Rate Of Major Cardiovascular Events Research Articles

Feasibility of on-site CT-FFR analysis on cardiac photon-counting CT in evaluation of hemodynamically significant stenosis in comparison to invasive catheter angiography.

Coronary CT angiography (CCTA) is an excellent tool in ruling out coronary artery disease (CAD) but tends to overestimate especially highly calcified plaques. To reduce diagnostic invasive catheter angiographies (ICA), current guidelines recommend CT-FFR to determine the hemodynamic significance of coronary artery stenosis. Photon-Counting Detector CT (PCCT) revolutionized CCTA and may improve CT-FFR analysis in guiding patients. In this single-center study, patients with obstructive CAD who underwent CCTA using PCCT and subsequent ICA were included. Delta CT-FFR was calculated by subtracting the CT-FFR values 1.8cm before and after the stenosis, with a cut-off value of ≥0.06 indicating hemodynamic significance. Revascularization during ICA defined a stenosis as hemodynamically significant. Sensitivity, specificity, negative and positive predictive value, and diagnostic accuracy of Delta CT-FFR have been determined. Patients were followed up to evaluate the rate of major adverse cardiovascular events (MACE) 6months after CCTA. A total of 28 patients (3 female, median age 68years) were enrolled in this study. Delta CT-FFR was pathological in all patients who underwent revascularization. No patients with normal Delta CT-FFR required stent placement. In 39.29% of the cases, calculation of Delta CT-FFR could have prevented patients from undergoing unnecessary ICA. The positive predictive value of Delta CT-FFR for CAD RADS 4a was 66.7%, negative predictive value 100%, and diagnostic accuracy 74%. Delta CT-FFR analysis using PCCT offers a feasible tool in identifying hemodynamically significant coronary artery stenosis and can help to reduce purely diagnostic ICA.

Outcomes of coronary artery aneurysms: insights from the Coronary Artery Ectasia and Aneurysm Registry (CAESAR).

Coronary artery ectasias and aneurysms (CAE/CAAs) are among the less common forms of coronary artery disease, with undefined long-term outcomes and treatment strategies. To assess the clinical characteristics, angiographic patterns, and long-term outcomes in patients with CAE, CAA, or both. This 15-year (2006-2021) retrospective single-centre registry included 281 patients diagnosed with CAE/CAA via invasive coronary angiography. Major adverse cardiovascular events included all-cause death, non-fatal myocardial infarction, unplanned ischaemia-driven revascularisation, hospitalisation for heart failure, cerebrovascular events, and clinically overt bleeding. Time-dependent event risks for the CAE and CAA groups were assessed using Cox regression models and Kaplan-Meier curves. CAEs (n = 161, 57.3%) often had a multi-district distribution (45.8%), while CAAs (78, 27.8%) exhibited a single-vessel pattern (80%). The co-existence of CAAs and CAE was observed in 42 cases (14.9%), and multi-vessel obstructive coronary artery disease was prevalent (55.9% overall). Rates of major adverse cardiovascular events were 14.3% in-hospital and 38.1% at a median follow-up of 18.9 (interquartile range [IQR] 6.0-39.9) months. The presence of CAAs was associated with increased major adverse cardiovascular events risk in comparison to CAE (hazard ratio [HR] = 2.26, 95% confidence interval [CI] 1.38-3.69, p = 0.001), driven by a higher hazard ratio of non-fatal myocardial infarctions (HR = 5.00, 95% CI 1.66-15.0, p = 0.004) and unplanned ischaemia-driven revascularisation in both dilated (HR = 3.23, 95% CI 1.40-7.45, p = 0.006) and non-dilated coronary artery segments (HR 3.83, 95% CI 2.08-7.07, p = 0.001). Overlap between obstructive and dilated coronary artery disease is frequent. Among the spectrum of dilated coronary artery disease, the presence of a CAA was associated with worse long-term outcomes.

Coffee consumption and adverse cardiovascular events in patients with atrial fibrillation

BackgroundThere is some evidence of reduced major cardiovascular event (MACE) rates associated with moderate coffee consumption in the general population. However, there is concern about the potential risks of coffee consumption in patients with atrial fibrillation (AF). Therefore, we aimed to investigate the association between coffee consumption and MACE in AF patients.MethodsData of patients with documented AF enrolled in two large prospective observational multicenter cohort studies (Swiss-AF and Beat-AF) were analyzed. Follow-up information was obtained on a yearly basis. Coffee consumption was categorized into two main groups: “daily” and “not-daily” coffee consumers as well as additional subcategories. The primary endpoint was MACE, defined as a composite of stroke or systemic embolism, myocardial infarction, hospitalization for acute heart failure, and cardiovascular mortality. Secondary endpoints were the individual components of MACE and all-cause mortality. We performed time-updated multivariable adjusted Cox regression analyses to investigate the association between coffee consumption and MACE.ResultsThe incidence rate for MACE was 5.09 per 100 person-years (py) in daily and 7.49 per 100 py in not-daily consumers (median follow-up duration: 4.7 years). After adjustment for pre-selected confounding variables, daily coffee consumption was associated with a 23% lower hazard for MACE compared to not-daily consumption (hazard ratio (HR) (95% confidence interval (CI)) 0.77 (0.66; 0.89)). Patients with moderate coffee consumption (2–3 cups/day) had the lowest hazard for MACE compared to patients with not-daily coffee consumption (HR (95% CI) 0.74 (0.63; 0.87)).ConclusionsIn a population of AF patients, daily coffee consumption was associated with a reduced risk for MACE, hospitalization for acute heart failure, and all-cause mortality. The results were inconclusive for stroke or systemic embolism, myocardial infarction, and cardiovascular death. In this analysis, we found no evidence of an unfavourable association of daily coffee consumption in AF Patients with adverse outcome events.Trial registrationClinicalTrials.gov Identifier: NCT02105844.

Age Variation in Patients with Troponin Level Elevation Without Obstructive Culprit Lesion or Suspected Myocardial Infarction with Non-Obstructive Coronary Arteries-Long-Term Data Covering over Decade.

Background/Objectives: Troponin level elevation without an obstructive culprit lesion is caused by heterogenous entities. The effect of aging on this condition has been poorly investigated. Methods: After screening 24,775 patients between 2010 and 2021, this study included a total of 373 patients with elevated troponin levels without an obstructive culprit lesion or suspected myocardial infarction with non-obstructive coronary arteries (MINOCAs) categorized into four age groups containing 78 patients (<51 years), 72 patients (51-60 years), 81 patients (61-70 years), and 142 patients (>70 years). This study analyzed the baseline characteristics, the in-hospital complications, in-hospital mortality, and the long-term outcomes. Results: The older patients exhibited a higher rate of major adverse cardiovascular in-hospital events than those of the other age groups (15.4% in the <51-year-old group vs. 36.1% in the 51-60-year-old group vs. 33.3% in the 61-70-year-old group vs. 47.2% in the >70-year-old group; p < 0.001). However, the rate of non-sustained ventricular tachycardia (nsVT) was higher in the 51-60-year-old patients than those of the other age groups (5.6% in the 51-60-year-old group vs. 1.3% in the 61-70-year-old group vs. 0.7% in the >70-year-old group; p = 0.027). At the 11-year follow-up, cardiovascular mortality was higher among the older patients compared to that of the younger patients (3.9% in the 61-70-year-old group vs. 4.2% in the >70-year-old group, p = 0.042), while non-cardiovascular mortality was comparable between the age groups. Conclusions: The older patients with troponin level elevation without an obstructive culprit lesion experienced a higher incidence of major adverse cardiovascular events during hospitalization compared to that of the younger groups. Additionally, higher cardiovascular mortality rates were revealed in the older patients at a long-term follow-up.

Long-term adverse event risks of oral JAK inhibitors versus immunomodulators: a literature review.

The long-term adverse event risks associated with oral Janus kinase (JAK) inhibitors compared to broader immunomodulators are poorly understood, with limited comparative studies available. This study aims to assess the long-term adverse event risks of oral JAK inhibitors compared to broader immunomodulators in dermatology. A PubMed search included terms such as specific drug names and "adverse events," "long-term safety," "malignancy," "cardiovascular events," and/or "infections." Included were studies with over one year of medication exposure reporting adverse events. A total of 25 studies were included, comprising 19 clinical trials and 6 cohort studies, representing greater than 100,000 patient years of data. We found comparable long-term incidence rates of malignancy (excluding non-melanoma skin cancer (NMSC)), venous thromboembolism (VTE), and serious infections between oral JAK inhibitors and broader immunomodulators. Oral JAK inhibitors demonstrated lower incidence rates of NMSC and major adverse cardiovascular events (MACE), but higher rates of herpes zoster virus (HZV) infections compared to non-JAK medications. Study limitations include variations in underlying diseases, age, and comorbidities between studies introducing patient population heterogeneity. Overall, oral JAK inhibitors may be viable long-term treatment options given their comparable safety profile to broader immunomodulators currently used in dermatology. However, monitoring for HZV infections may be warranted. These findings aid clinicians in making informed treatment decisions and prioritizing patient safety.

Safety and Efficacy of BioMime Sirolimus-Eluting Stent System in All-Comers Real-World Population With Coronary Artery Stenosis: MILES Global Registry.

This study evaluated the safety and efficacy of BioMime sirolimus-eluting stent (SES) system, with an ultra-low strut thickness (65 µm), in real-world all-comers population with coronary artery stenosis (CAD). This was a post-marketing, multicenter, single-arm, observational clinical registry among patients undergoing intervention for CAD. Patients were clinically followed up at 1, 9, 12, and 24 months after the index percutaneous coronary intervention. Four major indications, namely long stents of > 30 mm, stents with diameters of 4 and 4.5 mm, bifurcation subgroup, and chronic total occlusion (CTO) were evaluated as pre-specified subsets. A total of 771 patients (1,079 treated lesions) from 23 sites were included in this study. The mean length and diameter of the implanted stents were 25.57 ± 9.35 mm and 3.00 ± 0.44 mm, respectively. The mean minimum lumen diameter before and after the procedure was 1.00 ± 1.69 mm and 2.96 ± 1.35 mm, respectively. The cumulative rates of major adverse cardiovascular events (MACEs) and stent thrombosis (ST) at 1, 9, 12, and 24 months were 1.05%, 3.13%, 4.04%, 5.64% and 0%, 0.13%, 0.28%, 0.28%, respectively. In a subset with > 30 mm long stents, the cumulative rate of MACEs was 0.4%, 4.6%, 5.12%, and 7.01% at 1, 9, 12, and 24 months, respectively. The corresponding rates of ST were 0%, 0.42%, 0.43%, and 0.44%, indicating constant rate of ST after 9 months. In a subset of 4 and 4.5 mm diameter stents, the cumulative rate of MACEs was high (0%, 6.25%, 6.25%, and 10.41%) at 1, 9, 12, and 24 months, respectively. However, there was no case of ST until 24 months. In patients with bifurcation lesions, the cumulative rates of MACEs and ST were 2.46%, 6.32%, 11.53%, 16.21% and 0%, 1.27%, 1.28%, 1.35% at 1, 9, 12, and 24 months follow-up. In patients with chronic total occlusion, the cumulative rates of MACEs and ST were 0.79%, 5.04%, 6.83%, 7.07% and 0%, 0.84%, 0.85%, 0.88% at 1, 9, 12, and 24 months, respectively, indicating constant rate of ST after 9 months. The BioMime SES demonstrated good safety and efficacy outcomes at 24-month follow-up, with low rates of MACEs and ST in patients with CAD in the real-world setting.

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.

The correlation between severe asymptomatic carotid artery stenosis and severe multi-organ dysfunction after off-pump coronary artery bypass grafting.

The current research aimed to demonstrate the independent association between preoperative severe asymptomatic carotid artery stenosis (ACAS) and severe multi-organ dysfunction after off-pump coronary artery bypass grafting (OPCAB), which may further indicate the relationship between severe ACAS and adverse 30-day postoperative outcomes of patients undergoing OPCAB. This was a single-center, retrospective observational study including patients without a history of stroke or Transient Ischemic Attacks (TIA) (asymptomatic), who underwent for an isolated OPCAB in the center for operative treatment of coronary artery disease of Beijing Anzhen Hospital from January 2020 to December 2021. All enrolled patients underwent carotid artery ultrasound prior to OPCAB. The information was extracted independently by two authors of the study from the medical records. Both univariate and multivariate analyses were conducted. A total of 562 patients met the inclusion criteria for the current study. 63 (11.2%) suffered from severe ACAS. The Sequential Organ Failure Assessment (SOFA) maximum in the severe ACAS group was significantly higher than that in the non-severe ACAS group (9.76 ± 3.03 vs. 7.75 ± 2.96, p < 0.0001), and a higher proportion of patients in the severe ACAS group exhibited severe multi-organ dysfunction (44.4% vs. 14.0%, p < 0.0001). In addition, severe ACAS was related to an increased rate of 30-day postoperative major adverse cardiovascular and cerebral events (MACCEs), including a 30-day postoperative stroke. Severe ACAS was associated with an elevated risk of delirium, and acute kidney injury (AKI). The results of the multivariate analysis demonstrated that severe ACAS may be independently associated with severe multi-organ dysfunction (OR, 7.37, 95% CI 4.80-14.30, p < 0.0001) after OPCAB. Also, severe ACAS may be independently associated with 30-day postoperative stroke (OR, 2.83, 95% CI 1.03-7.75, p = 0,043). Severe ACAS was independently associated with severe multi-organ dysfunction after OPCAB, which may be associated further with an increased rate of 30-day postoperative mortality and complications. This study highlights: (1) the importance of personalized assessment for potential advantages and disadvantages in prognosis of severe ACAS patients undergoing OPCAB with carotid endarterectomy; (2) the role of multi-organ parameters, especially cardio-cerebral factors, should be emphasized during the process of severe ACAS management.

Efficacy and safety of upadacitinib in patients with active ankylosing spondylitis refractory to biologic therapy: 2-year clinical and radiographic results from the open-label extension of the SELECT-AXIS 2 study

BackgroundThe efficacy and safety of upadacitinib in patients with ankylosing spondylitis (AS) and inadequate response/intolerance to biologic disease-modifying antirheumatic drugs (bDMARD-IR) were evaluated through 1 year in the SELECT-AXIS 2 study. Here, we assess 2-year efficacy, safety, and imaging outcomes in SELECT-AXIS 2.MethodsPatients who received continuous upadacitinib, and those who switched from placebo to upadacitinib at week 14, could enter the open-label extension (OLE). Efficacy endpoints included Assessment of SpondyloArthritis international Society (ASAS) and Axial Spondyloarthritis Disease Activity Score (ASDAS) responses, and changes from baseline in measures of disease activity, back pain, function, and quality of life. Radiographic progression was evaluated using the modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS). As observed (AO) and AO with non-responder imputation (AO-NRI) analyses were used for binary endpoints; AO with mixed-effects model for repeated measures (AO-MMRM) for continuous endpoints; and AO-analysis of covariance for mSASSS. Treatment-emergent adverse events (TEAEs) in patients receiving ≥ 1 upadacitinib dose through week 104 are presented as events (E)/100 patient-years (PY). Subgroup analyses were performed by prior tumor necrosis factor/interleukin-17 inhibitor exposure and bDMARD lack of efficacy/intolerance.ResultsOf 420 patients who entered the bDMARD-IR AS study, 409 entered the OLE, and 331 (continuous upadacitinib, n = 163; placebo to upadacitinib, n = 168) completed week 104. Improvements in efficacy measures were sustained through the OLE, with similar response rates between the continuous upadacitinib and placebo to upadacitinib groups at week 104. At week 104, 64.9% and 61.7% of patients, respectively, had achieved ASAS 40% response (AO-NRI). Mean changes from baseline were similar between the two groups at week 104 across measures (ASDAS: -2.1 and -2.0; total back pain: -4.9 and -4.6, respectively; AO-MMRM). Over 93.0% of patients showed no radiographic progression (mSASSS mean change from baseline < 2) at week 104. The overall TEAE rate was 165.2 E/100 PY, with low rates of major adverse cardiovascular and venous thromboembolic events (0.3 E/100 PY each).ConclusionsUpadacitinib efficacy, including very low rates of radiographic progression, was demonstrated through 104 weeks in treatment-refractory patients with active AS. Treatment was well tolerated, with no newly identified safety signals.Trial registrationNCT04169373.

Minute Ventilation/Carbon Dioxide Production Slope Could Predict Short- and Long-Term Prognosis of Patients After Acute Decompensated Heart Failure.

(1) Background: Heart failure (HF) leads to functional disability and major cardiovascular events (MACEs). Cardiopulmonary exercise testing (CPET) is the gold standard for assessing aerobic capacity and prognostic stratification. This study aimed to evaluate the predischarge CPET variables in patients with acute decompensated HF and identify the submaximal CPET variables with prognostic value. (2) Methods: A retrospective cohort study was conducted at a tertiary center in Taiwan. Patients surviving their first episode of decompensated HF and undergoing predischarge CPET (February 2017 to January 2023) were analyzed. Follow-up was conducted until a MACE or administrative censoring (up to 5 years). Cox regression identified the significant predictors of MACE. (3) Results: The study included 553, 485, and 267 patients at the 3-month, 1-year, and 5-year follow-ups, respectively. MACE rates were 15.0%, 34.2%, and 50.9%. The VE/VCO2 slope was a significant predictor of MACE at all intervals. A VE/VCO2 slope >38.95 increased the risk of MACE by 2.49-fold at 3 months and 1.81-fold at 1 year (both p < 0.001). A slope > 37.35 increased the 5-year MACE risk by 1.75-fold (p = 0.002). (4) Conclusions: The VE/VCO2 slope is a significant submaximal CPET predictor of MACE in patients post-acute decompensated HF for both short- and long-term outcomes.

Dapagliflozin versus empagliflozin and major adverse cardiovascular events in type 2 diabetes: a nationwide cohort study

Abstract Background Large randomized clinical trials have shown that sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce the risk of adverse kidney and cardiovascular outcomes in patients with heart failure, chronic kidney disease, or type 2 diabetes mellitus (T2DM) at high risk of atherosclerotic cardiovascular disease. Whether these effects might differ between individual SGLT2-inhbitors remain unclear given the lack of head-to-head comparisons. Purpose To examine the association between treatment with dapagliflozin versus empagliflozin and the long-term rate of major adverse cardiovascular events (MACE) in patients with T2DM. Methods Using nationwide registries, all Danish residents with T2DM, who initiated treatment with dapagliflozin or empagliflozin from 2015 to 2020, were identified. Only treatment with dapagliflozin or empagliflozin was considered in the present analysis, since approximately 3% initiated treatment with other SGLT2-inhibitors (i.e., canagliflozin and ertugliflozin). Patients were followed from date of the first claimed prescription of dapagliflozin or empagliflozin until the outcome of interest, emigration, death, or end of study (December 31, 2021). The primary outcome was a composite endpoint of major adverse cardiovascular events (i.e., time to first heart failure hospitalisation, acute myocardial infarction (AMI), stroke, or all-cause mortality). The primary outcome was compared between the dapagliflozin and empagliflozin group, overall and in prespecified subgroups of interest, with multivariable Cox proportional hazards regression models. Results In total, 61,031 patients with T2DM initiated treatment with dapagliflozin (N=21,028; 34.5%) or empagliflozin (N=40,003; 65.5%). The median age of study population was 62.6 years (25th-75th percentile, 54.2-70.8 years), and 62.6% were men. There were no clinically significant differences between the dapagliflozin and empagliflozin group with respect to age, sex, and clinical characteristics. The median follow-up was 3.1 years (25th-75th percentile, 1.9-4.5 years). The adjusted long-term hazard ratios of the primary outcome, overall and in prespecified subgroups of interest, are displayed in the Figure. Compared with empagliflozin, treatment with dapagliflozin was not associated with a significantly different rate of the primary outcome (HR 1.02 [95% CI, 0.97-1.07]). The observed association was consistent across clinically relevant subgroups, including in patients with and without heart failure, chronic kidney disease, and atherosclerotic cardiovascular disease. Conclusion In a large, nationwide cohort of patients with T2DM, treatment with dapagliflozin was associated with a similar rate of major adverse cardiovascular outcomes compared with empagliflozin, and this association was consistent across clinically relevant subgroups. These findings suggest that the benefits of SGLT2-inhibitors can be characterized as a class-effect.

Exploring the long-term effects of dapagliflozin in patients with stable acute myocardial infarction and preserved ejection fraction through a propensity score matching study

Abstract Background and Aims The recent Emmy trial underscored notable improvements in cardiac structure and function among post-acute myocardial infarction (AMI) patients treated with Empagliflozin, compared to those receiving a placebo. However, limitations such as a small sample size and a short follow-up period hindered the assessment of potential differences in actual clinical events between the groups. Consequently, our study aimed to evaluate the long-term outcomes, survival rates, rates of major adverse cardiovascular events (MACE), and heart failure (HF) incidence in patients with preserved ejection fraction (EF) who experienced AMI and underwent successful percutaneous coronary intervention (PCI), comparing those who received early initiation of Dapagliflozin with those who did not. Methods Data from the Taipei Medical University Research Database in Taiwan identified 7,081 inpatients who met the criteria of AMI status post successful PCI, with a left ventricular ejection fraction (LVEF) greater than 50% and absence of clinical symptoms indicative of heart failure. Exclusion criteria included individuals with a pre-existing diagnosis of heart failure before the index AMI episode and those with an LVEF below 50%, resulting in the exclusion of 357 patients from our study. The study subjects were then divided into two groups: those treated with Dapagliflozin and those not treated with Dapagliflozin, with matching for age, diabetes mellitus, and chronic kidney disease in a 1:2 ratio. Results The cohort study included of 756 patients who met the criteria of this study, among whom 252 were Dapagliflozin users and 504 were not. Over a 7-year follow-up period, Kaplan-Meier survival analyses revealed a significant reduction in cardiovascular mortality and all-cause mortality among Dapagliflozin users compared to non-users (p &amp;lt; 0.01). However, no significant differences were observed in heart failure, recurrent AMI, or stroke during the follow-up. Multivariate Cox analysis indicated the use of Dapagliflozin (hazard ratio = 0.310, 95% confidence interval = 0.188-0.510, p &amp;lt; 0.001) and age of diagnosis (hazard ratio = 1.063, 95% confidence interval =1.045-1.081, p &amp;lt; 0.001) were both independent predictors of all cause death. Conclusions In patients with stabilized AMI, the use of Dapagliflozin was associated with a decreased risk of all-cause death, especially cardiovascular mortality. However, there were no significant differences observed in the rates of heart failure, recurrent AMI, or stroke over the seven-year follow-up period.Baseline characteristicsKaplan–Meier curves of all cause death

Prognostic implication of computational angiography-derived fractional flow reserve in patients with non-obstructive coronary artery disease

Abstract Background Non-obstructive coronary artery disease (NOCAD) is proved to have high association with rate of major adverse cardiovascular events (MACE) in recent studies, yet risk stratification of symptomatic Non-Obstructive Coronary Artery Disease (NOCAD) patients remains uncertain. Objectives Our study assessed clinical value of single-vessel, multi-vessel, and three-vessel computational angiography-derived fractional flow reserve (caFFR) measurement in NOCAD patients. Methods We enrolled patients with ≤ 50% stenosis with a caFFR value ≥ 0.8 in all three coronary arteries on coronary angiography. The sum of caFFR values in the three vessels was computed for each patient. Patient stratification was based on median value of the following criteria: single vessel analysis, multi-vessel analysis, 3-vessel (3V) analysis. The primary endpoint of this study was major adverse cardiac events (MACE) at 5 years, defined as a composite of cardiac death, myocardial infarction, and ischemia-driven revascularization. Results A total of 490 patients were included (mean age 64.39 ± 11.16, 55.5% male). The 5-year MACE rates in single-vessel analysis were statistically insignificant between low and high caFFR groups (Left anterior descending artery (P=0.163); Left circumflex artery (P=0.797); Right coronary artery (P=0.127)). In multi-vessel analysis, patients in multiple-vessel low-caFFR group (with 2-3 vessels lower than median value of all coronary arteries) show an increased risk of 5-year MACE than patients in single-vessel low-caFFR group (0-1 vessel) (hazard ratio [HR] 2.648, 95% confidence interval [CI] 1.141 - 6.145, P = 0.023). In 3-vessel analysis, patients in the low 3V-caFFR group demonstrated a greater 5-year MACE risk than the high 3V-caFFR group ([HR] 2.43, 95% 95%[CI] 1.087 - 5.433, P = 0.031). Conclusion In patients with NOCAD, the higher count of vessels exhibiting with low caFFR values and the low 3V-caFFR values have been found to be associated with increased rate of MACE over a 5-year period. We demonstrated that both multiple-vessel and 3V-caFFR measurements serve as valuable prognostic indicators for risk assessment in NOCAD patients.

Comparative characteristics and invasive management in patients with non-ST elevation acute coronary syndromes in two high-volume hospitals from Romania and Germany

Abstract Introduction Cardiovascular disease (CVD) carries the highest mortality burden across Europe, acute coronary syndromes (ACS) being responsible for most CVD-related deaths. However, significant regional differences in ACS management have been reported. Purpose To describe the characteristics and management of patients with higher-risk non-ST elevation ACS (NSTE-ACS) in 2 high-volume hospitals from 2 European countries with different prevalence of CVD and different income (Germany – GER and Romania – RO). Methods All consecutive invasively managed high and very-high risk NSTE-ACS patients admitted in 2022 in two high-volume hospitals from GER and RO were identified. Patient clinical profiles, coronary anatomy, revascularization strategies, and in-hospital outcomes were compared. Results were adjusted for age and gender. Results 707 patients (345 GER, 66.7% male; 362 RO, 71.5% male; p&amp;gt;0.05) were included. RO patients were younger (65.5 vs. 70.1 years), with higher rates of hypertension (88.7% vs. 82.0%), dyslipidemia (95.6% vs. 81.7%), diabetes (46.1% vs. 34.5%), and active smoking (37.3% vs. 23.5%) (all p&amp;lt;0.05); whereas GER patients had higher rates of atrial fibrillation (36.2% vs. 23.2%), chronic respiratory disease (24.6% vs. 10.5%), sleep apnoea (9.0% vs. 1.4%), thyroid disorders (24.1% vs. 6.4%), and prior revascularization by percutaneous coronary interventions (PCI) (36.5% vs. 20.2%) or coronary artery bypass grafting (CABG) (15.7% vs. 3.0%) (all p&amp;lt;0.05). Mean left ventricular ejection fraction (LVEF) was lower in the RO cohort (43.4% vs. 48%, p&amp;lt;0.001). Rates of myocardial infarction diagnosed by high-sensitivity troponin I assays (88.7% GER, 87.6% RO), and median diagnosis-to-cathlab intervals (12.8 hours GER, 15.5 hours RO) were similar (all p&amp;gt;0.05). In the obstructive coronary artery disease (CAD) group (80.3% GER, 84.3% RO), no differences were found in multivessel disease rates (67.1% GER, 69.8% RO) or mean SYNTAX score (18.6 GER, 16.9 RO) (all p&amp;gt;0.05). For type 1 NSTE-ACS (67% GER vs. 79% RO, p&amp;lt;0.001), PCI represented the main revascularization method (88.3% GER vs. 78.3% RO, p&amp;lt;0.05). Excluding patients with prior CABG undergoing PCI, complete revascularization (residual SYNTAX score ≤8), was reported in 77.1% GER and 84.4% RO of the PCI cases (p&amp;gt;0.05). Intravascular imaging was used in 28.4% of PCIs in GER, and in none in RO. In-hospital mortality (7.0% GER, 6.8% RO), and rates of major adverse cardiovascular events, defined as a composite of death, myocardial infarction, and stroke (8.1% GER, 9.1% RO), were similar (all p&amp;gt;0.05). Conclusions Higher-risk NSTE-ACS patient profiles mirror overall country CVD risk patterns. Compared to Germany, patients in Romania are younger, with a higher CVD risk factor burden, lower LVEF, underdiagnosis of major non-CVD comorbidities, and delayed CAD diagnosis. Despite similar guideline-directed management and in-hospital outcomes in both centres, these aspects may influence the long-term prognosis.

Primary Percutaneous Coronary Intervention in Multivessel Disease: Complete versus Culprit-only Revascularization

Objective: To compare the clinical outcomes of complete revascularization and culprit-only revascularization in patients with multivessel coronary artery disease (CAD) who presented with ST-segment elevation myocardial infarction (STEMI) at Hayatabad Medical Complex, Peshawar. Methodology: A prospective, randomized controlled trial was conducted, enrolling 400 patients with multivessel CAD. Patients were randomly assigned to either the complete revascularization group (n=200) or the culprit-only revascularization group (n=200). The primary outcomes assessed included cardiovascular death, reinfarction, and the need for repeat revascularization over a six-month follow-up period. Statistical analysis was performed using chi-square tests and Kaplan-Meier survival analysis. Results: Complete revascularization significantly reduced the rates of major adverse cardiovascular events compared to culprit-only revascularization. Cardiovascular death was lower in the complete revascularization group (4% vs 9%, p = 0.02), as was reinfarction (5% vs 11%, p = 0.01), and repeat revascularization (7% vs 15%, p = 0.004). Kaplan-Meier analysis showed a significant improvement in event-free survival in the complete revascularization group. Conclusion: Complete revascularization significantly improves clinical outcomes in patients with multivessel CAD presenting with STEMI, reducing cardiovascular death, reinfarction, and repeat revascularization. This study supports complete revascularization as a preferred treatment strategy in such patients to improve long-term outcomes. Keywords: coronary artery disease, STEMI, complete revascularization, culprit-only PCI, cardiovascular outcomes

Sarcopenia Influences Clinical Outcome in Hospitalized Patients with Peripheral Artery Disease Aged 75 Years and Older

ObjectivesSarcopenia represents a relevant comorbidity in patients with peripheral artery disease (PAD). However, only few studies exist assessing the clinical burden of sarcopenia in PAD. MethodsAll hospitalizations of patients aged ≥75 years who were admitted due to PAD within 2005-2020 in Germany were included in the study and stratified for sarcopenia. Temporal trends and the impact of sarcopenia on treatment procedures as well as adverse in-hospital events were investigated. ResultsOverall, 1,166,848 hospitalization-cases of patients admitted due to PAD (median age 81.0 [78.0-85.0] years; 49.5% female sex) were included, of which 2109 (0.2%) were coded with sarcopenia. Prevalence of sarcopenia in these patients increased during the observational period from 0.05% in 2005 to 0.34% in 2020 (β 2.61 [95%CI 2.42 to 2.80], P<0.001). Sarcopenic PAD patients were more often female (52.1% vs. 49.5%, P=0.015), obese (6.6% vs. 5.5%, P=0.021) and revealed higher prevalences of comorbidities (Charlson comorbidity index, 7.00 [6.00-9.00] vs. 6.00 [5.00-7.00], P<0.001). Sarcopenia was associated with reduced usage of reperfusion treatments (endovascular intervention: OR 0.409 [95%CI 0.358-0.466], P<0.001; surgical revascularization: OR 0.705 [95%CI 0.617-0.805],P<0.001), but higher conduction of amputation (OR 1.365 [95%CI 1.231-1.514], P<0.001) and higher rates of major adverse cardiovascular and cerebrovascular events (OR 1.313 [95%CI 1.141-1.512], P<0.001) and in-hospital death (OR 1.229 [95%CI 1.052-1.436], P=0.009). ConclusionsSarcopenia is an under-recognized condition in PAD patients of high clinical relevance causing a crucial disease burden. Awareness of the ailment needs to be increased in daily clinical practice to identify sarcopenia and improve clinical outcome of this vulnerable patient group.

The Influence of Remnant Cholesterol on Cardiovascular Risk and Mortality in Patients with Non-Functional Adrenal Incidentalomas and Mild Autonomous Cortisol Secretion: A Retrospective Cohort Study.

Background: Increased cardiovascular risk has been described in individuals with adrenal incidentalomas. The aim of the present study is to assess the effect of remnant cholesterol (RC) on the cardiovascular risk and mortality of patients with adrenal incidentalomas. Methods: A retrospective cohort study was conducted with patients with adrenal incidentalomas between 2001 and 2024. One hundred thirty-seven patients (mean age of 61.2 ± 11.5 years; 56.6% women) with non-functioning adrenal incidentalomas and with mild autonomous cortisol secretion (MACS) (cortisol post-dexamethasone suppression test ≥1.8 µg/mL) were included. The patients were divided into two groups using 30 mg/dL as the cut-off for RC. Logistic regression models were used to study the impact of RC on major adverse cardiovascular events and mortality (MACEs). Results: Patients with RC ≥ 30 mg/dL exhibited a higher prevalence of type 2 diabetes mellitus (T2D) (p < 0.001), lower HDL-C (p < 0.001) and LDL-C (p = 0.025) levels, a higher frequency of treatment with statins (p = 0.032), and a higher rate of non-fatal major cardiovascular events (p = 0.038) and MACEs (p = 0.038). Patients with MACS showed no differences in RC or complications during the follow-up. The relative risk of high RC was 2.65 (1.04-6.77) for cardiovascular events and 2.27 (1.05-4.92) for MACEs, with p < 0.05 in both cases. The only variables independently affecting MACEs were age ([odds ratio] OR = 1.13 [p = 0.004]), female sex (OR = 0.20; p = 0.016), LDL-C (OR = 1.02; p = 0.029), and RC (OR = 1.06; p = 0.014). T2D and HDL-C were not independently associated with MACEs. Conclusions: RC ≥30 mg/dL in patients with adrenal incidentalomas was associated with a higher prevalence of T2D, lower HDL-C levels, and a higher risk of MACEs. MACS was not associated with RC or MACEs during the follow-up.

Relationship of Subendocardial Perfusion to Myocardial Injury, Cardiac Structure, and Clinical Outcomes Among Patients With Hypertension.

Coronary microvascular dysfunction has been implicated in the development of hypertensive heart disease and heart failure, with subendocardial ischemia identified as a driver of sustained myocardial injury and fibrosis. We aimed to evaluate the relationships of subendocardial perfusion with cardiac injury, structure, and a composite of major adverse cardiac and cerebrovascular events consisting of death, heart failure hospitalization, myocardial infarction, and stroke. Layer-specific blood flow and myocardial flow reserve (MFR; stress/rest myocardial blood flow) were assessed by 13N-ammonia perfusion positron emission tomography in consecutive patients with hypertension without flow-limiting coronary artery disease (summed stress score <3) imaged at Brigham and Women's Hospital (Boston, MA) from 2015 to 2021. In this post hoc observational study, biomarkers, echocardiographic parameters, and longitudinal clinical outcomes were compared by tertiles of subendocardial MFR (MFRsubendo). Among 358 patients, the mean age was 70.6±12.0 years, and 53.4% were male. The median MFRsubendo was 2.57 (interquartile range, 2.08-3.10), and lower MFRsubendo was associated with older age, diabetes, lower renal function, greater coronary calcium burden, and higher systolic blood pressure (P<0.05 for all). In cross-sectional multivariable regression analyses, the lowest tertile of MFRsubendo was associated with myocardial injury and with greater left ventricular wall thickness and volumes compared with the highest tertile. Relative to the highest tertile, low MFRsubendo was independently associated with an increased rate of major adverse cardiac and cerebrovascular events (adjusted hazard ratio, 2.99 [95% CI, 1.39-6.44]; P=0.005) and heart failure hospitalization (adjusted hazard ratio, 2.76 [95% CI, 1.04-7.32; P=0.042) over 1.1 (interquartile range, 0.6-2.8) years median follow-up. Among patients with hypertension without flow-limiting coronary artery disease, impaired MFRsubendo was associated with cardiovascular risk factors, elevated cardiac biomarkers, cardiac structure, and clinical events.

Geographical Differences in the Safety and Efficacy of Tofacitinib Versus TNFi: APost Hoc Analysis of ORAL Surveillance.

In ORAL Surveillance, incidence rates (IRs) of major adverse cardiovascular events (MACE) and malignancies (excluding non-melanoma skin cancer [NMSC]) in cardiovascular (CV)-risk-enriched patients with rheumatoid arthritis (RA) were numerically greater with tofacitinib in North America versus the rest of the world, due to underlying risk factors. Here, we evaluated the safety and efficacy of tofacitinib versus tumor necrosis factor inhibitors (TNFi) among patients with RA across geographical regions. Patients with RA in ORAL Surveillance (NCT02092467), who were aged ≥ 50years with ≥ 1additional CV risk factor, received tofacitinib 5 or 10mg twice daily or TNFi; 45.9% were from either Poland or North America. This post hoc analysis stratified patients by region (Poland, North America, Other countries). Efficacy endpoints included Clinical Disease Activity Index, Disease Activity Score in 28 joints, with C-reactive protein (DAS28-4[CRP]), and Health Assessment Questionnaire-Disability Index (HAQ-DI). IRs and hazard ratios for adverse events were reported. Of 4362 patients (Poland, N = 759; North America, N = 1243; Other countries, N = 2360), more patients from North America versus Poland/Other countries had CV risk factors such as body mass index ≥ 30kg/m2 and history of diabetes/hypertension; however, more patients from Poland versus other regions were ever smokers and more patients from Poland/North America versus Other countries had history of coronary artery disease. MACE IRs were similar in North America and Poland, and numerically higher versus Other countries. IRs for malignancies (excluding NMSC) were numerically higher in NorthAmerica versus Poland/Other countries with tofacitinib. Serious infections IRs werenumerically higher in North America versus Poland across treatments. Venousthromboembolism/all-cause mortality IRs were generally comparable across regions. DAS28-4(CRP)/HAQ-DI improvements were generally lowest in North America. Differences in safety outcomes were driven by the presence of baseline risk factors; North America and Poland demonstrated a higher proportion of patients with some baseline CV risk factors/comorbidities versus Other countries. NCT02092467 (ClinicalTrials.gov).

Value of Cardiac Magnetic Resonance Imaging in Assessment of the Myocardial Reperfusion after Primary Percutaneous Coronary Intervention with or without Thrombus Aspiration in Patients with ST-Elevation Myocardial Infarction with High Thrombus Burden

Abstract Background Primary percutaneous coronary intervention (PCI) is effective in opening the infarct related artery in patients with myocardial infarction with ST-segment elevation. However, the embolization of atherothrombotic debris induces microvascular obstruction and diminishes myocardial reperfusion. Objective The study aims to evaluate the efficacy and safety of the manual thrombus aspiration during primary PCI for the acute ST-elevation myocardial infarction (STEMI) patients with high thrombus burden. Patients and Methods The current study was prospective cohort study which was conducted on 100 patients presenting to cardiology department in Ain Shams University hospitals with STEMI in the first 12 hours of presentation, comparing two group (50 patients in each group): the thrombus aspiration group(group A) who underwent manual thrombus aspiration before the provisional stenting and the conventional PCI group (group B) who underwent provisional stenting using standard technique without thrombus aspiration.). every patient is assigned to a particular group based on the operator’s preference. The blood flow of the culprit coronary artery in the thrombolysis in myocardial infarction (TIMI) and the myocardial blush grade(MBG) was recorded immediately after the emergency PCI operation in each group, then an echocardiogram was performed to determine the left ventricular dimensions and ejection fraction within in 1 week after the operation, cardiac MRI was performed 3 months after the operation to determine the left ventricular dimensions, ejection fraction, stroke volume and size of infarction and finally the data on major adverse cardiovascular events (MACE) during the 6 months of postoperative follow-up were collected. Results There were no statistically significant differences between the two groups in terms of the demographic data, the cardiovascular risk factors, the vital data at the time of the hospital admission, the Killip class and the pain to door. The postoperative final TIMI flow was TIMI III flow in 46 patients (92%) of the thrombus aspiration group vs 34 patients (68%) in the conventional PCI group with P- value = 0.003 (statically highly significant). The final MBG was grade III in 40 patients (80%) of the thrombus aspiration group vs 30 patients (60 %) in the conventional PCI group, grade II in 10 patients (20 %) vs 16 patients (32%) and grade 0 only in 4 patients (4 %) in the conventional PCI group with P- value = 0.033 (statically significant). The post operative ECHO showed smaller Left ventricular dimensions with higher Left ventricular systolic and diastolic function in the thrombus aspiration group than the conventional PCI group with p value = 0.000 (statically highly significant). The postoperative cardiac MRI showed smaller Left ventricular end -systolic and end -diastolic volumes index with higher Left ventricular systolic function and Left ventricular Stroke volume index in the thrombus aspiration group than the conventional PCI group with p value = 0.000 (statically highly significant). Moreover, the postoperative cardiac MRI showed smaller LV Size of infarction (LV myocardia scar) in the thrombus aspiration group than the conventional PCI group with p value = 0.000 (statically highly significant).finally, there was a significant reduced rate of cardiovascular death and major adverse cardiovascular events (MACE) with no difference regarding the rate of the cerebrovascular stroke within 6 months post procedure in the thrombus aspiration group compared to the conventional PCI group with p value = 0.027 (statically significant).