Predictor Of Major Adverse Cardiac Events Research Articles

Assessment of C-Reactive Protein/Serum Albumin Ratio in Relation to Acute Presentation and Early Outcome of Patients with Acute Coronary Syndrome

Background: Acute coronary syndrome (ACS) is the leading cardiovascular (CV) cause of mortality. C reactive protein (CRP) has linked with long-term risk of recurrent cardiovascular events or death. Albumin, in contrast to CRP known as a negative acute-phase protein. Thus a newly introduced marker assessed relation of CRP to albumin ratio (CAR), which may provide better results than the use of either marker alone. The aim of the study is to assess the association of C-reactive protein to albumin ratio (CAR) with in-hospital short-term major adverse cardiac events (MACEs) in acute coronary syndrome (ACS) patients. Patients & Methods: A multi-centers prospective cohort study was conducted at coronary intensive care units (CICU) in Baghdad during the period from March to October 2021 that included a total of 132 patients who were diagnosed as a case of ACS. They were assessed for major adverse cardiac events (MACEs) like cardiogenic shock, arrhythmias, post-MI angina, and acute heart failure while inside the ward, in addition to need for early interventional therapeutic approach in relation to (CAR) immediately at time of admission to hospital. Results: High values of CAR, whether using hs-CRP or CRP, were identified as an independent predictor for in-hospital MACEs (P value < 0.001 and 0.002 respectively. A cut-off value of CAR (using hs-CRP) is 3.18 mg/L in context of discrimination between medically treated ACS patients and death outcome in term of high CAR. A cut-off value of CAR (using CRP) as 9.13 mg/L suggests the usefulness in discrimination of outcome in relation to medically managed patients, at presentation. CAR had a positive significant correlation with hospital stay (r = 0.210, P = 0.036). Conclusion: The CAR was independently correlated with in-hospital short-term MACEs and can be used for risk stratification in patients with ACS.

Predictive values of bilirubin for in-hospital adverse events in patients with ST-segment elevation myocardial infarction after primary percutaneous coronary intervention

PurposeTo investigate the association between serum bilirubin levels and in-hospital Major Adverse Cardiac Events (MACE) in patients with ST-segment Elevation Myocardial Infarction (STEMI) undergoing primary Percutaneous Coronary Intervention (PCI). MethodsA total of 418 patients with STEMI who underwent primary PCI were enrolled from October 1st, 2021 to October 31st 2022. The average age of enrolled participants was 59.23 years, and 328 patients (78.50%) were male patients. Patients were divided into MACE (patients with angina pectoris after infarction, recurrent myocardial infarction, acute heart failure, cardiogenic shock, malignant arrhythmias, or death after primary PCI) (n = 98) and non-MACE (n = 320) groups. Univariate and multivariate logistic regression analyses were performed to estimate the association between different bilirubin levels including Total Bilirubin (TB), Direct Bilirubin (DB), Indirect Bilirubin (IDB), and risk of in-hospital MACE. The area under the Receiver Operating Characteristic (ROC) curve was used to determine the accuracy of bilirubin levels in predicting in-hospital MACE. ResultsThe incidence of MACE in STEMI patients increased from the lowest to the highest bilirubin tertiles. Multivariate logistic regression analysis showed that increased total bilirubin level was an independent predictor of in-hospital MACE in patients with STEMI (p for trend = 0.02). Compared to the first TB group, the ORs for risk of MACE were 1.58 (95% CI 0.77‒3.26) and 2.28 (95% CI 1.13‒4.59) in the second and third TB groups, respectively. The ROC curve analysis showed that the areas under the curve for TB, DB and IDB in predicting in-hospital MACE were 0.642 (95% CI 0.578‒0.705, p < 0.001), 0.676 (95% CI 0.614‒0.738, p < 0.001), and 0.619 (95% CI 0.554‒0.683, p < 0.001), respectively. ConclusionsThe current study showed that elevated TB, DB, and IDB levels are independent predictors of in-hospital MACE in patients with STEMI after primary PCI, and that DB has a better predictive value than TB and IDB.

Comparison Between 6 Minutes Walking Distance (6MWD), Changes in Rate Pressure Product (RPP) and Heart Rate Walking Speed Index (HRWSI) of 6 Minutes Walk Test (6MWT) Pre-Discharge as a Predictor Major Adverse Cardiac Event (MACE) in Patients with Acute Heart Failure

Background: Heart failure (HF) is a significant cause of morbidity and mortality worldwide in middle-aged and older adults. A simple 6MWT assay can provide useful information noninvasively for risk stratification and patient prognosis. A potential parameter is incorporating pulse and blood pressure values ​​into RPP and pulse rate with WS into HRWSI. It is easy to assess the risk of rehospitalization and mortality in HF patients and can be compared with conventional predictors and predictors with expensive biomarker examinations. Aims: To determine the role and comparison of 6MWD, RPP changes and HRWSI in patients with acute heart failure outcomes. Methods: This study was conducted with a prospective observational cohort design. This study is a collaborative study to determine whether 6MWD, changes in RPP and HRWSI at 6MWT pre-discharge can predict MACE events within 90 days after hospital discharge in patients with AHF. Result: The AUC value of 6WMD was 0.338, with a cut-off of 251.0 meters. The sensitivity and specificity of 6MWD were 72% and 63.5%. The AUC value of RPP changes was 0.692 with a cut point 3139.5. The sensitivity and specificity of RPP changes for MACE prediction were 90.0% and 48.0%. HRWSI AUC value was 0.721, with a cut-off of 22.66. The sensitivity and specificity of HRWSI was 80.0% and 64.0%. Low 6MWD had a survival of 54.6%, while patients with GJA who had high 6MWD had an 84.6% survival. Low RPP changes had a survival of 92.3%, and patients with high RPP changes had a survival of 58.8%. Low HRWSI had 88.9% survival, and patients with high RPP changes had 52.5% survival. Conclusion: 6MWD, changes in RPP and HRWSI of 6MWT are potential predictors for MACE within 90 days post hospital discharge in patients with acute heart failure.

Improving Risk Stratification of Patients With Chest Pain in the Emergency Department.

The HEARTS3 score is used to predict acute coronary syndrome by evaluating the findings of chest pain patients at the end of the second hour. Additionally, the American College of Cardiology (ACC)/American Heart Association (AHA) 2014 non-ST elevation acute coronary syndrome (NSTE-ACS) management guideline suggests assessing cardiac troponin levels at the third and sixth hours as a class 1A recommendation. This study aimed to explore the value of the HEARTS3 score for the evaluation of patients withchest pain and its utility for determining whether a patient is eligible for early discharge from the emergency department. This study was prospectively conducted between March 1, 2016 to May 31, 2016 at the ED of the Research and Training Hospital in İstanbul. A total of 136 patients were evaluated, and HEARTS3 scores were calculated at the second, third, and sixth hours. Receiver operating characteristic (ROC) curves were used to calculate the specificity, sensitivity,negative predictive value (NPV) and positive predictive value (PPV) of these scores. The primary outcome was the occurrence of major adverse cardiac events (MACEs) within 30 days. In total, 29 patients with MACEs and 107 patients without MACEs were identified within 30 days. Based on the ROC curve, the cutoff value for early discharge was 6. The area under curve (AUC) values were 0.943, 0.963 and 0.976 at the second, third, and sixth hours, respectively. The sensitivity of the second-hour HEARTS3 score was 96.6%, and the NPV was 98.6%. Both the sensitivity and NPV reached 100% at the sixth hour. The HEARTS3 score was considered a feasible method for the prediction of MACEs. We concluded that a patient with a HEARTS3 score less than 6 may be discharged without serial troponin and ECG examination.

Prediction of cardiovascular events using myocardial strain ratio derived from 13N-ammonia positron emission tomography.

Myocardial flow reserve (MFR), derived from ammonia N-13 positron emission tomography (NH3-PET), can predict the prognosis of patients with various heart diseases. We aimed to investigate whether myocardial strain ratio (MSR) was useful in predicting MACE and allowed for further risk stratification of cardiovascular events in patients with ischemic heart disease (IHD) in addition to MFR. Ninety-five patients underwent NH3-PET because of IHD. MFR was determined as the ratio of hyperemic to resting myocardial blood flow (MBF). MSR was defined as the ratio of strains at stress and rest. The endpoint was major adverse cardiac events (MACE), including all-cause death, acute coronary syndrome, heart failure hospitalization, and revascularization. The ability to predict MACE was assessed using receiver operating characteristic (ROC) analysis, and the predictability of ME was analyzed using Kaplan-Meier analysis. The Cox proportional hazards regression model was used to calculate the hazard ratio (HR) with 95% confidence interval (CI). The ROC curve analysis demonstrated a cutoff of 0.93 for MACE with MSR (sensitivity and specificity of 77% and 71%, respectively). Patients with MSR < 0.93 displayed a significantly higher MACE rate than those with MSR ≥ 0.93 (p = 0.0036). The Cox proportional hazards regression analysis indicated that MSR was an independent marker that could predict MACE in imaging and clinical parameters (HR, 7.32; 95% CI: 1.59-33.7, p = 0.011). MSR was an independent predictor of MACE and was useful for further risk stratification in IHD. MSR has the potential for a new indicator of revascularization in patients with IHD. • We hypothesized that combining myocardial flow reserve (MFR) with the myocardial strain ratio (MSR) obtained by applying the feature-tracking technique to ammonia N-13 PET would make it predictive of major adverse cardiac events (MACE) compared to MFR alone. • MSR was an independent predictor of MACE, allowing for further risk stratification in addition to MFR in patients with ischemic heart disease. • MSR is a potential new indicator of revascularization.

417 CLINICAL IMPACT OF HEALED CORONARY PLAQUES: AN OPTICAL COHERENCE TOMOGRAPHY STUDY

Abstract Introduction Pathological studies have shown that many atherosclerotic plaques destabilize without resulting in a clinical manifestation. Recent in vivo studies showed that healed plaques are more common in patients with chronic coronary syndrome (CCS) than in those with acute coronary syndrome (ACS), suggesting that they might be a marker of clinical stability. The aim of the present study was to evaluate the clinical impact of healed coronary plaques detected by optical coherence tomography (OCT) imaging. Methods A total of 208 patients with CCS or ACS who underwent OCT imaging of non-target/non-culprit vessels were enrolled. Only non-culprit segments were analyzed. Patients were divided into two groups according to the presence or absence of healed plaques detected by OCT. The incidence of major adverse cardiac events (MACE) at follow-up was assessed, defined as the composite of cardiac death, non-fatal myocardial infarction, and target vessel revascularization (TVR). Results Healed coronary plaques were observed in 39.7% of patients, and the prevalence was higher in those presenting with chronic coronary syndrome. Median follow-up time was 4 years, and was not different between the two groups. Patients with healed plaques had a significantly lower incidence of MACE at follow-up (13.6% vs 22%, p=0.019), mainly driven by a lower rate of non-fatal myocardial infarctions (4.9% vs 10.2%, p=0.05). The incidence of cardiac death and TVR was not significantly different between the two groups (1.2% vs. 3.1%, p=0.288; and 13.6% vs. 15.0%, p= 0.187, respectively). At multivariate Cox regression analysis, the presence of plaque disruption was an independent predictor of MACE (odds ratio [OR] 3.33, 95% confidence interval [CI] 1.39-7.98, p=0.007), while the presence of healed plaque was an independent protective factor (OR 0.44, 95% CI 0.22-0.89, p=0.022). Conclusions Healed coronary plaques detected by OCT imaging are associated with a favorable clinical outcome at long-term follow-up.

Acute Response in the Noninfarcted Myocardium Predicts Long-Term Major Adverse Cardiac Events After STEMI

BackgroundAcute ST-segment elevation myocardial infarction (STEMI) has effects on the myocardium beyond the immediate infarcted territory. However, pathophysiologic changes in the noninfarcted myocardium and their prognostic implications remain unclear. ObjectivesThe purpose of this study was to evaluate the long-term prognostic value of acute changes in both infarcted and noninfarcted myocardium post-STEMI. MethodsPatients with acute STEMI undergoing primary percutaneous coronary intervention underwent evaluation with blood biomarkers and cardiac magnetic resonance (CMR) at 2 days and 6 months, with long-term follow-up for major adverse cardiac events (MACE). A comprehensive CMR protocol included cine, T2-weighted, T2∗, T1-mapping, and late gadolinium enhancement (LGE) imaging. Areas without LGE were defined as noninfarcted myocardium. MACE was a composite of cardiac death, sustained ventricular arrhythmia, and new-onset heart failure. ResultsTwenty-two of 219 patients (10%) experienced an MACE at a median of 4 years (IQR: 2.5-6.0 years); 152 patients returned for the 6-month visit. High T1 (>1250 ms) in the noninfarcted myocardium was associated with lower left ventricular ejection fraction (LVEF) (51% ± 8% vs 55% ± 9%; P = 0.002) and higher NT-pro-BNP levels (290 pg/L [IQR: 103-523 pg/L] vs 170 pg/L [IQR: 61-312 pg/L]; P = 0.008) at 6 months and a 2.5-fold (IQR: 1.03-6.20) increased risk of MACE (2.53 [IQR: 1.03-6.22]), compared with patients with normal T1 in the noninfarcted myocardium (P = 0.042). A lower T1 (<1,300 ms) in the infarcted myocardium was associated with increased MACE (3.11 [IQR: 1.19-8.13]; P = 0.020). Both noninfarct and infarct T1 were independent predictors of MACE (both P = 0.001) and significantly improved risk prediction beyond LVEF, infarct size, and microvascular obstruction (C-statistic: 0.67 ± 0.07 vs 0.76 ± 0.06, net-reclassification index: 40% [IQR: 12%-64%]; P = 0.007). ConclusionsThe acute responses post-STEMI in both infarcted and noninfarcted myocardium are independent incremental predictors of long-term MACE. These insights may provide new opportunities for treatment and risk stratification in STEMI.

Clinical Characteristics and Prognosis of MINOCA Caused by Atherosclerotic and Nonatherosclerotic Mechanisms Assessed by OCT

BackgroundMyocardial infarction with nonobstructive coronary artery (MINOCA) is a heterogeneous syndrome caused by different pathophysiologic mechanisms. There is limited evidence regarding prognosis of patients with MINOCA caused by different mechanisms. ObjectivesThe present study aimed to assess the underlying mechanisms of MINOCA by optical coherence tomography (OCT) and to correlate with clinical outcomes. MethodsPatients with MINOCA were divided into 2 groups based on OCT findings: atherosclerotic MINOCA (Ath-MINOCA) and nonatherosclerotic MINOCA (non-Ath-MINOCA). Major adverse cardiac events (MACE) were defined as cardiac death, nonfatal MI, target lesion revascularization, stroke, and rehospitalization for unstable or progressive angina. ResultsAmong 7,423 patients with a clinical diagnosis of MI who underwent angiography, 190 of 294 MINOCA were studied using OCT. The causes of Ath-MINOCA (n = 99, 52.1%) were plaque erosion (n = 64, 33.7%), plaque rupture (n = 33, 17.4%), and calcified nodule (n = 2, 1.1%) whereas the causes of non-Ath-MINOCA (n = 91, 47.9%) were spontaneous coronary artery dissection (n = 8, 4.2%), coronary spasm (n = 9, 4.7%), and unclassified cause (n = 74, 38.9%). The 1-year MACE was 15.3% for Ath-MINOCA vs 4.5% for non-Ath-MINOCA (P = 0.015). An atherosclerotic cause was an independent predictor of MACE (HR: 5.36 [95% CI: 1.08-26.55]; P = 0.040), mainly driven by target lesion revascularization and rehospitalization, despite the composite endpoint including cardiac death and MI showing no difference. ConclusionsOCT identified a cause in 61.1% of MINOCA, in which Ath-MINOCA represents an important and distinct MINOCA subset. Ath-MINOCA were more common and associated with worse outcomes. (Incidence Rate of Heart Failure After Acute Myocardial Infarction With Optimal Treatment; NCT03297164; Paradigm Shift in the Treatment of Patients With ACS; NCT02041650)

Prognostic implications of unrecognized myocardial infarction before elective percutaneous coronary intervention

Unrecognized myocardial infarction (UMI) is associated with adverse outcomes. This prospective, single-center study elucidated the prevalence and prognostic significance of UMI before elective percutaneous coronary intervention (PCI) using delayed-enhancement cardiac magnetic resonance (DE-CMR). We enrolled 236 patients with stable coronary artery disease who underwent DE-CMR before elective PCI. The prevalence of UMI and the association of clinical and CMR-derived variables with major adverse cardiac events (MACE), defined as cardiovascular death, nonfatal MI, hospitalization for congestive heart failure, and unplanned late revascularization, were assessed. Final analysis revealed that 63/213 (29.6%) patients had UMI. Target territory UMI was observed in 38 patients (17.8% of the total cohort, 60.3% of patients with UMI). UMI was significantly associated with sex, diabetes mellitus, left ventricular ejection fraction, SYNTAX score, and fractional flow reserve in the target vessels. During follow-up (median, 23 months), MACE occurred in 17 (27.0%) patients with UMI and 17 (11.3%) without UMI (P = 0.001). Multivariable modeling revealed that UMI (hazard ratio: 2.18, 95%CI, 1.10–4.33, P = 0.001) was an independent predictor of MACE. Kaplan–Meier analysis indicated that the presence of UMI was significantly associated with a higher incidence of MACE. UMI was independently associated with a greater risk of MACE after successful PCI.

Major adverse cardiac events after elective infrarenal endovascular aortic aneurysm repair.

There is a significant cardiac morbidity and mortality after endovascular aneurysm repair (EVAR). However, information about long-term risk of cardiac events after EVAR and potential predictors is lacking. Therefore, the aim of this study was to determine incidence and predictors of major adverse cardiac events (MACE) at 1 and 5years after elective EVAR for infrarenal abdominal aortic aneurysms. Baseline, perioperative, and postoperative information of 320 patients was evaluated. The primary outcome was the incidence of MACE after EVAR, which was defined as acute coronary syndrome, unstable angina pectoris, de novo atrial fibrillation, hospitalization for heart failure, mitral valve insufficiency, revascularization (including percutaneous coronary intervention and coronary artery bypass grafting), as well as cardiovascular and noncardiovascular death. Kaplan-Meier analyses were performed to determine incidences of MACE, MACE excluding noncardiovascular death and cardiac events by excluding noncardiovascular and vascular death from MACE. Predictors of MACE were identified using univariate and multivariate binary regression analysis. Through 1 and 5years of follow-up after EVAR, freedom from MACE was 89.4% (standard error [SE], 0.018) and 59.8% (SE, 0.033), freedom from MACE excluding noncardiovascular death was 94.7% (SE, 0.013) and 77.5% (SE, 0.030) and freedom from cardiac events was 96.0% (SE, 0.011) and 79.1% (SE, 0.030), respectively. Predictors for MACE within 1year were American Society of Anesthesiologists (ASA) score of III or IV (odds ratio [OR], 3.17; 95% confidence interval [CI], 1.52-6.59) and larger abdominal aortic diameter (OR, 1.04; 95% CI, 1.01-1.08). A history of atrial fibrillation (OR, 0.14; 95% CI, 0.03-0.60) was a negative predictor factor. Predictors for MACE through 5years were a history of heart failure (OR, 4.10; 95% CI 1.36-12.32) and valvular heart disease (OR, 2.31; 95% CI, 0.97-5.51), American Society of Anesthesiologists score of 3 or 4 (OR, 1.66; 95% CI, 0.96-2.88), and older age (OR, 1.04; 95% CI, 1.01-1.08). MACE is a common complication during the first 5years after elective EVAR. Cardiac diseases at baseline are strong predictors for long-term MACE and potentially helpful in optimizing future postoperative long-term follow-up.

Clinical outcomes of drug-coated balloon for treatment of de novo coronary artery disease with and without diabetes

To retrospectively evaluate the efficacy of drug-coated balloon (DCB) in patients with de novo coronary artery disease with and without diabetes. Patients with de novo coronary artery and undergoing percutaneous coronary intervention (PCI) with DCB were enrolled from March 2018 and March 2020, including 312 patients being divided into the diabetes group (n=110), pre-diabetes group (n=48) and non-diabetes group (n=154). The primary endpoint was major adverse cardiac events (MACE) (MACE; cardiovascular death, non-fatal myocardial infarction, target lesion revascularization, and target vessel revascularization) at 24 months. In diabetes group, the incidence of MACE at 24 months (19.1%) was higher than in the non-diabetes group (12.5%) and pre-diabetes group (10.4%) (p<0.05). Cox regression revealed that diabetes (HR [hazard ratios] 2.049, 95% CI 1.056-4.284), bifurcation lesion (HR 5.255, 95% CI 2.765-9.986), Syntax score (HR 1.098, 95% CI 1.040-1.559) and hemoglobin A1c (HR 1.084, 95% CI 1.160-1.741) were independent predictors of MACE in patients performing PCI with DCB (all p<0.05). However, pre-diabetes did not increase the risk of MACE (HR 1.560, 95% CI 0.542-4.490, p>0.05). Diabetes increased the risk of MACE in patients performing PCI with DCB.

Abstract 12809: Cirrhotic Cardiomyopathy Before Orthotropic Liver Transplantation is Associated With Major Adverse Cardiac Events at 13-Months Post Orthotropic Liver Transplantation

Background: Major adverse cardiac events (MACE) are a leading cause of morbidity and mortality after orthotopic liver transplantation (OLT). Cirrhotic cardiomyopathy (CCM) is relatively common and a source of MACE in patients after OLT. Initial diagnostic criteria based on transthoracic echocardiogram (TTE) were described in 2005 and revised in 2019 with echocardiographic advancements (Table 1). We sought to identify CCM related predictors of MACE at 13 months post-OLT. Methods: This is a retrospective study of adult patients who underwent OLT between 2009-2019. All patients had TTE’s within one year pre-OLT and one month to 13 months post-OLT. We excluded TTE’s within one-month post-OLT to reduce contributions from stress cardiomyopathy. Patients with a left ventricular ejection fraction less than 50% pre-OLT were excluded. MACE was defined as death, MI, CHF hospitalization, or cardiac arrest. Multivariable Cox regression was used to identify independent predictors of MACE. Results: Of 568 OLT patients screened, 131 met inclusion criteria for this study. There were 103 and 23 patients who met 2005 and 2019 criteria, respectively. During the 13 month follow up period, 42 patients had MACE. Compared to those without MACE, patients with MACE had more ascites (93 vs 70%, p 0.003), hepatorenal syndrome (HRS) (17 vs 4%, p 0.019), delayed OLT &gt;10 days after admission (19 vs 7%, p 0.033), pre-OLT CCM per 2005 criteria (90% vs 73%, p 0.023), and lower diastolic blood pressure (60.81 vs 66.88, p 0.014). There was no difference in pre-OLT CCM per 2019 criteria (19 vs 17%, p 0.758) or MELD-Na score (21.24 vs 19.40, p 0.166). In multi-variable cox regression analysis adjusted for diastolic blood pressure, HRS, ascites, and OLT timing during admission, CCM per 2005 criteria remained significant as seen in Figure 1 (Hazard Ratio = 3, p 0.038). Conclusion: CCM per 2005 criteria is an independent predictor of MACE at 13 months post-OLT while CCM per 2019 criteria is not.

Abstract 12824: Predictive Value of Artificial Intelligence-Enabled Electrocardiography in Patients with Takotsubo Cardiomyopathy

Introduction: Recent studies have indicated high rates of future major adverse cardiovascular events in patients with Takotsubo cardiomyopathy (TTC). This study sought to evaluate the prognostic value of our institutional artificial intelligence-augmented electrocardiography (AI-ECG) algorithms in patients with TTC. Methods: This study enrolled consecutive patients in the prospective and observational Mayo Clinic Takotsubo syndrome registry. TTC was diagnosed according to the Mayo Clinic diagnostic. Our clinic’s previously developed and validated AI-ECG algorithms were used for detection of ECG-Age, probability of low ejection fraction, and probability of atrial fibrillation.Multivariable models were constructed to evaluate the association of AI-ECG and other clinical characteristics with major adverse cardiac events (MACE), defined as cardiac death, recurrence of TTC, nonfatal myocardial infarction, hospitalization for congestive heart failure, and stroke. Results: In the final analysis, 305 patients were studied over a median follow-up of 4.8 years. Patients with MACE were more likely to be older, have history of hypertension and chronic heart failure (CHF), worse renal function as well as having high-risk AI-ECG findings compared to those without. In the multivariate Cox proportional hazard analysis, the presence of 3 or 4 high-risk findings detected by AI-ECG, remained a significant predictor of MACE in the patients with TTC after adjusted by conventional risk factors (hazard ratio (HR) 2.17, 95% CI [1.33, 3.53], P=0.002; HR 2.44, 95% CI [1.38, 4.29], P=0.002, respectively). Conclusions: The combined use of developed AI-ECG algorithms derived from a single 12-lead ECG might identify ECG correlates of underlying non-transient myocardial dysfunction and detect subtle underlying patterns associated with worse outcomes in patients with TTC. This approach might be beneficial for stratifying high-risk patients with TTC.

Abstract 12059: Speckle-Tracking Echocardiography Derived Global Circumferential Strain Predicts Adverse Outcomes in Cardiac Sarcoidosis With Preserved Ejection Fraction

Introduction: Risk stratification in cardiac sarcoidosis (CS) remains challenging, especially in those with preserved left ventricular ejection fraction (LVEF). Myocardial strain parameters are more sensitive than LVEF for detecting early sub-clinical myocardial dysfunction, but their prognostic value in CS is not known. Methods: We investigated consecutive newly diagnosed CS patients between 2015 and 2018. All patients underwent 2D echocardiography including global longitudinal strain (GLS) and global circumferential strain (GCS) measurement, cardiac magnetic resonance (CMR) for late gadolinium enhancement (LGE) and FDG-PET imaging to derive the maximum standard uptake value (SUVmax). The LGE score was quantified as the number of myocardial segments with LGE. Major adverse cardiac events (MACE) were all-cause death, sustained ventricular arrhythmia (VA), device implantation and new onset heart failure (HF) admission. Results: A total of 120 patients were included with age of 55±12 years; 87% were Caucasian, 43% had hypertension and 13% had diabetes. Mean LVEF was 55±12.3%, GLS was -13.4±4.2%, GCS was -16.0±5.6% and regional wall motion abnormalities (RWMA) occurred in 36% of cases. During median follow-up of 4.3 years, 43 patients experienced MACE consisting of 15 deaths, 19 VAs, 7 devices and 2 HF admissions. In multivariate analysis syncope, ethnicity, echo-derived left atrial volume and RWMA were independent predictors of MACE along with CMR-derived right ventricular EF and LGE score. Although GLS and GCS were lower in those with MACE, neither had independent prognostic value. SUVmax was also not predictive of events. In a subgroup analysis of the 86 patients with LVEF ≥50%, 20 patients experienced MACE. Multivariate analysis showed non-Caucasian ethnicity (HR 3.18 [95% CI 1.02-9.88]; P = 0.04), RWMA (HR 3.76 [95% CI 1.29-10.98]; P = 0.02), LGE-score (HR 1.26 95% CI 1.05-1.51]; P = 0.01 and GCS (HR 1.18 [95% CI 1.04-1.36]; P = 0.01) were independent predictors of MACE. A GCS value above the optimal cut-off of -16.4% was associated with a worse outcome (log-rank P = 0.005). Conclusion Ethnicity, RWMA and LGE-score are robust markers of outcome in newly diagnosed CS. Reduced GCS provides additional prognostic information in those with preserved LVEF.

Abstract 10765: Association Between Prehospital Nitroglycerin and Clinical Outcome in Acute Coronary Syndrome

Introduction: Whether prehospital Nitroglycerin use is associated with major adverse cardiac events (MACE) remains unknown in the era of primary percutaneous coronary intervention (PCI) using stents. Hypothesis: We hypothesized that prehospital Nitroglycerin use would be associated with MACE in acute coronary syndrome (ACS) patients who underwent primary PCI. Methods: This retrospective observational study enrolled 947 consecutive patients who received the emergent PCI. Patients were classified into the two groups, with and without prehospital Nitroglycerin use. 250 patients were given prehospital Nitroglycerin sublingually or via oral spray or intravenously. The clinical outcome was MACE defined as a composite of all-cause death, myocardial infarction, and stroke at a one-year follow-up. Results: The Systolic blood pressure at the emergency department was 132 (105, 141) mmHg in the prehospital Nitroglycerin, and 135 (113, 158) mmHg in the non-Nitroglycerin group (P &lt; 0.001). Kaplan-Meier survival curves revealed that the MACE frequency was higher in the prehospital Nitroglycerin group (p = 0.021). Multivariate Cox regression analysis revealed that the prehospital Nitroglycerin use (hazard ratio, 1.65; 95% confidence interval [CI], 1.02-2.65; p = 0.002) was an independent predictor for MACE. Prehospital Nitrogricerin use, Killip classification, and Ejection fraction models resulted in a c-statistic with a statistically significant 95% PI and moderate discriminative performance (c-statistic=0.763; 95% CI, 0.7111-0.816, p&lt;0.001). Conclusions: The present results suggested that the prehospital Nitroglycerin use might worsen the one-year prognosis in ACS patients undergoing primary PCI.

Abstract 14755: Left Ventricular Three-Dimensional Speckle Tracking Echocardiography Predicts Adverse Clinical Outcomes in Heart Transplant Patients

Background: The prognostic value of 3D-GLS in HT recipients has not been evaluated. This study explored the long-term prognostic significance of 3D-GLS in HT recipients. Methods: The study comprised 296 consecutive patients who underwent HT between January 2015 and December 2019 at Union Hospital in Wuhan, China. All subjects underwent comprehensive transthoracic two-dimensional (2D) and 3D echocardiographic examinations. Patients were followed until January 1st, 2022. Major adverse cardiac events (MACE) were defined as a composite of heart failure hospitalization, re-transplantation and death. Results: After a median follow-up of 3.3 years, 53 HT patients experienced MACE. Patients with MACE displayed significantly impaired 2D-GLS and 3D-GLS compared with those without MACE. Kaplan-Meier analysis showed that the risk of MACE increased significantly with worsening tertiles of 2DGLS and 3DGLS (both log-rank p &lt; 0.001). Area under the curve for 3D-GLS was larger than that in 2D-GLS for MACE prediction. On multivariate Cox proportional hazards regression, 2D-GLS and 3D-GLS were independently associated with the MACE after adjustment for diabetes, history of rejection, hemoglobin, brain natriuretic peptide (BNP), and LV ejection fraction. In addition, 3D-GLS provided incremental prognostic value over 2D-GLS. Continuous net reclassification improvement analysis showed an improvement of + 23.3% was noted in the accuracy of classification between 3D-GLS and 2D-GLS. Conclusion: In heart transplant recipients, 3D-GLS is an independently predictor of MACE. These findings support the potential of 3D-GLS to identify higher risk HT patients.

Abstract 10933: Artificial Intelligence Enabled Fully Automated Myocardial Strain Quantification for Risk Stratification Following Acute Myocardial Infarction

Introduction: Feasibility of automated volume-derived cardiac functional evaluation has successfully been demonstrated using cardiovascular magnetic resonance (CMR) imaging. Notwithstanding, strain assessment has proven incremental value for cardiovascular risk stratification. Since introduction of deformation imaging to clinical practice has been complicated by time-consuming post-processing, we sought to investigate automation respectively. Methods: CMR data (n=1095 patients) from two prospectively recruited acute myocardial infarction (AMI) populations with ST-elevation (STEMI) (AIDA STEMI n=759) and non-STEMI (TATORT-NSTEMI n=336) were analysed fully automated and manually on conventional cine sequences. LV function assessment included global longitudinal, circumferential, and radial strains (GLS/GCS/GRS). Agreements were assessed between automated and manual strain assessments. The former were assessed for major adverse cardiac event (MACE) prediction within 12 months following AMI. Results: Manual and automated derived GLS showed the best and excellent agreement with an intraclass correlation coefficient (ICC) of 0.81. Agreement was good for GCS and poor for GRS. Amongst automated analyses, GLS (HR 1.12, 95% CI 1.08-1.16, p&lt;0.001) and GCS (HR 1.07, 95% CI 1.05-1.10, p&lt;0.001) best predicted MACE with similar diagnostic accuracy compared to manual analyses; area under the curve (AUC) for GLS (auto 0.691 vs. manual 0.693, p=0.801) and GCS (auto 0.668 vs. manual 0.686, p=0.425). Amongst automated functional analyses, GLS was the only independent predictor of MACE in multivariate analyses (HR 1.10, 95% CI 1.04-1.15, p&lt;0.001). Conclusions: Considering high agreement of automated GLS and equally high accuracy for risk prediction compared to the reference standard of manual analyses, automation may improve efficiency and aid in clinical routine CMR examinations.

Abstract 12201: Assessing Glycated Hemoglobin (a1c) Thresholds for Development of Cardiovascular Disease by Racial-Ethnic Groups; Insights From a Large Integrated Healthcare System

Introduction: Diabetes mellitus (DM) is the strongest risk factor for incident myocardial infarction (MI). Glycated hemoglobin (A1c) is used for diagnosing DM, but racial/ethnic specific A1c diagnostic thresholds do not exist. This study aims to determine whether A1c thresholds for predicting major adverse cardiac events (MACE) differ among racial-ethnic groups in a large, diverse integrated healthcare system. Methods: This is a retrospective cohort study of Kaiser Permanente Northern California members age 30 to 75 without cardiovascular disease for whom A1c during 2014, race/ethnicity data, and 5-year follow-up post A1c were available. Multivariable logistic regression was used to evaluate the odds of MACE (MI, stroke, cardiovascular death) after adjusting for demographic and clinical covariates including age, sex, race, A1c, BMI, smoking, DM meds. Univariate logistic regression with Youden’s index was used to determine A1c thresholds for MACE prediction stratified by race/ ethnicity. Receiver operating characteristic curves were plotted for each equation and a Youden’s index was calculated to determine the race-ethnic specific threshold for prediction of MACE. Results: A1c was associated with an increased odds of MACE (aOR 1.024, 95%CI: 1.022, 1.025). Compared to Whites, South Asian ethnicity was associated with increased odds of MACE (aOR 1.641, 95%CI: 1.456, 1.843). Hispanic (aOR 0.748, 95%CI: 0.702, 0.796) and East Asian ethnicities (aOR 0.804, 95% CI: 0.739, 0.874) were associated with lower odds of MACE. A Youden’s index range of A1c values between 6.0 to 7.3% predicted MACE, with the lowest values seen in Whites (6.0%) and South Asians (6.1%). A1c thresholds for Filipinos, East Asians, Blacks, and Hispanics were 7.3, 6.6, 6.5 and 6.5%, respectively. Conclusions: Our study shows South Asians have a higher odds of MACE compared to Whites. A1c values in a pre-diabetic range predicted MACE in Whites and South Asians, whereas thresholds for MACE prediction were in a diabetic range for other groups. Further studies will help identify whether these trends can be replicated in other geographic areas and influence risk prediction tools.

Interpretable Predictive Modeling for Major Adverse Cardiac Events Following Lung Cancer Radiotherapy

<h3>Purpose/Objective(s)</h3> Patients with locally advanced non-small cell lung cancer (NSCLC) are at increased risk of developing major adverse cardiac events (MACE) following radiotherapy. Our group previously identified cardiac substructure dose constraints associated with increased risk of MACE. We employ a machine learning (ML) approach to further identify predictors of MACE and evaluate ML capacity for personalized MACE risk-stratification. <h3>Materials/Methods</h3> Retrospective analysis of 701 patients with locally advanced NSCLC treated with thoracic radiotherapy between 2003-2014. MACE included unstable angina, heart failure, myocardial infarction, coronary revascularization, and cardiac death. We used extreme gradient boosting for MACE prediction. Input features included 195 demographic and 240 radiation dose and/or anatomic. Cardiac substructures were manually delineated; heart and chamber volumes were indexed to body surface area (BSA). We split data 70/30 into training/testing, balanced by MACE. Hyperparameters were bootstrap-tuned with 50-round grid search. Area under the receiver operator characteristic curve (AUC) evaluated model performance. We trained our model on any MACE regardless of timeframe and tested performance at varying timepoints (90-day, 180-day, etc.). Shapley values measured feature importance and were used to construct personalized risk profiles for each patient. <h3>Results</h3> Among 701 patients, 70 developed ≥1 MACE. The median age was 65 and median time to first MACE was 20.6 months. Training AUC for any MACE: 0.67; testing AUC: 0.73. Our model displayed time dependent performance improvement, with high accuracy for MACE closer to radiation start. Testing AUC for 90-day MACE: 0.97; 180-day MACE: 0.94. Table 1 displays additional AUCs. The top 10 predictive features for MACE were coronary heart disease history, right atrial volume, left circumflex coronary artery (CA) volume (V) receiving 15 Gy (V15Gy), heart volume, lung V55Gy and V70Gy, hypertension, left ventricle V15Gy, left main CA volume, and left anterior descending CA V15Gy. Based on patients' Shapley-derived risk profile, radiation dose variables generally became less predictive of MACE as time from radiation increased, while demographics remained generally predictive. <h3>Conclusion</h3> ML modeling enabled high precision for predicting short-term MACE in locally advanced NSCLC patients who received radiotherapy, though long-term MACE was less accurate. ML techniques show promise for identifying patients at high risk of short-term MACE. Our Shapley-derived individual risk profiles may assist with baseline cardiac risk assessment and identify opportunities for risk mitigation. Prospective validation may help implement these tools into clinical practice.

Prognostic value of coronary microvascular dysfunction assessed by coronary angiography-derived index of microcirculatory resistance in diabetic patients with chronic coronary syndrome

BackgroundCoronary microvascular dysfunction (CMD) is common and is associated with unfavorable cardiovascular events in patients with diabetes mellitus (DM). Coronary angiography-derived index of microcirculatory resistance (caIMR) is a recently developed wire- and hyperemic agent-free method to assess CMD. We aimed to investigate the prognostic impact of CMD assessed by caIMR on clinical outcomes in patients with DM and chronic coronary syndrome (CCS).MethodsCCS patients who underwent coronary angiography between June 2015 to May 2018 were included. Coronary microvascular function was measured by caIMR, and CMD was defined as caIMR ≥ 25U. The primary endpoint was major adverse cardiac events (MACE). Kaplan-Meier analysis and Cox proportional hazards models were used to assess the relationship between caIMR and the risk of MACE.ResultsOf 290 CCS patients, 102 patients had DM. Compared with non-diabetic patients, CMD (caIMR ≥ 25U) was higher among DM patients (57.8% vs. 38.3%; p = 0.001). During a mean 35 months follow-up, 40 MACE had occurred. Patients with caIMR ≥ 25 had a higher rate of MACE than patients with caIMR < 25 (20.6% vs. 8.2%, p = 0.002). Of these, the MACE rate was higher among DM patients with caIMR ≥ 25 than those with caIMR < 25 (33.9% vs. 14.0%; p = 0.022). In multivariable Cox analysis, caIMR ≥ 25 was independently associated with MACE in the DM patients but not in non-DM patients (HR, 2.760; 95% CI, 1.066–7.146; P = 0.036).ConclusionCMD assessed by caIMR was common and is an independent predictor of MACE among diabetic patients with CCS. This finding potentially enables a triage of higher-risk patients to more intensive therapy.