (p-value 0.0009). Conclusions: Many vaginitis patients do not receive testing, but Syndromic Vaginitis PCR testing may be an effective diagnostic tool for reducing costs associated with vaginitis infections.

Long-term safety and efficacy of glucagon-like peptide-1 receptor agonists in individuals with obesity and without type 2 diabetes: A global retrospective cohort study.

We aimed to investigate the long-term impact of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) on thyroid function, cardiovascular health, renal outcomes and adverse events in individuals with obesity and without type 2 diabetes (T2D). In this observational cohort study, we used propensity score matching to construct comparable cohorts of individuals with obesity and without T2D who were new to GLP-1 RA treatment and those who did not receive glucose-lowering medications. In total, 3,729,925 individuals with obesity were selected from the TriNetX Global Network, with an index event between 1 January 2016 and 31 March 2024. The primary outcomes were safety, cardiovascular, thyroid and clinical biochemical profile outcomes occurring within 5 years following the index event. After propensity score matching, the study included 12,123 individuals in each group. GLP-1 RA treatment was associated with a significantly lower risk of all-cause mortality (hazard ratio 0.23; 95% confidence interval 0.15-0.34) and several cardiovascular complications, including ischaemic heart disease, heart failure, arrhythmias, hypertension, stroke and atrial fibrillation (all p < 0.05). GLP-1 RAs were also associated with a lower risk of acute kidney injury and allergic reactions. These protective effects were consistent across various subgroups and regions. In this large observational study, GLP-1 RAs showed long-term protective effects on cardiovascular health, renal outcomes and adverse events in individuals with obesity and without T2D. Our findings suggest that GLP-1 RAs may offer a comprehensive approach to managing obesity and its related comorbidities, potentially improving overall health and survival in this population.

Trends in cardiac arrest outcomes & management in children with cardiac illness category compared to non-cardiac illness category: An analysis from the AHA get with the guidelines®-resuscitation registry

IntroductionContemporary rates of survival after pediatric in-hospital CPR events and trends in survival over the last 20 years have not been compared based on illness category. We hypothesized that survival to hospital discharge for surgical-cardiac category is higher than the non-cardiac category, and rates of survival after in-hospital CPR increased over time in all categories. MethodsThe AHA Get With The Guidelines®-Resuscitation registry was queried for index CPR events in children < 18 years of age from 2000 to 2021. Categories were surgical-cardiac (in-hospital CPR event following cardiac surgery); medical-cardiac (CPR event in non-surgical cardiac disease); and non-cardiac (CPR event in patients without cardiac disease). The primary outcome was survival to hospital discharge. We compared eras 2000–2004, 2005–2009, 2010–2014, and 2015–2021 with mixed logistic regression models, including event year as a continuous predictor and site as a random effect. ResultsOf 16,241 index events, in-hospital CPR event rates by illness category were: 19 % surgical-cardiac, 18 % medical-cardiac, and 63 % non-cardiac. Surgical-cardiac category had the highest rate of survival to hospital discharge compared to medical-cardiac and non-cardiac categories (56 % vs. 44 % vs. 46 %; p < 0.001). After controlling for age, location of event, and hospital size, the odds of survival were highest for surgical-cardiac category (aOR 1.28, 95 % CI 1.17–1.41) and lower for medical-cardiac category (aOR 0.90, 0.82–0.98), compared to the non-cardiac category. Odds of survival increased for all illness categories from the 2000–2004 era to the 2015–2021 era. Rates of improvement differed among illness categories with medical-cardiac having the lowest increased odds per era. Surgical-cardiac patients had the highest rates of extracorporeal resuscitation (ECPR) (20 % across the cohort), though the greatest increase in ECPR utilization was in the non-cardiac population (52 % increased odds per era). ConclusionsOver the last 20 years, both survival to hospital discharge and ECPR use has increased in all in-hospital CPR event illness categories. Children with surgical-cardiac CPR event have higher odds of survival to hospital discharge compared to non-cardiac CPR event categories, whereas odds of survival were lowest with medical-cardiac CPR events.

Significance of cerebral microinfarcts in antiphospholipid syndrome: A population-based study.

Acute ischemic stroke (AIS) or transient ischemic attack (TIA) is the most common neurological manifestations of patients with antiphospholipid syndrome (APS). Incidental diffusion-weighted imaging (DWI) positive subcortical and cortical lesions, or acute incidental cerebral microinfarcts (CMI), are microscopic ischemic lesions, detectable on MRI for 10-14 days only. We aimed to look at the prevalence of acute incidental CMI in a cohort of patients with APS and their association with subsequent AIS or TIA. This is a population-based cohort study of adults with APS diagnosis using International Statistical Classification-9 (ICD-9) and supporting laboratory results between January 2014 and April 2020. We included any patient undergoing brain MRI (index event) during the year prior APS diagnosis or at any time point following diagnosis. Age-matched subjects with negative APS laboratory workup were used as a control group. In the first analysis, we compared acute incidental CMI prevalence in both groups. We then performed a second analysis among APS patients only, comparing patients with and without acute incidental CMI for AIS or TIA as the primary outcome. Cox proportional hazards models used to calculate hazards ratio (HR) and 4 years cumulative risk. 292 patients were included, of which, 207 patients with APS. Thirteen patients with APS had acute incidental CMI on MRI (6.3%), compared with none in the control group (p = 0.013). Following multivariable analysis, APS was the sole factor associated with acute incidental CMI (p = 0.026). During a median follow-up of 4 years (IQR 3.5, 4) in patients with APS, following multivariable analysis, acute incidental CMI was associated with subsequent AIS or TIA (HR 6.73 [(95% CI, 1.96-23.11], p < 0.01). Acute incidental CMI are more common among patients with APS than in patients with negative APS tests, and are associated with subsequent AIS or TIA. Detecting acute incidental CMI in patients with APS may guide etiological workup and reevaluation of antithrombotic regimen.

Do Children With Accidental Gunshot-related Fractures Experience Greater Risk of Mental Illness and Psychiatric Disorders? A Propensity-matched Study.

Firearm violence is the leading cause of death and is a major source of morbidity for children in the United States. While gunshot wounds (GSWs) are known to cause lasting psychological repercussions beyond physical injury, these effects are not well documented compared with the physical implications. Our study explores the association between accidental gunshot-related fractures in children and subsequent psychiatric outcomes. Relative to non-GSW-related fractures, do children sustaining an accidental GSW-related fracture experience higher risk of mental illness and psychiatric disorders? This study utilized the TriNetX US Collaborative Network as it provides comprehensive inpatient and outpatient data, longitudinal follow-up, and complete medical records across different facilities, closely reflecting real-world patient outcomes in orthopaedic practice. We retrospectively evaluated children diagnosed with an accidental GSW-related fracture and compared mental health diagnoses to children who experienced non-GSW-related fractures. Between January 1, 2003, and March 1, 2023, a total of 5071 children in the United States without preexisting anxiety, mood, psychotic, substance use, or insomnia disorders were reported to have experienced an accidental GSW-related fracture. Among these patients, 55% (2773) had a follow-up period of at least 1 year and met the inclusion criteria for the exposure cohort. In the non-GSW-related fracture cohort, a total of 61% (985,070) of children among 1,613,891 without the preexisting aforementioned conditions had a minimum follow-up period of 1 year and met the inclusion criteria. A total of 2769 children were successfully matched in each cohort using a greedy nearest neighbor propensity score-matching algorithm. Matching was based on age, gender, race, fracture location, and BMI, as these characteristics were identified through a regression analysis as potentially associated with psychiatric outcomes (p < 0.01). The mean ± SD age was 15 ± 4 years, and 16% (451) in the GSW cohort were girls. In the non-GSW cohort 17% (474) were girls. With respect to race and ethnicity, 62% (1709 in the GSW cohort; 1679 in the non-GSW cohort) were Black and 14% (384 in the GSW cohort; 386 in the non-GSW cohort) were Hispanic. Outcomes of interest were recorded for up to 3 years after the index event. The accidental GSW-related fracture cohort experienced a greater hazard of developing anxiety disorders (HR 3.8 [95% confidence interval (CI) 3.2 to 4.6]; p < 0.001), substance use disorders (HR 3.6 [95% CI 3.0 to 4.2]; p < 0.001), mood disorders (HR 2.4 [95% CI 1.9 to 3.1]; p < 0.001), non-mood psychotic disorders (HR 2.4 [95% CI 1.5 to 3.9]; p < 0.001), and insomnia (HR 1.8 [95% CI 1.4 to 2.3]; p < 0.001). Orthopaedic surgeons should implement early psychiatric screenings and integrate mental health support for children with gunshot-related fractures to address elevated risk of anxiety disorders, psychotic disorders, mood disorders, substance abuse, and insomnia. Future studies should focus on identifying effective interventions that mitigate these long-term psychological outcomes, with an emphasis on practical, targeted approaches in clinical care. Level III, prognostic study.

Smoking cessation after acute myocardial infarction: a Swiss-wide cohort study

Abstract Background Smoking is a major cardiovascular risk factor and of great importance in terms of both primary and secondary prevention. The present study aims to identify patient characteristics associated with smoking cessation within 1 year after acute myocardial infarction (AMI) to inform physician-patient interactions, secondary prevention measures, and public health planning. Methods ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) patients enrolled between 2012 and 2022 in the AMIS Plus registry who were active smokers at the time of the index event were included. At the 1-year follow-up, patients were questioned about their smoking behaviour via telephone interview and were further classified into those who had quit (stoppers) or continued (continuers) smoking. Patient characteristics were collected at the time of the index event and at follow-up and then compared using descriptive statistics. Results From a total of 4523 patients with AMI, 4242 (93.8%) provided information regarding their smoking status at a median follow-up of 395 days (interquartile range 370 to 469) after the index event. Of 1691 (39.9%) active smokers at the time of AMI, 861 (50.9%) reported quitting whereas 830 (49.1%) were still smoking at the 1-year follow-up. Stoppers were younger (57 vs. 58 years, p&amp;lt;0.001), more likely to be male (82.8% vs. 77.7%, p=0.008) and have presented with STEMI (77.0% vs. 71.0%, p=0.005), and less likely to have had a previous AMI (6.6% vs. 13.3%, p&amp;lt;0.001) than continuers. Smoking cessation was more common in patients with a more severe AMI characterised by a greater extent of myocardial injury (in-hospital median peak creatine kinase level 1291 IU/L vs. 1101 IU/L, p=0.012), at least one in-hospital complication (13.9% vs. 9.9%, p=0.01), and participation in a rehabilitation programme (83.7% vs. 68.8%, p&amp;lt;0.001). Stoppers more frequently implemented other favourable lifestyle changes, such as dietary changes (56.2% vs. 45.2%, p&amp;lt;0.001) and increased physical activity (54.6% vs. 37.7%, p&amp;lt;0.001) than continuers. Self-reported weight gain was more prevalent among those who quit smoking (44.0% vs. 19.7%, p&amp;lt;0.001). Conclusions In Switzerland, half of the patients with AMI who were active smokers at the time of AMI, reported to have stopped smoking 1 year after the index event. Smoking cessation was associated with participation in a rehabilitation programme and occurred more often in patients with larger AMI sizes, higher in-hospital complication rates and more frequent implementation of other favourable lifestyle changes after AMI. The significant weight gain after smoking cessation seems to represent a major issue that should specifically be addressed.

The triglyceride-glucose index is a predictor for cardiovascular events and all-cause mortality in young and middle-aged patients with metabolic syndrome

Abstract Aims The association between the triglyceride-glucose (TyG) index and cardiovascular risk in young and middle-aged individuals with Metabolic syndrome (MetS) remains unclear. This study aimed to investigate the relationship between baseline TyG index and cardiovascular events and all-cause mortality in these patients among American adults. Methods This study enrolled 4937 young and middle-aged patients with MetS from the National Health and Nutrition Examination Survey (1999–2018). Mortality outcomes were determined by linking to National Death Index records up to December 31, 2019. Multivariate Cox proportional hazards models were constructed to analyze explore the associations between baseline TyG index and cardiovascular events or all-cause mortality. Non-linear correlations were explored using restricted cubic splines, and a two-piecewise Cox proportional hazards model for both sides of the inflection point was constructed. Results During the up to 9.3 years follow-up period, a total of 463 all-cause deaths and 143 cardiovascular events were recorded. The multivariate-adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) escalate from the lowest to the highest TyG index quartile. Specifically, for cardiovascular events, the HRs range from 1.00 (reference) to 2.29 (1.22, 4.31) with a significant trend (P = 0.004). For all-cause mortality, the HRs vary from 1.00 (reference) to 1.59 (1.09, 2.32), also showing a significant trend (P = 0.003). The restricted cubic splines revealed a J-shaped association between the baseline TyG index with cardiovascular events and all-cause mortality in MetS patients. Conclusions The high TyG index was identified as an independent predictor of elevated rates of cardiovascular events among young and middle-aged patients with MetS. Additionally, a J-shaped curve pattern was observed in the association between these factors.

The triglyceride-glucose index, ventricular arrhythmias and major cardiovascular events in patients at high risk of sudden cardiac death

BackgroundThe association between the triglyceride-glucose (TyG) index and ventricular arrhythmias (VAs) is unclear. This study aimed to investigate the relationship between the TyG index, VAs, and major cardiovascular events in patients at high risk of sudden cardiac death (SCD).MethodsWe enrolled 1046 patients at high risk of SCD with an indication for implantable cardioverter-defibrillator (ICD) implantation at the Chinese National Center for Cardiovascular Diseases. The primary outcome was VAs, defined as sustained ventricular tachycardia and ventricular fibrillation documented by the ICD. The secondary outcomes were cardiac mortality, heart transplantation, and rehospitalization for heart failure.ResultsThe mean (± SD) age was 59.6 ± 14.0 years old, and 25.7% were female. During the mean follow-up of 36.1 months, 342 (32.7%) patients had VAs, and 185 (17.7%) patients had major cardiovascular events. The mean fasting glucose and triglyceride levels were 111.9 ± 42.7 mg/dL and 140.0 ± 95.4 mg/L, respectively, with a TyG index range of 6.96–11.8. In the Fine-Gray subdistribution hazard model analysis, an increase in the TyG index was associated with a significant increase in the VAs (per 1 TyG index, hazard ratio [HR] 2.95; 95% confidence interval [CI], 2.29–3.80) and secondary outcome (HR 2.84; 95% CI 1.86–4.34). When stratified into tertiles, the risk of VAs was significantly higher in the highest tertile (HR 4.08; 95% CI, 2.81–5.92) than in the lowest tertile. Analysis of the secondary outcome revealed similar findings (HR 3.18; 95% CI, 1.73–5.85).ConclusionsIn our cohort, the pre-operational TyG index is significantly associated with VAs and major cardiovascular events for patients with high risk of SCD.

Cardio-renal syndromes in patients admitted with ST-elevation myocardial infarctions: Incidence and impact on renal and overall outcome

Abstract Background The importance of cardiorenal syndromes (CRS) in patients with heart failure has been shown in many studies. However, there is little data on the impact of a combination of heart failure and renal disease in patients with acute myocardial infarctions. Aim of the present study was to investigate, how often a combination of heart failure (HF) and kidney disease (KD) could be detected in patients with ST-elevation myocardial infarctions and to estimate its impact on outcome. Methods All patients from a German heart center, admitted with STEMI between 2006 and 2022 were analysed. CRS was defined as a combination of heart failure (HF: left ventricular ejection fraction (LV-EF&amp;lt;40%), HF) and kidney disease (KD: GFR at admission &amp;lt;60 ml/min). Patients were assigned in a 2x2 model: HF-/KD-, HF-/KD+, HF+/KD-, HF+/KD+. Outcome analysis was adjusted by confounders in a multivariate Cox-regression-model. Acute kidney injury (AKI) was calculated by AKIN-criteria (KDIGO) Results Of a total of 8276 STEMI-patients included in the study 5696(69%) had a preserved LV-EF and no KD (HF-/KD-), 1354 (16%) a preserved LV-EF and KD (HF-/KD+), 743 (9%) a reduced LV-EF and no KD (HF+/KD-) and 483 (6%) both a reduced LV-EF and KD (HF+/KD+, CRS-Group). In the CRS-group patients were on average older (74.2±12 yrs. vs. 60.8±13 yrs., p&amp;lt;0.01), more likely to be female (36.9% vs. 23.1% in the control group, p&amp;lt;0.01) and more likely to be diabetics (31.0% vs. 16.8% in the control group, p&amp;lt;0.01). CRS was associated with higher rates of cardiogenic shock (41.5% vs. 8.7% in the control group) and higher rates of subsequent AKI with a 18x higher risk to develop AKIN-3 with or without the need for renal replacement therapy (RRT), (table, upper part). In patients with CRS in 11% of patients a temporal RRT was necessary vs. 0.5% in controls. Furthermore, in CRS-patients in-hospital and 1 year-mortality-rates were markedly higher (table, lower part). When adjusting outcomes for confounders (age, gender, CS, diabetes, anterior STEMI, 3 VD) the detrimental effect of CRS on outcome remained: AKIN-3/RRT: OR 16.5, 95% CI 7.5-30.0, p&amp;lt;0.01, In-hospital-mortality: OR 14.2, 95% CI 7.8-21, p&amp;lt;0.01, 1-year-mortality: HR 10.5, 95% CI 7.5-14.1, p&amp;lt;0.01. Conclusions In this analysis of registry data, cardiorenal disease could be detected in 6% of STEMI-patients, with higher rates in women and in diabetics. Patients with cardiorenal disease showed a more than 18-fold higher risk of suffering severe renal failure during the index event and a 24-fold higher risk of in-hospital death. Patients with either heart failure or renal disease were situated between the CRS and control group with regard to outcome. These results underline the additive effects of cardiac and renal disease.Table:Event rates by HF and KD group

Long-term prognostic value of microvascular obstruction by cardiac magnetic resonance in ST-segment elevation myocardial infarction

Abstract Background Microvascular obstruction (MVO) has been associated with a higher risk of cardiac remodelling and adverse events following ST-segment elevation myocardial infarction (STEMI). However, long-term prognostic implications of MVO in STEMI beyond five years of follow-up have not been assessed to date. Purpose To investigate the relation of MVO with all-cause mortality and recurrent ischemic events at long-term follow-up after STEMI. Methods This is a pooled analysis of three observational studies including 876 prospectively enrolled reperfused first STEMI patients, who underwent cardiac magnetic resonance imaging with late gadolinium enhancement, between 2003-2019, from four university medical centers in the Netherlands and Spain. Median follow-up duration was 6.3 (IQR 3.6-9.3) years. The primary outcome was all-cause mortality. The secondary outcome was a combined endpoint of all-cause mortality and recurrent ischemic events (i.e. myocardial infarction or stroke). We performed Cox regression analyses with a time-dependent covariate. Model 1 included correction for clinical covariates only, i.e. age, sex, smoking, diabetes mellitus, hypertension, and LAD culprit artery. Model 2 included imaging characteristics, i.e. infarct size and left ventricular ejection fraction, in addition to the clinical covariates. Results The study population consisted of 876 patients, mean age 59 years ± 12, 720 men (82%). MVO was present in 499 patients (58%). The presence of MVO was significantly associated with all-cause mortality up to six years post-STEMI, independent from clinical characteristics (Hazard Ratio [HR] 2.23, 95% CI 1.09-4.57, p=0.029), but not after six years post-STEMI (HR 0.98, 95% CI 0.45-2.12, p=0.958). Presence of MVO was not significantly associated with a combined endpoint of all-cause mortality and recurrent ischemic events before or after six years of follow-up (HR 1.27, 95% CI 0.81-1.99, p=0.294 and HR 0.68, 95% CI 0.35-1.31, p=0.244, respectively). All other traditional prognosticators, except age, also lacked predictive value at long-term follow-up beyond six years. Conclusions In STEMI patients, the presence of MVO by cardiac magnetic resonance imaging is associated with a more than two-fold higher risk of all-cause mortality up to six years after the index event. This relation seems to dissipate beyond this time period. Furthermore, presence of MVO was not associated with recurrent ischemic events at long-term follow-up post-STEMI.

Favourable lifestyle changes 1 year after acute myocardial infarction

Abstract Background Acute myocardial infarction (AMI) is a life-threatening event that should be an excellent motivator to adopt a healthy lifestyle. We aimed to evaluate the proportion of patients with AMI who reported favourable lifestyle changes 1 year after AMI. Methods Harnessing a nationwide prospective cohort of patients with AMI in Switzerland, ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) patients enrolled in the AMIS Plus registry between 2012 and 2022 were followed-up 1 year after the event by telephone interview. Favourable lifestyle changes, often addressed in hospitals or rehabilitation programmes were defined as smoking cessation, weight reduction (for overweight patients at index presentation), dietary changes, increased physical activity and stress reduction. Self-reported lifestyle changes were stratified according to AMI type, sex, and age. Results From 7906 AMI patients, 7234 (91.5%) with follow-up data were included. Of these, 5627 (77.8%) were male, 1607 (22.2%) female, 4664 (64.5%) had a STEMI, and 2570 (35.5%) a NSTEMI. At a median follow-up of 397 (interquartile range 371 to 465) days, 861 (50.9%) smokers at the time of the AMI had quit smoking, 1297 (35.0%) overweight patients had lost weight, 2567 (44.8%) patients had implemented nutritional changes, 2415 (41.2%) had increased their physical activity, and 1729 (30.5%) had reduced their stress levels. Patients with STEMI were more likely to stop smoking (53.0% vs. 45.1%, p=0.005), change their diet (46.4% vs. 41.6%, p&amp;lt;0.001), increase their physical activity (43.5% vs. 36.8%, p&amp;lt;0.001), or reduce stress (31.4% vs. 28.7%, p=0.04) compared to NSTEMI patients. Male sex was associated with smoking cessation [52.5% vs. 44.4%; p=0.008; age-adjusted odds ratio (OR), 0.78; 95% confidence interval (CI), 0.61-0.99; p=0.043], dietary change (47.8% vs. 33.7%; p&amp;lt;0.001; age-adjusted OR, 0.67; 95% CI, 0.58-0.77; p&amp;lt;0.001), and an increase in physical activity (43.5% vs. 32.9%; p&amp;lt;0.001; age-adjusted OR, 0.77; 95% CI, 0.67-0.88; p&amp;lt;0.001). However, after adjusting for age, stress reduction was comparable between males and females (30.9% vs. 28.9%; p&amp;lt;0.001; age-adjusted OR, 1.09; 95% CI, 0.94-1.26; p=0.25). Conclusions A substantial proportion of patients with AMI in Switzerland reported favourable lifestyle changes within 1 year after the index event. In general, STEMI as well as male patients were more likely to report multiple favourable lifestyle changes. Nevertheless, there is still room for improvement in terms of secondary prevention measures.

Interleukin 21, plasminogen activator inhibitor 1 and fractalkine improve risk stratification in elderly patients with pulmonary embolism

Abstract Background The importance of clinical parameters for predicting short-term mortality in hemodynamically stable patients with pulmonary embolism (PE) is acknowledged within the Pulmonary Embolism Severity Index (PESI) Score. Little is known about the value of novel biomarkers in this context. Given the pathophysiology of PE, markers related to inflammation and thrombosis, such as interleukin 21 (IL-21), fractalkine and plasminogen activator inhibitor 1 (PAI1) are of particular interest. Purpose To identify new protein biomarkers that improve 90d mortality prediction compared to the PESI score in elderly PE patients. Methods 1003 patients with venous thromboembolism aged ≥65 years were recruited between 2009 and 2011 from 9 hospitals in Switzerland (SWITCO65+ cohort). Among these, 778 patients were excluded due to missing data, deep venous thrombosis only, blood sample taken &amp;gt;1 day after diagnosis, no initial anticoagulation, systolic blood pressure &amp;lt;90 mmHg, withdrawal within 1 day or denying further use of data; 225 patients were prospectively included. Outcome was independently adjudicated up to 1 year after the index event. To identify candidate proteins, untargeted proteomic analyses (OLINK) were conducted in cases with 90d all-cause mortality (n=20) matched 1:2 (age, sex) to controls without events (n=40). 26 candidate proteins were then validated in all 225 PE patients using ELISA and Mesoscale analyses. Using ROC analyses, the most promising proteins to predict death within 90d were identified within this cohort. Optimal biomarker cut-off levels were derived using the Youden Index and survival analyses were computed. To evaluate the predictive value of these biomarkers, hazard ratios (HR) were calculated after adjusting for age, sex, and BMI. AUC-ROC analyses were performed to assess the biomarkers’ value for risk prediction compared to the PESI score. Results Baseline characteristics (Figure 1) did not differ between patients who died within 90d and those who did not, except for median PESI score (108 [95 – 125] vs. 87 [79 – 101], p&amp;lt;0.001). Optimal biomarker cut-off values were: IL-21: 56.17pg/ml, PAI1: 36.82pg/ml, fractalkine: 66’515pg/ml. Increased levels of IL-21 and PAI1 were associated with increased mortality (HR IL-21 = 1.5 [95% CI: 0.99 - 2.79], HR PAI1 = 2.6 [95% CI: 1.7 – 4.8]), whereas patients with elevated fractalkine levels were at lower risk to die within 90d (HR fractalkine = 0.37 [95% CI: 0.16 - 0.60]). For prediction of 90d mortality, the three assessed biomarkers showed a higher AUC than the PESI score. Combining the PESI score with the biomarkers did not further improve the AUC (Figure 2). Conclusions The protein biomarkers IL-21, PAI1 and fractalkine improve prediction of 90d mortality in elderly, hemodynamically stable PE patients compared to the PESI score. These biomarkers highlight the contribution of inflammation and thrombosis in the pathophysiology of PE and warrant further investigation.Baseline CharacteristicsROC Curves for Biomarkers and PESI Score

Efficacy of combination lipid lowering therapy in achieving low density lipoprotein cholesterol targets after one month of event in patients with acute coronary syndrome

Abstract Introduction Rapid reduction in low-density lipoprotein cholesterol (LDL-C) levels reduces the risk of recurrent events in patients with acute coronary syndrome (ACS) with benefits proportional to LDL-C reduction. Early use of combination lipid-lowering therapy (LLT) is therefore recommended. Proprotein convertase subtilisin/kexin type-9 inhibitors (PCSK9i) combined with high-intensity statins (HIS) improve LDL-C goal attainment but are unaffordable for many patients in India and worldwide. Purpose We share our experience with the use of dual RE (rosuvastatin plus ezetimibe) and triple REB (rosuvastatin plus ezetimibe and bempedoic acid) combination LLT in patients admitted with ACS. Methods All ACS patients admitted to our institute over one year (January 2023 to December 2023) were considered in this retrospective analysis. Those with unavailable lipid profile reports, either at the time of ACS or at 1-month follow-up, were excluded. Clinical and laboratory details were obtained from hospital records. The primary objective was to assess the percentage change in LDL-C levels from index event to 4 weeks follow-up. Results A total of 299 patients were included, out of which 60 were on HIS alone, 71 were on RE, and 168 were on REB (Figure). The majority (99%) of patients in the REB group were statin naïve, compared to the other two groups. The baseline mean LDL-C levels at the time of the index event were 95.3+30.5, 103.2+39.6, and 115.6+32.9 mg/dl, respectively (p&amp;lt;0.001) (Table). The mean LDL-C levels at four weeks post-ACS reduced to 52.9+21.2, 45.9+20.5, and 43.7+15.4 mg/dl, respectively (p&amp;lt;0.01). The percentage reduction in LDL-C level was 44.4%, 55.5%, and 62.2%, respectively (p&amp;lt;0.001). REB enabled 70.8% and 95.2% of patients to achieve the Lipid Association of India, and American College of Cardiology recommended LDL-C targets of &amp;lt;50 mg/dl and &amp;lt;70 mg/dl within 4 weeks. These target levels were achieved in 67.6% and 88.7% of patients on the dual RE therapy and 50% and 81.6% of patients, respectively, on HIS alone. Conclusion Our study demonstrates the capacity to rapidly achieve LDL-C goals after ACS with triple REB therapy, an affordable regimen compared to costly PCSK9i therapy.Figure.Lipid lowering strategies usedComparison of study groups

Nomogram-based prediction of MACE in older adults with STEMI

Abstract Introduction Despite the significant progress made in diagnosing and treating patients with ST elevation myocardial infarction (STEMI), high-risk subgroups such as older adults (those over 65 years-old) still face considerable residual risk of major adverse cardiovascular events (MACE) following treatment for their index event. Thus, it is crucial to create accurate, validated, and actionable tools to stratify patients according to their risk of MACE after admission for STEMI. Purpose Utilizing clinical data obtained from a registry of patients diagnosed with STEMI, this study aims to develop a nomogram that can reliably predict the likelihood of MACE incidence. Methods Using a large electronic single-center registry, all consecutive patients with STEMI, undergoing primary percutaneous coronary intervention (PCI), and aged 65 and above were identified. Demographic, laboratory, clinical and intra-procedural variables were examined. Univariate and multivariate logistic regression analyses were utilized to identify those factors which were independently associated with MACE incidence in the post PCI follow-up period. A nomogram was developed in a training set, and performance metrics such as receiver operating curves (ROC), calibration plots, and decision curve analysis were used for validation in a testing set. Analyses were performed using tidyverse and rms packages in R programming language. Results 1946 patients were included in the study and split into 70% training and 30% testing sets. Both groups were similar in terms of baseline demographic and clinical characteristics. Mean follow-up period was 17 months. Total MACE incidence in the post PCI follow-up period was 18%. Thirty-eight factors with limited missing information (&amp;lt;5%) were examined for their relationship with MACE incidence and after performing univariate and multivariate analysis 8 were selected for construction of the nomogram: left-ventricular ejection fraction (LVEF), serum creatinine, hemoglobin and fasting blood glucose levels, presence of valvular heart disease, post PCI TIMI flow grade, diameter of the stent placed in the culprit lesion, and presence of shock in the post PCI setting. The area under the curve (AUC) for MACE prediction in post PCI follow-up period showed acceptable discrimination (c-statistic=73%, 95%CI 71.2% to 76.3%). Calibration plots demonstrated that the nomogram model was well-calibrated, and its predictions were closely aligned with observed outcomes. Additionally, decision curve analysis indicated that the model exhibited strong discriminatory ability in predicting MACE. Conclusions A nomogram developed using a combination of laboratory, clinical, and procedural parameters reliably predicts future risk for MACE in older adults following STEMI. Future implementation of this model may identify the highest risk individuals to target more aggressive preventive efforts in a vulnerable cohort of patients.Plot 1Plot 2

Comparison of clinical symptoms and prognosis of non-post-menopausal women to age matched men admitted with ST-elevation myocardial infarctions

Abstract Background Although ST-elevation-myocardial infarctions (STEMI) in women before menopause are relatively uncommon, previous studies have shown that women in general are more likely to present with atypical symptoms and to show higher adverse event rates, which might at least be attributable to the on average higher age of women during the index event. Aim of the present study was therefore to compare in an age-matched cohort of STEMI-patients younger 55 years the likelihood of atypical symptoms between genders and to investigate the impact of female gender on short and long-term-outcome. Methods Patients &amp;lt;55 years of age with STEMI admitted between 2006 and 2022 to a German heart center were included in the analysis and women were compared to men with regard to clinical symptoms and outcome. To exclude local bias women of all ages with STEMI from the registry were compared to men in a control group. Results Of 12094 STEMI-patients in the total cohort 3343 (28%) were women and 8751 (72%) were men. Women had a mean age of 69.7±13 yrs. compared to 62.2±12 in men. Women with STEMI had a 40% higher chance to present without typical chest pain (no CP, 12.0% vs. 8.5%, p&amp;lt;0.01) and were more likely to present with dyspnea (26.1% vs. 22.7% p&amp;lt;0.01). While rates of late STEMI-presenters were numerically higher in women, this difference failed to reach significance (12.8% vs. 11.9%, p=0.16). When focusing however on the study group (&amp;lt;55 yrs. of age) there was no more age difference (women 47.2±6 yrs. vs. 47.5±6 yrs. in men, p&amp;lt;0.3) and rates of no CP were not different between genders: 5.7%(women) vs. 5.4% (men), p=0.79, nor were rates of dyspnea : 20.0% (women) vs. 18.5% (men), p=0.45. There was even a trend towards lower rates of late STEMI-presenters in women: 8.3% vs. 10.9% in men, p=0.077, although diabetes-rates were higher in women (16.9% vs. 11.8%, p&amp;lt;0.01). Despite similar initial symptom presentations, women showed a marked 60% increase in 30-day- (6.9% vs. 4.3%, p=0.017) and 1-year-mortality (8.7% vs. 5.3%, p&amp;lt;0.01). The disadvantage for women remained, when adjusting mortality rates for confounders (age, diabetes, anterior STEMI, multivessel disease, PCI result) in a Cox regression model (table, upper part). This could be confirmed in a subgroup multivariate analysis excluding patients with no CP or not undergoing emergency PCI (table, lower part). Conclusions In STEMI-patients younger 55 years women showed a more than 60% higher short- and long-term-mortality compared to their male peers. This disadvantage, at least with our data, cannot be sufficiently explained by higher rates of delayed STEMI-presentations or absence of typical chest pain. Further studies are needed to identify possible causes for this higher vulnerability of young women to acute myocardial infarctions.Table:Mortality in Women vs. men&amp;lt;55 yrs

Feasibility and end-user perceptions of a novel digital care assistant and support program for people after stroke or transient ischemic attack (CAPS)

Abstract Background The Care Assistant and support Program for people after Stroke (CAPS) or transient ischaemic attack (TIA) is a clinician-led program designed to improve the secondary prevention of stroke. The program combines person-centred goal setting and risk-factor monitoring through a web-based clinician portal, SMS goal-aligned messages, a mobile application (app), and a wearable device. We aimed to determine the feasibility of CAPS among people living with stroke or TIA, and clinicians who would deliver the program in future. Methods Open label single group pre-posttest mixed-methods evaluation of the 12-week program. Eligible lived-experience participants were recruited through the Australian Stroke Clinical Registry. Eligibility: diagnosis of stroke or TIA in preceding 6 months - 3 years, ≥18 years old, smartphone/tablet ownership, living in the community. Following surveys and interviews of lived-experience participants, ten clinicians experienced in stroke care were invited to participate in focus groups to discuss the program. We used descriptive statistics to evaluate feasibility outcomes, i.e. participant perceptions of usability, acceptability and satisfaction, and clinician perceptions on program design and delivery. Results From 600 invitations, 34 eligible participants commenced the program (27% female, 33% TIA, median 1.7 years from index event; one withdrew). Usability of the CAPS app was rated as ‘Good’ to ‘Excellent’ (System Usability Scale), with moderate sustained usage by study conclusion (&amp;gt;60%). Participants frequently reviewed their health data within the app (average twice a day/participant over 12 weeks), and entered their health measurements an average 73 times/participant. The majority (≥90%) of participants thought the program fitted well into their daily lives or helped engage them in self-monitoring, with 76% indicating they would use the program, if publicly available. Clinician participants included three nurses, three allied health professionals, two neurologists, a stroke consultant, and a general practitioner (GP) in focus groups. Overall, eight had positive perceptions of the CAPS program. Three clinicians indicated the measurements collected in the app captured "vital information", and five saw the value of CAPS to improve secondary prevention. Recommended modifications to the program included tracking atrial fibrillation and blood cholesterol. Seven believed participants would receive the most benefit from the program if delivered within three months post-discharge. Six indicated that GP-led multidisciplinary care was the best model to deliver CAPS. Conclusions The CAPS program was feasible to deliver and acceptable to people living with stroke or TIA. Clinicians saw the value of CAPS for secondary prevention, with feedback prompting further focus groups with GPs to develop the potential model of care. Findings have informed the design of a Phase II randomised feasibility trial.