Killip Class Research Articles

30 days mortality prediction and risk factor analysis of Asian patients with ACS using interpretable machine learning algorithm

Abstract Background Thrombolysis in Myocardial Infarction (TIMI) is used to predict the mortality rate in patients with acute coronary syndrome (ACS). TIMI was developed with limited data on the Asian cohort and was based on the Western cohort. STEMI and NSTEMI have separate TIMI scores. There has been limited research on Asian ACS patients using interpretable machine learning (ML) algorithms. Purpose To construct a single 30-day mortality risk scoring system, as well as identify and analyse risk factors in ASIAN patients with ACS, that is applicable to both STEMI and NSTEMI patients, using an interpretable ML algorithm. Methods The National Cardiovascular Disease Database registry data of 9054 patients was used. 70% of the data was used for algorithm development, with the remaining 30% used for validation Fifty-four parameters were considered, demographics, cardiovascular risk, medications, and clinical variables. To provide better guidance and advice for clinical judgement, the gradient boosting algorithm (XGBoost) for classification analysis and SHapley Additive exPlanation (SHAP) value analysis graphs were used. Each indicator's SHAP value indicates the impact on model output (mortality) and was calculated using the XGBoost model. The performance evaluation metric was the area under the curve (AUC). The model was validated with a validation dataset and compared to the conventional score TIMI for STEMI and NSTEMI. Results The performance on validation dataset of the XGBoost algorithm using the top ten predictors from SHAP for; STEMI (AUC = 0.8534, 95% CI: 0.8226–0.8842, Accuracy: 0.8053, Sensitivity: 0.73125, Specificity: 0.81355) and NSTEMI (AUC = 0.8145, 95% CI: 0.77–0.8589, Accuracy: 0.7972, Sensitivity: 0.64356, Specificity: 0.81232) outperformed TIMI score (STEMI AUC = 0.785, NSTEMI AUC = 0.543). Killip class, age, heart rate, fasting blood glucose, ACEI, creatine kinase, systolic blood pressure, HDLC, cardiac catheterization, and oralhypogly are the top ten predictors chosen by the SHAP feature selection in ascending order. Cardiac catheterization and pharmacotherapy drugs as selected predictors improve mortality prediction in STEMI and NSTEMI patients compared to TIMI. The variable names are displayed on the y-axis in ascending order of importance. The average SHAP value is shown next to them. The SHAP value is shown on the x-axis. The colour represents the value of the feature, ranging from small to large, allowing comprehension of the distribution of the SHAP values for each feature (Figure 1). We can see that having a high killip class and being older are linked to a lower survival rate in ACS patients. Cardiac catheterization procedures, as well as the use of ACEI and OHA, both improve patient mortality (Figure 2). Conclusions A single algorithm would classify ACS patients better than TIMI, which requires two distinct scores. In order to better predict 30-day mortality in an ASIAN population, interpretable ML can be used. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Technology Development Fund 1

Cardiac magnetic resonance predictors of readmission for heart failure in elderly vs not elderly patients after ST-segment elevation myocardial infarction

Abstract Background Patients with ST-segment elevation acute myocardial infarction (STEMI) have an increased risk of re-admission for acute heart failure (AHF). However, identification of patients at higher risk of AHF is challenging, especially in elderly individuals. The implications of cardiac magnetic resonance (CMR) imaging soon after the acute event for this specific purpose are unknown. Purpose We aim to study the clinical and CMR predictors of AHF in elderly and not elderly patients after STEMI. Methods STEMI patients treated with percutaneous coronary intervention and discharged from three university hospitals were included in a multicenter registry. We registered baseline clinical characteristics, echocardiographic parameters and early (1-week) CMR parameters - left ventricular ejection fraction (LVEF, %), infarct size (% of left ventricular mass) and microvascular obstruction (MVO, number of segments). Univariate and multivariate comparisons were performed in elderly (>70 years) and not elderly (≤70 years) patients to predict AHF during follow-up. Results The cohort was comprised of 759 patients, of which 177 (23.3%) were elderly (>70 years). During a mean follow-up of 5.23±3.54 years, 79 (10.4%) patients presented AHF. In not elderly patients, Killip class at admission (HR 2.05 [1.32–3.17], p=0.001), anterior infarction (HR 3.43 [1.13–10.36], p=0.03) and CMR-LVEF (HR 0.94 [0.91–0.98] per increased %, p=0.001) independently predicted AHF. However, a combined risk score comprising these variables was not superior to CMR-LVEF alone to predict AHF during follow-up (AUC 0.81 [0.74–0.88] vs. 0.81 [0.73–0.88], p=NS). In elderly patients, CMR-LVEF was the only predictor of AHF in the final multivariable model (HR 0.94 [0.91–0.97], p<0.001), although its predictive power was moderate (AUC 0.68 [0.56–0.80], p=0.001). Most AHF events in the not elderly subgroup occurred in patients with reduced (≤40%) CMR-LVEF (71%), while in the elderly subgroup AHF occurred more frequently in patients with preserved (≥50%, 30%) or mildly reduced (40–49%, 32%) CMR-LVEF than reduced (≤40%) CMR-LVEF (38%). Conclusions LVEF quantified by CMR soon after STEMI can accurately predict the risk of AHF in not elderly (≤70 years) patients and identify those individuals at higher risk (i.e. CMR-LVEF ≤40%). However, in elderly (>70 years) patients most AHF occur in patients with CMR-LVEF >40%, emphasizing the need for better predictive strategies in this population. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Instituto de Salud Carlos III and “Fondos Europeos de Desarrollo Regional FEDER” and Conselleria de Educaciόn – Generalitat Valenciana.

Relationship between liver fibrosis and in-hospital outcomes in patients with acute coronary syndrome undergoing PCI

Abstract Background Patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) still experience a high rate of in-hospital complications. Liver fibrosis (LF) is a risk factor for mortality in the general population. However its prognostic role in ACS patients has been poorly investigated. Purpose We investigated whether the presence of LF detected by the validated fibrosis-4 (FIB-4) score may indicate ACS patients at higher risk of poor outcome. Methods In the prospective ongoing REAl-world observationaL rEgistry of Acute Coronary Syndrome (REALE-ACS), LF was defined by a FIB-4 score >3.25. The primary endpoint was in-hospital adverse events (AEs) including a composite of in-hospital cardiogenic shock, PEA/asystole, acute pulmonary edema and death. Results A total of 469 consecutive ACS consecutive patients were enrolled. Overall, 21.1% of patients had a FIB-4 score >3.25. Patients with LF were older, less frequently on P2Y12 inhibitors (p=0.021) and admitted with higher serum levels of white blood cells (p<0.001), neutrophils to lymphocytes ratio (p<0.001), C-reactive protein (p=0.013), high-sensitive troponin T (p<0.001), creatin-kinase MB (p<0.001), D-Dimer levels (p<0.001). STEMI presentation and higher Killip class/GRACE score were more common in the LF group (p<0.001). 71 patients experienced 110 AEs. At the multivariate analysis including clinical and laboratory risk factors, FIB-4 >3.25 (OR 3.1, 95% CI 1.4 to 6.9), admission left ventricular ejection fraction% below median (OR 9.2, 95% CI 3.9 to 21.7) and Killip class ≥II (OR 6.3, 95% CI 2.2 to 18.4) were the strongest independent predictors of in-hospital AEs. Conclusions LF detected by FIB-4 score >3.25 was associated with more severe ACS presentation and worse in-hospital AEs irrespective of clinical and laboratory variables. Funding Acknowledgement Type of funding sources: None.

Prognostic importance of NT-proBNP following high-risk myocardial infarction in the PARADISE-MI Trial

Abstract Background/Introduction N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a marker of ventricular wall stress and a potent predictor of death and heart failure (HF) across multiple populations (from healthy insurance applicants to various disease entities). Purpose To evaluate the prognostic importance of NT-proBNP in patients with acute myocardial infarction (AMI) complicated by left ventricular systolic dysfunction, pulmonary congestion, or both and ≥1 of 8 predefined risk-augmenting factors (age ≥70 years, diabetes, previous MI, eGFR <60 ml/min/1.73 m2, atrial fibrillation, LVEF <30%, Killip class III/IV, or ST elevation MI without reperfusion) enrolled in PARADISE-MI. Methods Patients were randomized to sacubitril/valsartan 200mg or ramipril 5mg twice daily within 0.5 to 7 days of presenting with an AMI. Patients with prior HF were excluded. NT-proBNP and high-sensitivity troponin T (hsTnT) were collected at randomization in a prespecified sub-study of 1129 patients. The primary endpoint of PARADISE-MI was a time-to-first composite of cardiovascular (CV) death or incident HF (hospitalization or outpatient symptomatic HF); secondary endpoints included all-cause death and the composite of fatal or non-fatal MI or stroke. Results Median NT-proBNP was 1757 pg/ml [interquartile range, 896–3462 pg/ml] at randomization (4.0±1.8 days after presentation with the index MI). Patients with higher NT-proBNP levels at baseline were older, more commonly women and more frequently had hypertension, atrial fibrillation, renal dysfunction, and pulmonary congestion at randomization (all p<0.001). NT-proBNP concentrations were only weakly correlated with levels of hsTnT at randomization (r=0.38, p<0.001). NT-proBNP at baseline was strongly associated with the primary composite endpoint (adjusted HR 1.45 per doubling NT-proBNP; 95% CI, 1.23–1.70), independent of clinical variables as well as hsTnT (Figure). NT-proBNP was also independently associated with all-cause death (aHR 1.74; 95% CI, 1.38–2.21) and fatal or non-fatal MI or stroke (aHR 1.24; 95% CI, 1.05–1.45). The relative effect of sacubitril/valsartan versus ramipril on the primary composite endpoint was not statistically different across the spectrum of NT-proBNP (p-interaction = 0.46). Conclusions When assessed within the first week of a high risk AMI NT-proBNP is not only associated with incident HF and death but also with atherosclerotic events and provides prognostic information that is independent of hsTnT in this post AMI population. Funding Acknowledgement Type of funding sources: None.

Quality matters: low-density lipoprotein electronegativity but not quantity determines mortality risk in acute coronary syndromes

Abstract Background Changes in the protein composition of low-density lipoprotein (LDL) particles induce a shift in their electronegativity, a phenomenon implicated in both pro-inflammatory and pro-atherogenic signalling (1). While high levels of LDL foster the build-up of atherosclerotic plaques, and as such the susceptibility for the development of acute coronary syndromes (ACS), LDL levels assessed at the time of presentation fail to associate with fatal events following the index event (2). Experimental data suggest that altered LDL electronegativity exerts functional effects on both the myocardium and vasculature (1,3). Purpose We aimed to study the association between LDL electronegativity, assessed at the time of acute presentation, and all-cause mortality following the index ACS. Methods We designed a case-cohort study in 2'619 ACS patients prospectively recruited in the investigator-driven, multicentre SPUM-ACS study (ClinicalTrials.gov Identifier: NCT01000701). Plasma LDL levels were quantified at baseline and LDL was chromatographically resolved into 5 subfractions (L1-L5), with the L1/L5 ratio serving as a proxy for overall LDL electronegativity. By employing least-squares ordinary regression models determinants of plasma L1, L5, and the L1/5 ratio were studied, and the association with mortality of both LDL levels and its electronegativity were estimated using weighted Cox regression models. Results Cases and controls showed similar lipid profiles, but distinct LDL electronegativity, demonstrated by an increase in the L1/L5 ratio in cases vs. controls (P<0.05; Fig. 1). The highest-ranked determinants of the L1/L5 ratio were total cholesterol, LDL, high-density lipoprotein, age and triglycerides. Higher L1/L5 ratios were associated with increased risk all-cause and cardiovascular death at both 30-day (adjusted [adj.] hazard ratio [HR], 2.35, 95% confidence interval [CI], 1.81–3.03, and 2.37, 95% CI, 1.83–3.07, per standard-deviation [SD] increase) and 1-year intervals (adj. HR, 1.88, 95% CI 1.43–2.46, and 1.81, 95% CI 1.36–2.42 per SD increase). In contrast, LDL levels were not associated with these outcomes, neither at 30-day (adj. HR, 1.20, 95% CI, 0.64–2.24, and 1.20, 95% CI, 0.64–2.56 per SD increase) nor 1-year intervals (adj. HR, 1.35, 95% CI, 0.69–2.63, and 1.25, 95% CI 0.56–2.78 per SD increase). These associations were independent of age, sex, cardiometabolic risk factors and baseline risk, as assessed by the updated GRACE score. When compared with established risk factors (hsTnT levels, BMI, Killip class, eGFR, LDL levels), the L1/L5 ratio superseded several risk factors as an independent predictor for fatal events following ACS (Fig. 2). Conclusions In contemporary patients with ACS, LDL electronegativity independently predicts fatal events after the acute event, while LDL levels do not. Our results suggest that LDL quality rather than quantity provides predictive utility for premature death within 1 year after the index ACS. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science FoundationSwiss Heart FoundationTheodor-Ida Herzog StiftungFoundation for Cardiovascular Research – Zurich Heart House

Analysis of myocardial salvage with cardiac magnetic ressonance and angiography depending on the STEMI revascularization pathway in a PPCI centre

Abstract Background Reperfusion networks have permitted improvements in reperfusion delays in primary percutaneous coronary intervention (PPCI)-treated ST elevation myocardial infarction (STEMI). However, the impact on myocardial salvage (MS) of direct transfer to the catheterization laboratory (cath-lab) to minimize system delay remains unknown. Objective We sought to quantify the myocardial salvage index (MSI) acutely and to assess adverse remodeling at 6 months in PPCI-treated STEMI according to the mode of patient presentation. Methods Between 2005 and 2021 we included 493 patients in a single center registry of first PPCI-treated STEMI who were studied with Late gadolinium enhanced (LGE) cardiac magnetic resonance (CMR) in the acute phase. Among them, 414 (84.0%) underwent a second LGE-CMR at 6 months. Subjects were classified depending on the mode of presentation: those diagnosed out-of-hospital and directly transferred to the cath-lab by the Emergency Medical Services (EMS group, 29.82%); subjects with first medical contact in a PCI-capable hospital (PCI-H group, 41.75%); and patients presenting to a non-PCI-capable center and transferred for PCI (non-PCI-H group, 28.43%). We computed the angiographic area at risk by BARI score, and combined it with the LGE-CMR derived infarct size to compute a validated MSI, expressed as percentage of area at risk. The change in ejection fraction (EF) and indexed left ventricle end-diastolic volume (iLVEDV) from baseline to 6 months was also computed. Results The mean age was 58.9±11.9 years, 84.5% were male and 51.4% had anterior STEMI. Total median ischaemic time was (median (interquartile range)) 126 (105–161) min in the EMS group, 201 (145–321) min in the PCI-H group and 300 (173–592) min in the non-PCI-H group (p<0.01). MSI was 45.28±2.6%, 39.63±2.2% and 35.53±2.7% respectively (p=0.034). In a multiple linear regression model adjusting for relevant covariables, including initial TIMI flow, area at risk, Killip class, age, sex, diabetes, number of vessels and presence of collaterals, a 7.50% (95% CI 0.9 to 14.1%) increase in MSI was observed in the EMS group compared to the PCI-H group, and 11.03% (95% CI 3.9 to 18.2%) compared to the non-PCI-H group (p=0.027 and 0.003 respectively). At 6 months, the mean absolute increase in EF was 5.36±0.6% for the EMS group, 4.03±0.5% for the PCI-H group and 3.52±0.6% for the non-PCI-H group (p<0.05 in the adjusted analysis) and the increase in iLVEDV was 2.37±7.3, 5.51±6.6 and 18.30±7.6 mL/m2 respectively (p=0.28). Conclusions Patients with out-of-hospital diagnostis of STEMI by the EMS who were directly transferred to the cath-lab showed shorter total ischaemic times, resulting in increased myocardial salvage and a trend towards improved indexes of left ventricular function at 6 months. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Grant from La Maratό de TV3 and grant from Fundaciό La Caixa

Left atrial strain analysis improves non-invasive estimation of left ventricular filling pressures in takotsubo syndrome

Abstract Background Takotsubo syndrome (TTS) is associated with a non-negligible risk of in-hospital (IH) complications. Elevated left ventricular filling pressures (LVFP), measured invasively as LV end-diastolic pressure (LVEDP), showed to predict adverse IH outcomes in this population. Recently, novel indexes of left atrial (LA) function, including LA reservoir and LA pump strain, demonstrated a close correlation with increased LVFP in unselected patients. Purpose To assess the ability of LA reservoir and LA pump strain to improve non-invasive estimation of LVFP and to predict IH complications in TTS patients. Methods We retrospectively enrolled patients with confirmed TTS diagnosis at invasive left heart catheterization and coronary angiography. LVEDP was assessed invasively at the time of catheterization. Transthoracic echocardiography was performed with 48 hours from hospital admission. IH complications were collected, including occurrence of acute heart failure (pulmonary oedema/cardiogenic shock; Killip class III/IV), death from any cause and life-threatening arrhythmias. Results A total of 62 patients were analysed (72.2±10.1 years, female 80%). IH complications occurred in 25 (40.3%). Patients who experienced IH complications had higher LVEDP and lower LVEF, LA reservoir strain and LA pump strain values compared to patients without IH complications (all P≤0.001). At multivariate analysis, EF and LVEDP were independent predictors of worse IH outcomes (P≤0.001 and P=0.004 respectively). Correlation analysis proved that lower values of both LA reservoir and pump strain were associated with increasingly higher LVEDP (r −0.859, P≤0.001 and r −0.848, P≤0.001 respectively). Receiving operating characteristic (ROC) curve analysis showed that the AUC for LVEDP to predict IH complications was 0.814 (95% CI 0.679–0.949, P≤0.001) with an optimal cut-off value of 24.5 mmHg (sensitivity 77%, specificity 53%). Therefore, we performed ROC curve analysis to compare the ability of LA strain values and standard echocardiographic parameters currently used for non-invasive LVFP assessment to predict LVEDP ≥24.5 mmHg. As a result, we obtained higher AUC for LA reservoir and pump strain [0.909 (95% CI 0.818–0.999, P≤0.001) and 0.889 (95% CI 0.789–0.988, P≤0.001), respectively] vs E/e' 0.800 (95% CI 0.663–0.937, P≤0.001), LAVi 0.666 (P=0.092) and tricuspid regurgitation (TR) peak velocity 0.582 (P=0.596). The incorporation of LA strain values in a multivariable model including E/e' ratio, LAVi and TR peak velocity to predict a LVEDP ≥24.5 mmHg led to a significant incremental predictive value (changes in χ2=11.99; P=0.002). Conclusion In patients with TTS, lower LA reservoir and pump strain values correlate with increased LVEDP and improve non-invasive estimation of LVFP. LA strain analysis may be an easy tool to individuate subjects at higher risk of IH complications. Funding Acknowledgement Type of funding sources: None.

The diastolic blood pressure U-curve

Abstract Introduction It is known that low diastolic blood pressure (DBP) at admission is associated with short-term cardiovascular events after acute coronary syndrome (ACS). However, there is a lack of further investigation into the nonlinear relationship between admission diastolic blood pressure (DBP) and adverse outcomes of ACS patients. Objective To investigate the relationship between admission diastolic blood pressure and subsequent cardiovascular mortality in patients with acute coronary syndrome. Methods Retrospective study of patients with ACS periodically included in our center registry between October/2012 and September/2018. Patients with class killip 4 at admission or that needed ionotropic support during hospitalization were excluded. The association between admission DBP and cardiovascular mortality during the follow-up period among this population was analyzed using multivariate COX regression model. Results were presented according to DBP quartiles: Q1, less than 70 mm Hg; Q2, from 71 to 80 mm Hg; Q3, from 81 to 90 mm Hg; Q4, above 90 mmHg. Results A total of 548 patients were included in this cohort study. Mean patient age was 65.9±13.1 years and 75.2% were men. A nonlinear relation was observed between DBP at admission and cardiovascular mortality over the follow-up. During a median follow-up of 42 months (IQR: 27–59), 47 patients (8.6%) died from cardiovascular causes. After adjusting for potential confounders (age and diabetes mellitus), patients in Q3 had the lowest risk for cardiovascular death by Cox proportional hazard model (HR 0.44; 95% CI: 0.16–1.00). Meanwhile, compared with Q1, Q3 patients had significantly lower risk for cardiovascular death (HR 0.35, 95% CI: 0.13–0.92). Conclusion Among patients admitted for ACS, there is a U curve relationship between admission DBP and risk for cardiovascular death. These results could be explained by a reduction in diastolic coronary blood flow which influences myocardial oxygen supply relative to the necessary demand in an ACS. Funding Acknowledgement Type of funding sources: None.

Ten-year prognostic impact of acute heart failure in STEMI patients: a prospective cohort study

Abstract Background Cardio-vascular death (CVD) in patients with acute myocardial infarction (AMI) significantly decreased due to reperfusion and advances in pharmacotherapy. Acute heart failure (AHF) remains a common and unfavorable AMI-related complication. Aim To determine the incidence and prognostic value of Killip Class II–IV of AHF in long term follow-up of patients with ST-elevation myocardial infarction (STEMI). Methods All patients with STEMI were admitted to our emergency cardiology department during 1995–2011. CVD up to ten years after STEMI was the main outcome endpoint. We compared CVD in patients with and without AHF, and revascularization. Survival curve was generated by the Kaplan-Meier method. Predictors of mortality after STEMI were determined by multivariable Cox regression. Results Prospective cohort study includes 1625 STEMI patients; the mean age of the patients was 54.4±0.3 years, time from symptom onset was 5.0±0.2 hour, 1497 were men (92.1%), and 899 patients (55.5%) were revascularized (TLT – 632 (38.9%), PCI – 267 (16.4%), including 159 patients with stent implantation (9.8%). 412 patients had AHF - Killip Class II–IV (25.4%) during first 24 hours. Ten-year survival after STEMI was 85%; survival exceeded 88% in patients without AHF, but was 75% for those with AHF. Among patients who underwent revascularisation ten-year survival was 82.9% for patients in group with AHF, and was 87.1% for those without AHF. In multivariable Cox regression, age ≥65 years, female gender and HF were the predictive factors for CVD. Kaplan-Meier survival curves demonstrated higher incidence of CVD in AHF patients in compare with those without AHF in long-term follow-up (Figure 1). Conclusion According to the study AMI care is associated with high rates of long term survival, ten-year rates exceed 85%. AHF during first 24 hour in patients with STEMI worsens the prognosis, but reperfusion therapy increases survival. Further efforts to improve survival should be directed to patients with AHF and low revascularization rate that are associated with poor survival after AMI. Funding Acknowledgement Type of funding sources: None.

Intravenous antiplatelet therapy with cangrelor vs. tirofiban in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

Abstract Background Intravenous antiplatelet drugs provide rapid and sustained inhibition of platelet aggregation and can mitigate the ischemic risk of patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). However, there are few real-world studies comparing cangrelor to tirofiban in this patient population. Purpose The aim of this study was to evaluate the effectiveness and the safety of cangrelor compared to tirofiban in a real-world population of STEMI patients undergoing pPCI. Methods This was a prospective, multicenter, observational study including consecutive STEMI patients who received either cangrelor or tirofiban during pPCI at six Italian high-volume pPCI centers from January 2020 to January 2022. The study population was divided into two groups according the antiplatelet treatment received (cangrelor or tirofiban). The primary study outcome was impaired myocardial revascularization assessed by post-procedural Thrombolysis in Myocardial Infarction (TIMI) flow grade <3. The secondary outcome measures were major bleeding, defined as Bleeding Academic Research Consortium (BARC) type 3 or 5, and all-cause mortality during the hospitalization. Results A total of 478 STEMI patients received intravenous antiplatelet therapy during pPCI. Of them, 16 patients were excluded since they received both cangrelor and tirofiban as bailout strategy. Thus, the final study population included 462 patients (mean age 63.9±11.8 years; 79.7% males): 223 patients received cangrelor (48.3%), and 239 tirofiban (51.7%). Patients treated with tirofiban had higher prevalence of prior myocardial infarction (p=0.016) and prior PCI (p=0.048) than patients receiving cangrelor (Table 1); also, they showed higher SYNTAX score (p=0.038) than patients receiving cangrelor, and a higher proportion of stent thrombosis as culprit lesion (p=0.047; Table 2). Conversely, patients treated with cangrelor had worse Killip class (p<0.001), and underwent more frequently pPCI via femoral access. Post-procedural TIMI flow<3 was reported in 114 (24.7%) patients. At propensity score adjusted regression analysis, the use of cangrelor was associated with a lower probability of post-procedural TIMI flow<3 (aOR: 0.530; 95% CI: 0.313–0.900; p=0.019) than tirofiban. Major bleeding and all-cause death occurred in 28 (6.1%) and 19 (4.1%) patients. There was no difference in the risk of major bleeding (aOR: 1.626; 95% CI: 0.618–4.279; p=0.324) and death (aOR: 2.724; 95% CI: 0.719–10.318; p=0.140) between groups. Conclusions In this real-world population of STEMI patients undergoing pPCI, periprocedural use of cangrelor was associated with improved myocardial reperfusion compared to tirofiban, but with no differences in terms of major bleeding or death during the hospitalization. Funding Acknowledgement Type of funding sources: None.

First medical contact facility type as a determinant of prognosis in a regional ST elevation myocardial infarction network

Abstract Background Delay in primary percutaneous coronary intervention (PPCI) in ST elevation myocardial infartion (STEMI) is associated with worse prognosis. In our regional STEMI network, the first medical contact (FMC) facility type defines 4 different assistance pathways (i.e. emergency medical services'diagnosis on the field and direct transfer to the catheterization laboratory (cath. lab) of a PCI hospital (EMS group); direct admission to a PCI hospital (PCI-H group); admission to community hospital and transfer to the cath lab of the PCI-H (CH group); diagnosis in a primary care centre and transfer to the cath lab of the PCI-H (PCC group). Each different FMC has been associated with different degrees in reperfusion delay. Objective To determine the influence of FMC facility type on 1-year mortality in patients with STEMI in our regional STEMI network. Methods This is a retrospective study based on the STEMI network registry, a mandatory registry conducted since its implantation and supervised by the regional health authorities. We included STEMI patients treated with PPCI from January 2010 to December 2020. We analyzed differences in clinical variables, reprefusion times and 1-year all-cause mortality regarding the FMC facility type. Results We included 18332 patients (EMS 34.25%, PCI-H 12.28%, CH 33.47%, PCC 20.01%). Initial Killip classes III–IV: EMS 8.43%, PCI-H 7.51%, CH 5.54%, PCC 3.76%; p<0.001. All comorbidities and complications in first medical assistance were more frequent in EMS and PCI-H groups (p<0.05). PCC group had the lowest risk profile regarding comorbidities and first medical assistance complications (p<0.05 for most of variables). The PCI-H group had the shortest system delay (median 82 min, p<0.001), the EMS group had the shortest total ischemic time (median 151 min, p<0.001). Crude 1-year mortality was EMS 8.6%, PCI-H 9.11%, CH 8.25%, and PCC 4.77% (p<0.001). After adjusting for several covariables with a logistic regression model, PCI-H and CH groups were associated with higher 1-year mortality compared to EMS group (OR 1.23 (IC95% 1.01–1.49; p=0.04) and OR 1.16 (IC95% 1.01–1.34; p=0.04) respectively), while PCC group was associated with lower 1-year mortality (OR 0.69 (IC95% 0.57–0.84; p<0.01)). Conclusions First medical contact with EMS and direct transfer to the cath lab was associated with lower adjusted 1-year mortality compared to first medical contact with a PCI hospital or a community hospital. Funding Acknowledgement Type of funding sources: None.

Comparing the long-term prognosis of myocardial infarction with non-obstructive coronary arteries to myocardial infarction with obstructive coronary artery disease

Abstract Background The long-term survival rates of myocardial infarction with non-obstructive coronary arteries (MINOCA) patients is lower than in the general population. Nevertheless, there are conflicting results regarding the prognosis of MINOCA patients in comparison to myocardial infarction with obstructive coronary artery disease (MI-CAD) patients. Purpose The aim of this study was to assess the long-term all-cause mortality of MINOCA patients and compare it to MI-CAD patients. Methods Retrospective analysis of 2443 consecutively admitted patients for acute myocardial infarction (AMI), in a single coronary intensive care unit. Only patients with 5 years of follow-up and those who died before the 5-year mark were considered. Patients were divided into two groups according to the presence or absence of obstructive coronary artery disease on angiography (≥50% stenosis). Demographic characteristics, symptoms at presentation, past medical history, laboratory characteristics and medication at discharge were compared using the Mann-Whitney U or χ2 test (according to variable type) to ensure comparability between groups. Five-year all-cause mortality was the target endpoint. Five-year survival was modelled through the Cox proportional hazard regression model. The variable of interest (MINOCA vs MI-CAD) and possible confounders that displayed statistically significant differences in the initial demographic analysis were included in univariable Cox regressions, and those with statistically significant associations were included in a multivariable model. Those that displayed non-significant associations in the multivariable model were subsequently removed until we were left with significant associations only, giving us an adjusted hazard ratio. Results Comparison between groups is presented in table 1. MINOCA patients were younger and more often women. They were less likely to have smoking habits, diabetes, or a previous history of AMI. They had a lower Killip class, as well as lower troponin I, serum creatinine and low-density lipoprotein cholesterol at admission. On the other hand, they had higher left ventricular ejection fractions. They were also less likely to have beta-blockers or aspirin prescribed at discharge. All-cause mortality at 5 years was 13.1% among MINOCA patients and 28.3% among MI-CAD patients, with an unadjusted hazard ratio (HR) of 0.421 (95% CI 0.322–0.550), p<0.001. Adjusting for known confounders, the HR was 0.461 (95% CI 0.261–0.816), p=0.008. Conclusions Compared with MI-CAD patients, those with MINOCA were slightly younger and had fewer comorbidities. In spite of having a worse long-term prognosis when compared to the general population, MINOCA patients have a significantly higher 5-year survival rate than MI-CAD patients, even after adjustment of confounding factors. Funding Acknowledgement Type of funding sources: None.

Utility of the Age Shock Index in 27312 patients with an acute coronary syndrome

Abstract Introduction The Shock Index (SI), defined as the ratio of heart rate (HR) to systolic blood pressure (SBP), represents a bedside reflection of the integrated response from the cardiovascular and autonomic systems and has been reported to predict adverse prognosis in patients with acute coronary syndromes (ACS). Age Shock Index (ASI), the product of SI multiplied with age, could also be useful in this setting, but its prognostic value is yet to be determined in ACS patients. Methods Acute myocardial infarction patients included in a national registry between October 2010 and January 2022. Optimal shock index cutoff was determined according to ROC curve analysis. Patients were categorized into two groups based on their initial ASI. Baseline characteristics, management and outcomes were compared between the two groups. The primary outcome was in-hospital cardiovascular death. Results A total of 27312 patients were included with a mean age of 66±13 years, 72.3% male, 47.5% with ST-elevation myocardial infarction. Based on ROC analysis, which showed AUC=0.80, the optimal ASI cutoff was 44 (with a sensitivity of 73% and a specificity of 74%); 19997 patients (73.2%) had an ASI <44 and 26.8% had an ASI ≥44. The former group was older (mean age of 75±10.0 vs 63±13.0 years, p<0.001), and had more comorbidities: arterial hypertension (77.3% vs 66.3%, p<0.001), diabetes mellitus (39.8% vs 28.1%, p<0.001), peripheral artery disease (7.1% vs 4.4%, p<0.001) and previous history of heart failure (11.0% vs 4.3%, p<0.001). Patients with ASI ≥44 had higher Killip class at admission and worse left ventricular ejection fraction on discharge (46.0±13.0 vs 53.0±11.0, p<0.001). In a multivariate regression analysis, after adjusting for possible confounders, ASI ≥44 was an independent predictor of cardiovascular death (HR 3.09, 95% CI: 2.56–3.71, p<0.001). ASI was a significantly better predictor of cardiovascular death than Shock Index (AUCASI = 0,80 vs AUCSI = 0.72, p<0,0001), but not in comparison to GRACE score (AUCASI=0.80 vs AUCGRACE=0.85, p<0.001) and TIMI (score AUCASI=0.80 vs AUCGRACE=0.84, p<0.001). At one year, using a Kaplan Meyer survival analysis, mortality was higher in patients with ASI ≥44 (log rank p<0.001) Conclusion ASI can identify almost immediately ACS patients at high risk of cardiovascular death, and combined with its simple use, makes it a practical tool for early risk stratification in these patients. Funding Acknowledgement Type of funding sources: None.

Beta-blockers in acute coronary syndrome: does rhythm matter?

Abstract Introduction Beta-blockers (BB) are recommended in patients with previous acute myocardial infarction (AMI), aiming to reduce morbidity and mortality. Their benefit is greater in patients with associated left ventricular dysfunction. However, in patients with atrial fibrillation (AF) its prognostic benefit is controversial. Purpose To assess and compare the in-hospital and 1-year prognostic impact of BB prescription after acute coronary syndrome (ACS), in patients with previous or de novo AF, and in patients with sinus rhythm (SR). Methods This was a national multicentre retrospective study of patients hospitalized for ACS between October 2010 and December 2021. A total of 35279 patients was included, and divided in two groups according to the prescription or not of BB. Patients with previous history of ischemic heart disease (myocardial angina, AMI or coronary revascularization) or heart failure, as well as presenting in Killip class IV or submitted to coronary artery bypass graft during admission were excluded. The impact of BB prescription on in-hospital and 1 year mortality rates, in patients with AF versus SR, was compared. Results A total of 14906 patients was selected, 82.5% with and 17.5% without BB prescription. Most patients were in SR (90.2%), with 9.8% presenting previous or new-onset AF. Patients without BB prescription were older (67±14 vs. 63±13 years) and had more comorbidities, namely valvular disease (2.3% vs. 1.2%, p<0.001) and chronic pulmonary obstructive disease (7.1% vs. 3.1%). The mean left ventricular ejection fraction was 53±13% in patients without BB prescription and 52±11 in the group with BB prescription (p<0.001). In-hospital and after discharge BB prescription was less frequent in AF patients (80.2% vs. 82.5% and 74.7% vs. 78.8%, respectively). The in-hospital mortality rate was 2.2%, 1.3% in the BB group and 6.6% in patients without BB prescription (p<0.001). At 1 year, mortality rate increased to 5.1%. BB prescription was associated with lower in-hospital mortality rate regardless of the rhythm, with an 81% risk reduction in SR (OR = 0.19, 95% CI 0.14–0.24) and 79% in AF patients (OR = 0.21, 95% CI 0.13–0.35). In a multivariate regression analysis, after adjusting for all the possible confounders, in-hospital BB prescription was associated with 70% of mortality risk (OR = 0.30, 95% CI 0.23–0.35). Overall, after discharge BB prescription was associated with reduced 1-year mortality risk (HR = 0.57, 95% CI 0.44–0.73), although it didn't reach statistical significance in AF patients (p=0.413). Nevertheless, in a bivariate Cox regression, rhythm showed no impact on BB protective effect (p-interaction = 0.335). As expected, AF had a negative prognostic impact (HR = 3.85, 95% CI 2.66–5.02). Conclusion BB prescription was associated with reduced in-hospital and 1 year mortality rates. The prognostic benefit of BB therapy was equivalent in ACS patients in sinus rhythm and with previous or new-onset AF. Funding Acknowledgement Type of funding sources: None.

Sacubitril/valsartan compared to ramipril in high risk post myocardial infarction patients stratified according use of mineralocorticoid receptor antagonists: insight from PARADISE MI trial

Abstract Background Mineralocorticoid receptor antagonists (MRAs) reduce the risk of cardiovascular death or heart failure admission in patients with myocardial infarction (MI) and left ventricular systolic dysfunction (LVSD) combined with either heart failure (HF) or diabetes. Whether use of MRA and initiation of sacubitril/valsartan are safe and whether MRAs modify the effect of sacubitril/valsartan initiation in high-risk MI patients is unknown. Purpose This analysis examined whether background treatment with a MRA modifies the treatment effect and safety of sacubitril/valsartan in patients with a MI and LVSD and/or pulmonary congestion. Methods In the PARADISE MI Trial (Prospective ARNI vs. ACE inhibitor trial to DetermIne Superiority in reducing heart failure Events after Myocardial Infarction) N=5661 patients were randomized to either sacubitril/valsartan (97/103 mg twice daily) or ramipril (5 mg twice daily) within 7 days of their MI. The primary outcome in this analysis was the composite of worsening HF (HF hospitalization or outpatient worsening) or cardiovascular death evaluated by the clinical endpoint committee (CEC-adjudicated) or the investigators. Safety was defined as symptomatic hypotension, hyperkalemia >5.5 mmol/L or permanent drug discontinuation. Results A total of 2338 patients (41%) were treated with an MRA and they were more often Caucasian (79% vs. 73%), had worse left ventricular ejection fraction (34±8 vs. 38±10%), a higher KILLIP Class (63% vs. 55% in class II or more) and a lower estimated Glomerular filtration rate (71 vs. 73 ml/min/1.73 m2), than patients not taking an MRA. Age (63 years), sex (24% females), and frequency of diabetes (42%) did not differ. The treatment effect of sacubitril/valsartan compared with ramipril was similar in patients taking or not taking an MRA: hazard ratio (MRA): (95% confidence interval [CI]): 0.96 (0.77, 1.19) versus (95% CI: 0.87 (0.71, 1.05), respectively, for the primary endpoint (p value for interaction = 0.51) (CEC adjudicated) (Figure 1); similar findings were observed if investigator reported endpoints were evaluated (P=0.61 for interaction). Safety of sacubitril/valsartan compared to ramipril initiation was not changed by +/−MRA use, but an increase in symptomatic hypotension was observed (HR(MRA): 1.37 and HR: 1.39, P<0.001) in both groups (P=0.968 for interaction), whereas an increased risk of hyperkalemia or permanent drug discontinuation was not observed in the sacubitril/valsartan group (P>0.05 for all comparisons). Conclusions As expected, patients taking MRAs had a higher risk. Use of a MRA did not modify the treatment effect and safety of initiation of sacubitril/valsartan compared to ramipril in the post MI setting in patients with LVSD and/or congestion. Our analyses support that sacubitril/valsartan and MRAs can be used simultaneously. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Novartis sponsored Randomized clinical trial

Utility of pulmonary echography with a handheld ultrasound device in patients with acute coronary syndrome.

The objectives of this study are to establish the usefulness of lung ultrasound with a handheld device to predict the risk of developing heart failure with the need for mechanical ventilation (MV) in acute coronary syndrome (ACS). This is a prospective study of consecutive patients admitted because of ACS-type myocardial infarction, without data of HF at admission in a tertiary hospital, between February 2017 and February 2018. Lung ultrasounds were performed with a handheld cardiologic device in the first 24h, and defined as echo-positive (PE+) when exams revealed 3 or more B-lines in 2 or more bilateral quadrants. We related this finding to the need for MV during admission. We included 119 patients (65.1 ± 12.8year; 75.6% male, 24.4% female; 87.4% in Killip class I, 12.6% in Killip class II). Pulmonary echography was positive (PE+) in 21 patients (17.6%). The sensitivity of PE+ to predict MV was 93.3%, the specificity 93.3%, and the area under the curve 0.93. In Cox regression analysis adjusted by CRUSADE score and Killip class, PE+ patients had a hazard ratio of 64.55 (CI 7.87; 529.25, p < 0.001) of needing MV. PE+ was associated with more frequent use of inotropes and mortality. Pulmonary ultrasonography with a handheld echocardiograph was predictive of severe heart failure and the need for mechanical ventilation in ACS with high specificity and sensitivity.

Novel scoring system based on clinical examination for prediction of in-hospital mortality in acute coronary syndrome patients: a retrospective cohort study

BackgroundThis study aims to develop PADjadjaran Mortality in Acute coronary syndrome (PADMA) Score to predict in-hospital mortality in acute coronary syndrome (ACS) patients based on clinical examination only. Additionally, we...

A model for predicting acute heart failure in patients with acute myocardial infarction by taking into account energy and adipokine metabolism indicators

Acute heart failure (AHF) is one of the most common complications of acute myocardial infarction (AMI). Currently, adropin, irisin, fatty acid binding protein 4 (FABP 4) and C1q/TNF-binding protein 3 (CTRP 3) are considered to be valid markers of energy homeostasis and the adipokine system in AMI patients. The aim of the study was to predict the development of AHF in AMI patients by taking into account indicators of energy homeostasis and adipokine system using generalized linear mixed model. The study examined 189 patients with acute ST-segment elevation myocardial infarction. Concentrations of adropin, irisin, insulin, FABP4 and CTRP3 were determined by enzyme-linked immunosorbent assay. Fasting capillary blood glucose level was measured by glucoseoxidase method. Insulin resistance (IR) was assessed using homeostasis model assessment of insulin resistance (HOMA-IR). The study identified thrombolysis in myocardial infarction (TIMI) grade before intervention. A generalized linear mixed model was used to develop a method for predicting AHF in AMI patients. The study showed decreased levels of adropin, irisin and CTRP3 and increased levels of FABP4 in AMI patients. A mathematical model for predicting AHF development in AMI patients was proposed. The model consisted of fixed effects, namely, two one-factor indicators (HOMA-IR and systolic blood pressure (BP)), one two-factor indicator (systolic and diastolic BP) and one three-factor indicator (adropin, irisin and CTRP3) and random effects such as four one-factor indicators (FABP4, TIMI Grade Flow, platelets, total cholesterol). The accuracy of predicting the absence of Killip class I AHF was 100%, Killip class II AHF – 0%, Killip class III AHF – 11%, Killip class IV AHF – 82%. It should be noted that systolic BP on day 1 was a strong negative prognostic factor, while HOMA-IR, the combined effect of adropin, irisin and CTRP3, the combined effect of systolic and diastolic BP were positive prognostic factors. Thus, the model showed a very high sensitivity in predicting Killip class IV AHF. The overall accuracy of the model was 89.4%.

Culprit plaque location within the left circumflex coronary artery predicts clinical outcomes in patients experiencing acute coronary syndromes with percutaneous coronary intervention: Data from the ORPKI registry.

The left circumflex (LCx) artery is the most diagnostically challenging of the coronary branches in terms of diagnostics because the clinical presentation and electrocardiography (ECG) do not always suggest critical occlusion despite its presence. Therefore, it is important to determine the factors contributing to the clinical manifestation and outcome, such as the culprit location. To determine the relationship between the location of the culprit plaque and clinical outcomes in the LCx artery. Data from the Polish Registry of Invasive Cardiology Procedures (ORPKI) from the years 2019-2020 concerning percutaneous coronary intervention (PCI) procedures were extracted and analyzed using appropriate statistical tests. 97 899 clinical records were analyzed. Patients with proximal occlusion received a worse grade using the Killip classification. Patients with Thrombolysis in Myocardial Infarction (TIMI) score 0 had worse clinical presentation in each of the occlusion locations. The periprocedural cardiac arrest and death rates were the highest among patients with proximal circumflex (Cx) occlusion. The death rate among patients with proximal occlusion and non-ST-segment elevation myocardial infarction (NSTEMI) was greater than among patients with distal occlusion and ST-segment elevation myocardial infarction (STEMI). Among patients with proximal occlusions of the Cx artery and TIMI 0 grade flow on initial angiogram, a STEMI-like approach should be undertaken apart from initial ECG findings. This is driven by a higher rate of critical and fatal complications such as cardiac arrest and periprocedural death. Fatal complications occur more often in patients with proximal occlusion of Cx than in medial or distal occlusion. Grade IV according to the Killip classification can suggest a proximal culprit location.

Impact of the COVID-19 pandemic on the treatment and prognosis of acute myocardial infarction in Xuzhou, China.

The treatment of acute myocardial infarction (AMI) during the COVID-19 pandemic has been affected to varying degrees. This study is the first to explore the impact of COVID-19 on the treatment and prognosis of rural and urban AMI in developing countries. A total of 128 patients with AMI in our hospital during the COVID-19 pandemic were enrolled. A total of 197 patients diagnosed with AMI before the COVID-19 pandemic were selected as the control group and one year of follow-up was performed. Hospital stay and the proportion of Killip class ≥ 2 patients were increased among rural AMI patients in the 'during COVID-19' group, compared with the 'before COVID-19' group. Among ST-segment elevation myocardial infarction (STEMI) total and rural STEMI patients, the treatment time in the during-COVID-19 group was longer than that in the before-COVID-19 group, whereas only the symptom to door (S to D) total and door to balloon (D to B) were extended in urban STEMI patients. In AMI total and rural AMI patients, major adverse cardiovascular events (MACEs) and all-cause mortality were increased in the during-COVID-19 group compared with the before-COVID-19 group. Kaplan-Meier analysis revealed that the survival and occurrence of MACEs in AMI total and rural AMI patients were significantly higher in the during-COVID-19 group. The COVID-19 pandemic led to delayed treatment and worse prognosis in AMI patients. Rural areas appear to be at a greater risk.