Lower Major Adverse Cardiovascular Events Research Articles

Evolving use and clinical outcomes of coronary intravascular lithotripsy: insights from an international, multicentre registry

BackgroundIntravascular lithotripsy (IVL) is increasingly used for treatment of coronary artery calcification. This study aimed to evaluate contemporary utilisation patterns, safety and efficacy of IVL in an unselected real-world patient...

Glucagon-like Peptide-1 Agonists Reduce Cardiovascular Events in Cancer Patients on Immune Checkpoint Inhibitors.

Immune checkpoint inhibitors (ICIs) are associated with an increased risk of major adverse cardiovascular events (MACE). Glucagon-like peptide-1 agonists (GLP1a), initially developed for type 2 diabetes mellitus (T2DM), have shown promising results in reducing cardiovascular events. We aimed to investigate the effect of GLP1a on cardiovascular events in patients receiving ICIs. We conducted a retrospective, propensity score-matched cohort study using the TriNetX database. We identified adults with cancer and T2DM who received ICIs between April 2013 and May 2023. The primary efficacy outcome was incident MACE, defined as a composite of myocardial infarction, need for coronary revascularization, heart failure, ischemic stroke, and cardiac arrest. The secondary efficacy outcomes were the individual components of MACE as well as myocarditis and pericarditis. Safety outcomes included the occurrence of immune-related adverse events, serious adverse events related to GLP1a use, and all-cause mortality. We identified 7651 patients eligible for inclusion, among which 479 received GLP1a and 7172 received non-GLP1a diabetes medications. After matching (469 patients each), baseline characteristics were well-balanced. Over a median 12-month follow-up, the GLP1a cohort had a significantly lower MACE incidence than the non-GLP1a cohort (9.0 vs. 17.1 events per 100 patient-years) with a 54% lower risk of MACE (Hazard ratio (HR),0.46 [95% CI: 0.32-0.67]). There were reductions in myocardial infarction or need for coronary revascularization, heart failure, and all-cause mortality, with no differences in other cardiovascular events. GLP1a use did not increase risk of adverse events, including pancreatitis, biliary disease, bowel obstruction, gastroparesis, and immune-related adverse events. GLP1a use in cancer patients with T2DM receiving ICIs was associated with reduced MACE and all-cause mortality without an increased risk in serious adverse events.

Impact of intravascular ultrasound for coronary bifurcations treated with last generations stents: insights from the BIFURCAT-ULTRA registry.

Bifurcation lesions are associated with higher rates of major adverse cardiovascular events (MACE). To investigate the impact of imaging-guided PCI in a real-world population with coronary bifurcation lesions. From the ULTRA-BIFURCAT registry, we compared IVUS vs. angiographic guidance in a cohort of 3486 propensity matched patients. MACE a composite of all-cause death, myocardial infarction (MI), target-lesion revascularization (TLR) and stent-thrombosis was the primary endpoint. Subgroup analyses were performed for unprotected left main (ULM) and non-ULM disease. PSM generated 1743 pairs. MACE occurred in 154 (9%) patients in the IVUS guided group and in 199 (11%) patients in the angio-guided group (p=0.09). IVUS guidance was associated with lower MACE in the ULM population [HR 0.62, 95% CI 0.46-0.83], but had no impact in the non-ULM population [HR 1.12, 95% CI 0.83-1.51], p for interaction=0.006. IVUS was associated with reduction in all-MI [HR 0.32, 95% CI 0.16-0.64] in the ULM population and with lower ST in the non-ULM population [HR 0.24, 95% CI 0.08-0.71]. Provisional stenting was associated with lower MACE in the ULM population [HR 0.67, 95% CI 0.45-0.98], whereas kissing balloon [HR 0.75, 95% CI 0.56-0.99] and ultra-thin stents [HR 0.44, 95% CI 0.29-0.67] were protective factors in the non-ULM population. In a real-world scenario, IVUS guidance during DES implantation is associated with a lower rate of MACE in patients with ULM coronary bifurcation lesions. In non-ULM bifurcations, no difference was observed on MACE, while IVUS guidance was associated with a lower rate of ST.

Abstract 4141481: Outcomes of the upfront two stent strategies for bifurcation percutaneous coronary interventions: Insights from PROGRESS-BIFURCATION registry

Background: Upfront two-stent techniques are often used in bifurcation percutaneous coronary interventions (PCI), but there is controversy about optimal strategy selection. Methods: We examined the clinical, angiographic characteristics, and long-term outcomes of 206 bifurcation PCIs using the double kissing (DK) crush or the culotte techniques in 192 patients between 2014-2023 from the Prospective Global Registry for the Study of Bifurcation Lesion Interventions (NCT05100992). For the long-term outcomes adjusted hazard ratios (aHR) and 95% confidence intervals (CI) were calculated using the mixed effects Cox proportional hazards model. Results: DK crush was more commonly used (70.4%). Patients in the culotte group had similar baseline characteristics with the DK crush group. Lesions treated with culotte were more likely to be in the left anterior descending (54.1% vs. 35.9%, p<0.001) and circumflex arteries (21.3% vs. 9.0%, p<0.001), had smaller proximal (3.50 [3.00, 3.75] vs. 3.50 [3.30, 4.00] mm, p=0.032) and distal (3.00 [2.75, 3.00] vs. 3.00 [3.00, 3.50] mm, p=0.047) main vessel diameters, and were less likely to have severe calcification (6.6% vs. 32.4%, p<0.001). Technical success (96.7% vs. 98.6%, p=0.583), procedural success (93.1% vs. 93.9%, p=0.758), and in-hospital major adverse cardiovascular events (MACE) (3.4% vs. 6.1%, p=0.726) were similar in both groups. During a mean follow-up of 38-month, 32 (28.3%) patients experienced MACE. On multivariable analysis, culotte was associated with similar MACE (aHR 1.19; 95%CI 0.78-1.80; p=0.680), mortality (aHR 1.11; 95%CI 0.68-1.79; p=0.810), and target vessel PCI revascularization (aHR 0.58; 95%CI 0.30-1.13; p=0.460) compared with DK crush (Figure). Conclusions: Bifurcation PCI with DK crush and culotte had similarly high technical and procedural success, low in-hospital MACE, and long-term outcomes.

Clinical characteristics and predictors of adverse cardiovascular events from the australia-new zealand spontaneous coronary artery dissection (ANZ-SCAD) registry

Abstract Background Spontaneous coronary artery dissection (SCAD) is an increasingly recognised cause of acute coronary syndrome (ACS), predominantly affecting women. Our understanding of SCAD remains incomplete with limited prospective data on determinants of major adverse cardiovascular events (MACE). Purpose We aimed to describe the clinical characteristics of patients with SCAD from a large, multicentre SCAD registry. We aimed to identify the predictors of MACE (defined as the composite of all-cause death, non-fatal myocardial infarction, stroke, heart failure, and revascularisation). Methods Observational, multi-centre prospective and retrospective cohort study recruiting patients with SCAD from 23 hospitals in Australia and New Zealand. Patients aged=>18 years with SCAD and an ACS were eligible for inclusion. Prospectively recruited patients gave their informed consent with a waiver of consent for retrospectively recruited patients. All invasive coronary angiography imaging was adjudicated by an independent core laboratory to confirm the diagnosis of SCAD. Cox proportional hazard analysis was used to evaluate the association between MACE and SCAD recurrence with predefined clinical variables. Results From a total 487 patients recruited, 423 (132 prospective and 291 retrospective) patients with SCAD confirmed on core laboratory review were included for analysis. Mean age was 52.4±10.7 years, 89.7% were female and 73.1% were Caucasian. Percutaneous coronary intervention (PCI) was performed in 10.6% of patients. On discharge, 64% of conservatively managed patients were on dual antiplatelet therapy (DAPT). At 15 (interquartile range 5-36) months median follow-up, the accumulated MACE rate was 6.6%. On multivariate analysis, percutaneous coronary intervention (PCI) was associated with a higher risk of MACE [hazard ratio (HR) 3.50, 95% confidence interval (CI) 1.56-7.89, p=0.002], while discharge on at least one antiplatelet medication was associated with a lower risk of MACE (HR 0.13, 95% CI, 0.05-0.36, p<0.001). In patients managed conservatively (n=353), discharge on at least one antiplatelet medication (n=337) was associated with lower MACE (HR 0.27, 95% CI 0.1-0.73, p=0.01), with no difference between single and dual antiplatelet therapy (DAPT) (p=0.74). In patients managed conservatively and on DAPT (n=226), aspirin and clopidogrel was associated with a lower risk of MACE (HR 0.31, 95% CI 0.10-0.93, p=0.038) compared with DAPT consisting of aspirin and ticagrelor (HR 3.25, 95%CI 1.07-9.85 p=0.038) on multivariate analysis. Conclusion Patients with SCAD are at significant risk of MACE. In conservatively managed patients treated with DAPT, aspirin and clopidogrel was independently associated with a lower risk of MACE than aspirin and ticagrelor

Efficacy of diet with low glycemic index on coronary artery disease

Abstract Background Coronary artery disease (CAD) is a leading cause of morbidity and mortality worldwide, with dietary factors playing a significant role in its pathogenesis. The glycemic index (GI) of foods has been implicated in cardiovascular health, with low GI diets hypothesized to reduce the risk of CAD and improve outcomes [1]. However, the efficacy of low glycemic index diets in patients with established CAD remains uncertain. Objective This study aimed to assess the efficacy of a low glycemic index diet on coronary artery disease by evaluating changes in cardiovascular biomarkers and major adverse cardiovascular events (MACE) using Kaplan-Meier analysis and Cox regression models. Material and Methods A randomized controlled trial was conducted involving 156 patients with established coronary artery disease (Aged 43-75 years, mean age 62.4±12.7 years, male=57%). Participants were randomized to either a low glycemic index diet group or a control group receiving standard dietary advice. Changes in cardiovascular biomarkers, including lipid profiles, inflammatory markers, and glycemic control parameters, were assessed at baseline and follow-up visits. Major adverse cardiovascular events, including myocardial infarction, stroke, and cardiovascular death, were recorded over a median follow-up period of 6.2±2.4 years. Kaplan-Meier analysis and Cox regression models were used to evaluate the association between adherence to a low glycemic index diet and MACE. Results Preliminary analysis demonstrated significant improvements in cardiovascular biomarkers, including reductions in LDL cholesterol, triglycerides, and inflammatory markers, in the low glycemic index diet group compared to the control group (p < 0.05). Kaplan-Meier analysis revealed a lower incidence of MACE in patients adherent to the low glycemic index diet compared to non-adherent patients (log-rank p < 0.05). Cox regression analysis confirmed the independent association between adherence to a low glycemic index diet and reduced risk of MACE after adjusting for confounding factors (hazard ratio [HR], 0.75; 95% confidence interval [CI], 0.60-0.95; p < 0.001). Conclusion Our findings suggest that a low glycemic index diet may be efficacious in reducing cardiovascular risk and improving outcomes in patients with coronary artery disease. Adherence to a low glycemic index diet was associated with favorable changes in cardiovascular biomarkers and a reduced risk of major adverse cardiovascular events. Further research is warranted to confirm these findings and elucidate the mechanisms underlying the cardioprotective effects of low glycemic index diets.

Safety and effectiveness of glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: insights from the SPUM-ACS study

Abstract Aims Data on Glycoprotein IIb/IIIa inhibitors (GPI) use in real world ACS patients following the introduction of potent P2Y12 inhibitors and newer generation stents are scant. Here, we aimed to assess the utilization, effectiveness, and safety of GPI in a large prospective cohort of contemporary ACS patients. Methods SPUM-ACS is a prospective, multicentre study in which ACS patients between 2009 and 2017 were recruited. The primary endpoint of the present study was major adverse cardiovascular events (MACE), a composite of all-cause death, non-fatal myocardial infarction (MI) and non-fatal stroke at one year. Any bleeding events, BARC 3-5 bleeding, and net adverse cardiovascular events (NACE) comprised the secondary endpoints. Results A total of 4395 ACS patients were included in the analysis. GPI-treated patients had more total coronary artery occlusion (56% vs 35%, p<0.001) and thrombus (60% vs 35%, p<0.001) at angiography. Among the propensity score matched (PSM) population (1992 patients equally split into two groups), GPI-treated patients showed lower MACE risk (PSM adjusted HR 0.70, 95% CI 0.49-0.99) but a higher risk of any (PSM adj HR 1.46, 95% CI 1.06-1.99) and major bleedings (PSM adj HR 1.73, 95% CI 1.09-2.76), resulting in a neutral effect on NACE (PSM adj HR 0.87, 95% CI 0.65-1.17). These results remained consistent across all subgroups. When including only patients treated with potent P2Y12, the incidence of MACE was not different between the two groups, (log rank p=0.50 and PSM adjusted HR 0.94, 95% CI 0.60-1.48). In the PSM population, GPI use (HR 0.76, 95% CI 0.59-0.99, p=0.04), TIMI 3 at the end of the procedure (HR 0.16, 95% CI 0.08-0.30, p<0.001) and potent P2Y12 inhibitor use (HR 0.70, 95% CI 0.49-0.99, p=0.04) were protective independent predictors of MACE at follow-up, while oral anticoagulation at discharge (4.48, 95% CI 2.10-9.52, p<0.001), multivessel disease (HR 1.95, 95% CI 1.09-3.48, p=0.02) and KILLIP class ≥ 2 at admission (HR 1.98, 95% CI 0.99-3.95, p=0.05) were adverse independent predictors. Conclusion In ACS patients undergoing PCI and broadly treated with potent P2Y12 inhibitors, GPI use reduced the risk of MACE at 1 year, while increasing the risk of major bleedings, with a neutral effect on NACE. The routine use of these pharmacological agents should be discouraged, while in selected patients GPI use should be considered following personalized balancing between ischaemic and bleeding risk.Events in PSM populationEvents in PSM population

Prognostic impact of left ventricular ejection fraction improvement after transcatheter aortic valve replacement

Abstract Introduction Transcatheter aortic valve replacement (TAVR) has become an efficient and save alternative to surgical aortic valve replacement (SAVR). While severe aortic stenosis as well as severe aortic regurgitation (AR) is known to negatively impact left ventricular ejection fraction (LVEF), prior studies have shown that TAVR can lead to improvement in LVEF. So far, little is known about the prognostic implication of LVEF-improvement as a sole predictor of outcomes. Purpose The aim of this study was to assess the prognostic significance of early LVEF improvement in patients undergoing TAVR. Materials and Methods Patients undergoing TAVR in a large tertiary university hospital have been consecutively included in a large prospective registry. Transthoracic echocardiography (TTE) was performed at baseline, after TAVR before discharge, at 1 month and annually thereafter. Significant LVEF improvement was defined as >10% relative increase of LVEF at 30 days compared to baseline LVEF. Primary outcome was all-cause mortality at 5 years. Secondary outcome were major adverse cardiovascular events (MACE), including death, non-fatal myocardial infarction, stroke, bleeding and unplanned re-interventions of the aortic valve. Results Among 1481 patients undergoing TAVR between September 2011 and June 2023, LVEF at baseline and at 30 days was available in 1013 patients. 665 patients (65.6%) had normal LVEF at baseline, whereas 348 patients (34.4%) had a reduced LVEF. Of these, 137 patients (13.5%) showed significant improvement of LVEF ≥10%) after 30 days, while 266 patients (26.3%) showed no significant LVEF-improvement (<10%). The combined patients with persevered LVEF at baseline had significantly better outcomes than those with impaired EF (p=<0.001). LVEF improvement was not associated with mortality at 5 years (p= 0.51), however with lower MACE rate at 5 years (p=0,024). Conclusion Normal LVEF before TAVR is an independent predictor for improved outcomes. In addition, early improvement of LVEF is associated with beneficial outcomes in patients undergoing TAVR.Course of LVEF after TAVROutcomes after TAVR

Antithrombotic therapy in patients with atrial fibrillation after myocardial infarction and percutaneous coronary intervention

Abstract Background Antithrombotic treatment with oral anticoagulants is recommended in clinical practice guidelines for patients with myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI) and concurrent atrial fibrillation (AF). Previous randomized controlled trials comparing warfarin and DOAC have primarily focused on bleeding complications. Consequently, the benefits and risks in an all-comer population remain uncertain. Purpose This study aimed to evaluate adherence to clinical practice guidelines within a large nationwide cohort and to compare outcomes among patients with MI and AF who were treated with dual antiplatelet therapy (DAPT), Warfarin, or DOAC. Method We utilized data from the nationwide SWEDEHEART registry to identify all patients with MI and AF between January 2010 and January 2021. We included all patients who underwent PCI and had a CHA2DS2-VASC score of ≥2 for men and ≥3 for women. The follow-up was one year. Patients were allocated into one of three antithrombotic treatment groups based on discharge medications: (1) Warfarin-based, (2) DOAC-based, and (3) DAPT only. The warfarin- and DOAC-based groups comprised patients on either dual or triple antithrombotic therapy. Study outcomes included: (1) major adverse cardiovascular events (MACE), defined as a composite of all-cause death, MI, or stroke; (2) net adverse cardiovascular events (NACE), which included MACE and bleeding complications; and (3) the individual components of MACE and NACE. Cox regression models were used to adjust for differences in baseline characteristics. Results Mean age among the 12,321 patients included was 76.1 years. At discharge, 3,563 (29%) were treated with warfarin, 3,671 (30%) received DOAC treatment, and 5,087 (41%) with DAPT alone. The percentage of patients treated with OAC increased from 30% in 2010 to 84% in 2021. Warfarin- and DOAC-based strategies were associated with lower MACE compared to DAPT alone, with adjusted hazard ratios [HR] (95% CI) of 0.77 (0.69-0.97) and 0.78 (0.69-0.90), respectively, as well as lower rates of NACE with adjusted [HR] (95% CI) of 0.84 (0.76-0.93) 0.84 (0.75-0.94), respectively. This difference was primarily driven by a difference in mortality, with adjusted ]HR] (95% CI) of 0.78 (0.67-0.91) and 0.80 (0.68-0.94), respectively. There were significantly fewer stroke events in the DOAC group (2.5 % vs 3.3%) compared with DAPT. No significant differences in bleeding events were observed between any of the treatment groups. Conclusions In this real-life retrospective study, we observed an increased utilization of guideline recommended OAC treatment over time. Both DOAC and warfarin treatment regimens were associated with a lower incidence of MACE and NACE compared to DAPT alone. No significant difference in outcomes were observed comparing DOAC vs Warfarin.

Statin Therapy Reduces Radiation-Induced Cardiotoxicity in Patients With Breast Cancer Receiving Adjuvant Radiotherapy.

To evaluate the efficacy of statin therapy in reducing major adverse cardiovascular event (MACE) risk among patients with breast cancer undergoing breast-conserving surgery and adjuvant whole breast radiotherapy. A retrospective cohort study was conducted using data from the Taiwan Cancer Registry Database linked to the National Health Insurance Research Database. Patients diagnosed with left-sided early breast invasive ductal carcinoma between 2016 and 2019 were included. Propensity score matching was employed to compare MACE risk between statin users and nonusers. Cox regression models were used to estimate adjusted hazard ratios (aHRs) for MACE, considering cumulative defined daily doses and daily defined doses of statins. Among 1481 patients undergoing breast-conserving surgery and adjuvant whole breast radiotherapy, statin use significantly reduced MACE risk (aHR, 0.34 [95% CI, 0.25-0.44]). Hydrophilic statins, particularly rosuvastatin and pravastatin, demonstrated the greatest risk reduction. Higher cumulative defined daily doses and daily intensity doses of statins were associated with lower MACE risk, indicating a dose-response relationship. The 5-year cumulative incidence of MACE was significantly lower in statin users compared with nonusers (12.24% versus 31.70%). Statin therapy is associated with a reduced risk of MACE in patients with breast cancer undergoing breast-conserving surgery and adjuvant whole breast radiotherapy. Hydrophilic statins rosuvastatin and pravastatin exhibit the most pronounced cardioprotective effects. These findings suggest a potential role for statins in mitigating cardiovascular complications in this population and highlight the need for further research to optimize statin therapy in survivors of breast cancer undergoing radiotherapy.

Major adverse cardiovascular events' reduction and their association with glucose-lowering medications and glycemic control among patients with type 2 diabetes: A retrospective cohort study using electronic health records.

Cardiovascular diseases are a common cause of death among patients with type 2 diabetes (T2DM). Major adverse cardiovascular event (MACE) risks can be significantly reduced under adequate glycemic control (GC). This study aims to identify factors that influence MACE risk among patients with T2DM, including Hemoglobin A1c variability score (HVS) and early use of MACE-preventive glucose-lowering medications (GLMs). We conducted a longitudinal cohort study to retrospectively review electronic health records between 2011 and 2022. Patients with T2DM ≥18 years without previous stroke or acute myocardial infarction (AMI) were included. Cox regression was utilized to investigate MACE risk factors and compare MACE risk reduction associated with early use of MACE-preventive GLMs. A total of 19 685 subjects were included, with 5431 having MACE, including 4453 strokes, 977 AMI, and 1 death. There were 11 123 subjects with good baseline GC. Subjects with good baseline GC had 0.837 (confidence interval [CI]: 0.782-0.895) times lower MACE risk than their counterpart. Subjects with a single MACE-preventive GLM at baseline with continuous use >365 days showed a decreased MACE hazard ratio (0.681; CI: 0.635-0.731). Among all MACE-preventive GLMs, semaglutide provided a more significant MACE-preventive effect. This study identified that GLM, early GC, and HVS are MACE determinants among patients with T2DM. Novel GLM, adequate GC, and reduction of HVS can benefit MACE outcomes.

Percutaneous coronary intervention vs. medical therapy in patients on dialysis with coronary artery disease in China.

The available evidence regarding the benefits of percutaneous coronary intervention (PCI) on patients receiving dialysis with coronary artery disease (CAD) is limited and inconsistent. This study aimed to evaluate the association between PCI and clinical outcomes as compared with medical therapy alone in patients undergoing dialysis with CAD in China. This multicenter, retrospective study was conducted in 30 tertiary medical centers across 12 provinces in China from January 2015 to June 2021 to include patients on dialysis with CAD. The primary outcome was major adverse cardiovascular events (MACE), defined as a composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke. Secondary outcomes included all-cause death, the individual components of MACE, and Bleeding Academic Research Consortium criteria types 2, 3, or 5 bleeding. Multivariable Cox proportional hazard models were used to assess the association between PCI and outcomes. Inverse probability of treatment weighting (IPTW) and propensity score matching (PSM) were performed to account for potential between-group differences. Of the 1146 patients on dialysis with significant CAD, 821 (71.6%) underwent PCI. After a median follow-up of 23.0months, PCI was associated with a 43.0% significantly lower risk for MACE (33.9% [n=278] vs. 43.7% [n=142]; adjusted hazards ratio 0.57, 95% confidence interval 0.45-0.71), along with a slightly increased risk for bleeding outcomes that did not reach statistical significance (11.1% vs. 8.3%; adjusted hazards ratio 1.31, 95% confidence interval, 0.82-2.11). Furthermore, PCI was associated with a significant reduction in all-cause and cardiovascular mortalities. Subgroup analysis did not modify the association of PCI with patient outcomes. These primary findings were consistent across IPTW, PSM, and competing risk analyses. This study indicated that PCI in patients on dialysis with CAD was significantly associated with lower MACE and mortality when comparing with those with medical therapy alone, albeit with a slightly increased risk for bleeding events that did not reach statistical significance.

Clinical and Angiographic Outcomes of Bilateral Internal Thoracic Artery Revascularization: In Situ vs Free Grafts

BackgroundBilateral internal thoracic artery (ITA) grafting is associated with improved long-term outcomes; however, the appropriate graft configuration remains controversial. We compared the long-term outcomes of different graft configurations. MethodsBetween 2009 and 2015, 1171 patients underwent isolated bilateral ITA grafting for left-sided complete revascularization at 4 Japanese cardiac surgery centers: underwent in situ left ITA to the left anterior descending artery plus in situ right ITA to the left circumflex artery (LR group, n = 278), in situ right ITA to the left anterior descending artery plus in situ left ITA to the left circumflex artery (RL group, n = 665), and in situ left ITA to the left anterior descending artery plus free right ITA to the left circumflex artery (free group, n = 228). Major adverse cardiovascular events (MACEs), including mortality, myocardial infarction and revascularization, and ITA patency, were compared. ResultsAmong the 3 groups, the free group showed significantly lower MACEs and overall mortality rates (P < .001). Nonfatal myocardial infarction and revascularization rates showed no marked differences among the groups. A weighted analysis revealed a decreased risk of MACEs and death in the free group. No marked difference was observed in the patency of the ITA anastomosed to the left anterior descending artery. Patency of the ITA grafted to the circumflex artery in the LR group was significantly lower relative to the other groups. Using a free right ITA grafted to the circumflex artery reduced the risk of graft failure. ConclusionsThe free right ITA configuration for left-sided revascularization might have better long-term outcomes and significantly better patency than other grafts.

Prognostic Value of the Advanced Lung Cancer Inflammation Index Ratio in Patients with Acute Myocardial Infarction Complicated by Cardiogenic Shock: A Cohort Study.

Acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) carries a high mortality risk. Inflammation and nutrition are involved in the pathogenesis and prognosis of both AMI and CS. The advanced lung cancer inflammation index ratio (ALI) combines the inflammatory and nutritional status. Our present study aimed to explore the prognostic value of ALI in patients with CS following AMI. In total, 217 consecutive patients with AMI complicated by CS were divided into two groups based on the ALI admissions cut-off: 12.69 and 12.69. The primary endpoint of this study was 30-day all-cause mortality. The secondary endpoints were gastrointestinal hemorrhage and major adverse cardiovascular events (MACEs), including 30-day all-cause mortality, atrioventricular block, ventricular tachycardia/ventricular fibrillation, and nonfatal stroke. The association of ALI with the study endpoints was analyzed by Cox regression analysis. During the 30-day follow-up period after admission, 104 (47.9%) patients died and 150 (69.1%) suffered MACEs. The Kaplan-Meier analysis revealed significantly higher cumulative mortality and lower MACE rates in the low-ALI group compared to the high-ALI group (both log-rank p 0.001). The 30-day mortality rate was significantly higher in patients with ALI 12.69 compared to ALI 12.69 (72.1% vs. 22.6%; p 0.001). Furthermore, the incidence of MACEs was higher in patients with ALI 12.69 (85.6% vs. 51.9%; p 0.001). The receiver operating curve showed that ALI had a modest predictive value (area under the curve [AUC]: 0.789, 95% confidence interval [CI]: 0.729, 0.850). After multivariable adjustment, ALI 12.69 was an independent predictor for both 30-day all-cause mortality (hazard ratio [HR]: 3.327; 95% CI: 2.053, 5.389; p 0.001) and 30-day MACEs (HR: 2.250; 95% CI 1.553, 3.260; p 0.001). Furthermore, the addition of ALI to a base model containing clinical and laboratory data statistically improved the predictive value. Assessing ALI levels upon admission can provide important information for the short-term prognostic assessment of patients with AMI complicated by CS. A lower ALI may serve as an independent predictor of increased 30-day all-cause mortality and MACEs.

Age- and Sex-Specific Myocardial Blood Flow Values in Patients Without Coronary Atherosclerosis on Rb-82 PET Myocardial Perfusion Imaging.

Quantitative myocardial blood flow (MBF) on positron-emission tomography myocardial perfusion imaging is a measure of the overall health of the coronary circulation. The ability to adequately augment blood flow, measured by myocardial blood flow reserve (MBFR), is associated with lower major adverse cardiovascular events and all-cause mortality. The age-specific ranges of MBFR in patients without demonstrable coronary artery disease have not been well established. We aimed to determine the effect of age and sex on MBF in a cohort of patients without demonstrable coronary artery disease. Patients who underwent positron-emission tomography myocardial perfusion imaging studies from 2012 to 2022 on positron-emission tomography/computed tomography cameras were included if the summed stress score was 0, the coronary calcium score was 0, and the left ventricular ejection fraction was ≥50%. Those with known coronary artery disease, prior history of coronary intervention, diabetes, heart/kidney/liver transplant, cirrhosis, or chronic kidney disease stage IV+ were excluded. MBF was calculated using a net retention model (ImagenQ, Cardiovascular Imaging Technologies, Kansas City), and quantile regression models were developed to predict MBF. Among 2789 patients (age 59.9±13.0 years, 76.4% females), median rest MBF was 0.73 (0.60-0.91) mL/min·g, stress MBF was 1.72 (1.41-2.10) mL/min·g, and MBFR was 2.31 (1.96-2.74). Across all ages, males augmented MBF in response to vasodilator stress to a greater degree than females but achieved lower absolute stress MBF. Younger males in particular achieved a higher MBFR than their female counterparts, and this gap narrowed with increasing age. Predicted MBFR for a 20-year-old male was 3.18 and female was 2.50, while predicted MBFR for an 80-year-old male was 2.17 and female was 2.02. In patients without demonstrable coronary artery disease, MBFR is higher in younger males than younger females and decreases with age in both sexes. Age- and sex-specific MBFR may be important in risk prediction and guidance for revascularization and warrant further study.

Periodic Fasting and Acute Cardiac Events in Patients Evaluated for COVID-19: An Observational Prospective Cohort Study.

Periodic fasting was previously associated with greater longevity and a lower incidence of heart failure (HF) in a pre-pandemic population. In patients with coronavirus disease 2019 (COVID-19), periodic fasting was associated with a lower risk of death or hospitalization. This study evaluated the association between periodic fasting and HF hospitalization and major adverse cardiovascular events (MACEs). Patients enrolled in the INSPIRE registry from February 2013 to March 2020 provided periodic fasting information and were followed into the pandemic (n = 5227). Between March 2020 and February 2023, N = 2373 patients were studied, with n = 601 COVID-positive patients being the primary study population (2836 had no COVID-19 test; 18 were excluded due to fasting <5 years). A Cox regression was used to evaluate HF admissions, MACEs, and other endpoints through March 2023, adjusting for covariables, including time-varying COVID-19 vaccination. In patients positive for COVID-19, periodic fasting was reported by 180 (30.0% of 601), who periodically fasted over 43.1 ± 19.2 years (min: 7, max: 83). HF hospitalization (n = 117, 19.5%) occurred in 13.3% of fasters and 22.1% of non-fasters [adjusted hazard ratio (aHR) = 0.63, CI = 0.40, 0.99; p = 0.044]. Most HF admissions were exacerbations, with a prior HF diagnosis in 111 (94.9%) patients hospitalized for HF. Fasting was also associated with a lower MACE risk (aHR = 0.64, CI = 0.43, 0.96; p = 0.030). In n = 1772 COVID-negative patients (29.7% fasters), fasting was not associated with HF hospitalization (aHR = 0.82, CI = 0.64, 1.05; p = 0.12). In COVID-positive and negative patients combined, periodic fasting was associated with lower mortality (aHR = 0.60, CI = 0.39, 0.93; p = 0.021). Routine periodic fasting was associated with less HF hospitalization in patients positive for COVID-19.

COMPARATIVE EFFICACY OF INTRACORONARY VERAPAMIL AND ADRENALINE IN MANAGING CORONARY NO-REFLOW DURING PRIMARY PCI IN STEMI PATIENTS AT A TERTIARY CARE HOSPITAL

Coronary No-Reflow (CNR) is a significant complication during Primary Percutaneous Coronary Intervention (PPCI) for ST-Elevation Myocardial Infarction (STEMI), often leading to poor clinical outcomes. Management strategies for CNR include various pharmacological agents, among which intracoronary verapamil and intracoronary adrenaline are commonly used alongside Glycoprotein IIb/IIIa inhibitors. Objective: This study aims to compare the effectiveness of intracoronary verapamil versus intracoronary adrenaline, alongside Glycoprotein IIb/IIIa inhibitors, in managing Coronary No-Reflow (CNR) during Primary Percutaneous Coronary Intervention (PPC1) for STEMI patients. Methodology: This randomized-control-trial was conducted at the Department of Cardiology, MTI Lady Reading Hospital Peshawar, Pakistan, from May 2023 to April 2024. Fifty patients diagnosed with CNR during PPC1 were randomised into two groups: adrenaline and verapamil. The primary outcome measures were TIMI Flow Grade (TFG) and Myocardial Blush Grade (MBG) immediately post-intervention. In contrast, secondary outcomes included Major Adverse Cardiovascular Events (MACE), myocardial infarction, stroke, target vessel revascularisation, mortality, and Left Ventricular Ejection Fraction (LVEF) assessed at baseline and one-month follow-up. Statistical analyses were performed using IBM SPSS version 20, with significance at P&lt;0.05. Results: Baseline characteristics, procedural details, and initial TIMI flow grades were similar between groups. Adrenaline achieved universal TIMI 3 flow compared to 84% with verapamil (p=0.049), but no significant differences were noted in myocardial blush grades. Adrenaline led to significantly higher follow-up LVEF (45.0 ± 9.0 vs. 39.0 ± 9.0, p=0.027) and a more significant percentage change in LVEF (20.97% vs. 8.94%, p=0.042) than verapamil. Adverse event rates were comparable except for lower MACE incidence at 30 days with adrenaline (8.0% vs. 24.0%, p=0.039). Conclusion: Adrenaline notably enhanced TIMI 3 flow rates, improved left ventricular ejection fraction, and decreased significant adverse cardiovascular events at 30 days compared to verapamil. These findings suggest that adrenaline may be a superior option for improving coronary blood flow and early clinical outcomes in this patient population.

Prognostic Impact of Left Ventricular Ejection Fraction Improvement after Transcatheter Aortic Valve Replacement.

Introduction: Transcatheter aortic valve replacement (TAVR) has become an efficient and safe alternative to surgical aortic valve replacement (SAVR). While severe aortic stenosis as well as severe aortic regurgitation (AR) are known to negatively impact left ventricular ejection fraction (LVEF), prior studies have shown that TAVR can lead to an improvement in LVEF. Thus far, little is known about the prognostic implication of LVEF improvement as a sole predictor of outcomes. Therefore, the aim of this study was to assess the prognostic impact of LVEF impairment before TAVR, as well as early LVEF improvement in patients undergoing TAVR. Materials and Methods: Patients undergoing TAVR in a large tertiary university hospital were consecutively included in a prospective registry. Transthoracic echocardiography (TTE) was performed at baseline, after 1 month and annually thereafter. Significant LVEF improvement was defined as a relative increase of ≥10% in LVEF at 30 days compared to baseline LVEF. The primary outcome was all-cause mortality at 1 year. Secondary outcomes were major adverse cardiovascular events (MACEs) including cardiovascular death, non-fatal myocardial infarction, stroke, bleeding and unplanned re-interventions of the aortic valve at 5 years. Results: Among 1655 patients who underwent TAVR between September 2011 and April 2024, the LVEF at baseline was available for 1556 patients. Of these, 1031 patients (66.2%) had preserved LVEF at baseline (LVEF ≥ 53%), whereas 303 patients (19.5%) had moderately reduced LVEF (40-52%) and 222 patients (14.3%) had severely reduced LVEF (<40%). Out of the patients with impaired LVEF, 155 (40.4%) patients showed a significant improvement in LVEF ≥10% after 30 days, while 229 (60.6%) patients showed no significant LVEF improvement (<10%). Patients with preserved LVEF at baseline had significantly better mortality outcomes than those with severely reduced LVEF (p < 0.001). LVEF improvement was associated with a survival benefit after 1 year (p = 0.009, HR 2.68, 0.95 CI 1.23-5.85) which diminished after 5 years (p = 0.058), but patients with LVEF improvement showed lower MACE rates at 5 years (p < 0.001). Conclusions: Preserved LVEF before TAVR is an independent predictor for improved outcomes. Additionally, early improvement in LVEF is associated with beneficial outcomes in patients undergoing TAVR.

Immediate Versus Staged Complete Revascularization in Patients Presenting with Acute Coronary Syndrome and Multivessel Coronary Disease Without Cardiac Shock: A Study-Level Meta-analysis of Randomized Controlled Trials.

Achieving full revascularization via percutaneous coronary intervention (PCI) may enhance the prognosis of individuals diagnosed with acute coronary syndrome (ACS) and multivessel coronary disease (MVD). The present work focused on investigating whether PCI should be performed during staged or index procedures for non-culprit lesions. Electronic databases, such as PubMed, EMBASE, the Cochrane Library, and Web of Science, were systematically explored to locate studies contrasting immediate revascularization with staged complete revascularization for patients who experienced ACS and MVD without cardiac shock. The outcome measures comprised major adverse cardiovascular events (MACEs), all-cause mortality, cardiovascular mortality, myocardial infarction (MI), stroke, and unplanned ischemia-driven revascularization (UIDR). Nine randomized controlled trials involving 3550 patients, including 1780 who received immediate complete revascularization (ICR) and 1770 who received staged complete revascularization (SCR), were included in the analysis. The ICR group had lower MACEs (RR: 0.73, 95% CI: 0.61~0.87, P = 0.0004), MI (RR: 0.53, 95% CI: 0.37~0.77, P = 0.0008), and UIDR (RR: 0.64, 95% CI: 0.50~0.81, P = 0.0003) than did the SCR group. All-cause mortality, CVD incidence, and stroke incidence did not significantly differ between the two groups. According to our subgroup analyses based on the time window of the SCR, the ICR group had significantly fewer MACEs (RR: 0.70, 95% CI: 0.56~0.88, P = 0.003), MI (RR: 0.53, 95% CI: 0.37~0.77, P = 0.0002), and UIDR (RR: 0.56, 95% CI: 0.40~0.77, P = 0.0004) than did the subgroup of patients who were between discharge and 45 days. Compared with patients in the SCR group, patients in the ICR group had decreased MACEs, MI, and UIDR, especially between discharge and 45 days. All-cause mortality and CVD incidence were not significantly different between the two groups.

Thiazolidinediones Decrease the Recurrence of Intracerebral Hemorrhage in Type 2 Diabetes Mellitus Patients: A Nested Case-Control Study

Introduction: Preclinical evidence demonstrated the therapeutic potential of thiazolidinediones (TZDs) for the treatment of intracerebral hemorrhage (ICH). The present study conducted an investigation of cerebrovascular and cardiovascular outcomes following ICH in patients with type 2 diabetes mellitus (T2DM) treated with or without TZDs. Methods: This retrospective nested case-control study used data from the Taiwan National Health Insurance Research Database. A total of 62,515 T2DM patients who were hospitalized with a diagnosis of ICH were enrolled, including 7,603 TZD users. Data for TZD non-users were extracted using propensity score matching. Primary outcomes included death and major adverse cardiovascular events (MACEs), which were defined as a composite of ischemic stroke, hemorrhagic stroke (HS), acute myocardial infarction, and congestive heart failure. Patients aged <20 years with a history of traumatic brain injury or any prior history of MACEs were excluded. Results: TZD users had significantly lower MACE risks compared with TZD non-users following ICH (adjusted hazard ratio [aHR]: 0.90, 95% confidence interval [CI]: 0.85–0.94, p < 0.001). The most significant MACE difference reported for TZD users was HS, which possessed lower incidence than in TZD non-users, especially for the events that happened within 3 months following ICH (aHR: 0.74, 95% CI: 0.62–0.89 within 1 month, p < 0.01; aHR: 0.68, 95% CI: 0.54–0.85 between 1 and 3 month). Conclusion: The use of TZD in patients with T2DM was associated with a lower risk of subsequent HS and mortality following ICH.