NSTEMI Patients Research Articles

Machine learning algorithms using the inflammatory prognostic index for contrast-induced nephropathy in NSTEMI patients.

Aim: Inflammatory prognostic index (IPI), has been shown to be related with poor outcomes in cancer patients. We aimed to investigate the predictive role of IPI for contrast-induced nephropathy (CIN) development in non-ST segment elevation myocardial infarction patients using a nomogram and performing machine learning (ML) algorithms.Materials & methods: A total of 178 patients with CIN (+) and 1511 with CIN (-) were included.Results: CIN (+) patients had higher IPI levels, and IPI was independently associated with CIN. A risk prediction nomogram including IPI had a higher predictive ability and good calibration. Naive Bayes and k-nearest neighbors were the best ML algorithms for the prediction of CIN patients.Conclusion: IPI might be used as an easily obtainable marker for CIN prediction using ML algorithms.

Abstract 4145873: Optimal Timing for Coronary Artery Bypass Grafting in NSTEMI Patients: A Retrospective Cohort Analysis of In-Hospital Mortality and Stroke Prevalence Over 2017 to 2021

Background: Recent studies have suggested performing coronary artery bypass grafting (CABG) within 24 hours of acute myocardial infarction increases mortality risk. However, the ideal timing after the first day remains unclear. This study aims to suggest an optimal timing of CABG in NSTEMI patients using the large National Inpatient Sample (NIS) database over a 5-year period. Methods: This retrospective cohort study analyzed survey-weighted NIS data over 2017-2021, including adult-age admissions with NSTEMI as the principal diagnosis who underwent CABG without prior transfer from another hospital. Patients were categorized into eight groups based on days from admission to CABG (0, 1, 2, 3, 4, 5, 6, and ≥7 days). Baseline characteristics were compared across groups. Multivariate regression analysis adjusted for multiple confounders to assess the association between Time-to-CABG and in-hospital mortality and stroke prevalence. Results: Table 1 presents the baseline characteristics across the eight groups, encompassing 142,200 included admissions (mean age 65.24 years; 26.78% female). In-Hospital Mortality: The adjusted odds ratios (OR) were less than one for groups 1 through 7 compared to group 0, indicating that immediate CABG (day 0) is associated with higher mortality risk. While the reduced odds in the day 1 group were not statistically significant, substantial and statistically significant reductions in mortality were observed between days 2 and 5 (OR: 0.624 - 0.609; p<0.05). After day 5, the OR for mortality trended up, reaching 0.667 (p<0.05) on day 6 and 0.692 (p<0.05) for surgeries performed on day 7 or later. Stroke Prevalence: The adjusted ORs for stroke prevalence were significantly lower for groups 1 through 7 compared to the CABG within 24-hour group (all p-values <0.05). The lowest ORs were observed between days 2 and 4 (OR: 0.654 and 0.542, p<0.05, respectively). After day 4, the ORs increased, reaching 0.672 (p<0.05) for surgeries performed on day 5 and 0.609 (p<0.05) on day 7 and beyond. Conclusion: The mortality risk in NSTEMI patients remained higher if CABG was performed in the first 48 hours of admission (end of day 1) compared to later. This risk also increased if CABG was done after day 5. Combined with the possible risk of stroke being increased from day 5, we suggest the optimal time-to-CABG is between admission day 2 and day 4 in NSTEMI patients. Future prospective studies are warranted to confirm these findings and guide clinical practice.

High-risk features in non-culprit lesions and clinical outcome after NSTEMI versus STEMI.

Complete non-culprit (NC) revascularization may help reduce recurrent events after NSTEMI, especially if NC lesions would harbor high-risk plaque features similar to STEMI. The study aimed to assess differences in fractional flow reserve (FFR)-negative NC plaque morphology in patients presenting with NSTEMI versus STEMI and assess the association of high-risk plaque morphology and clinical outcome. In the prospective PECTUS-obs study, 438 patients presenting with myocardial infarction (MI) underwent optical coherence tomography (OCT) of all FFR-negative intermediate NC lesions. The primary endpoint was the occurrence of major adverse cardiovascular events (MACE, all-cause mortality, non-fatal MI or unplanned revascularization) at two-year follow-up. Four hundred and twenty patients had at least one analyzable OCT, including 203 (48.3%) with NSTEMI and 217 (51.7%) with STEMI. The prevalence of high-risk plaques (HRP), including thin-cap fibroatheromas (TCFA), plaque rupture and thrombus, was comparable between groups. MACE occurred in 29 (14.3%) NSTEMI patients and 16 (7.4%) STEMI patients (Punivariable=0.025 and Pmultivariable=0.270). Incidence of MACE was numerically higher among patients with HRP, irrespective of the clinical presentation at index (Pinteraction=0.684). Among high-risk plaque criteria, plaque rupture was associated with MACE in both NSTEMI (p<0.001) and STEMI (p=0.020). Presence of NC HRP is comparable between NSTEMI and STEMI and leads to numerically higher event rates in both. These results call for additional research on complete revascularization in NSTEMI and treatment of HRP.

Randomized trial of early exercise rehabilitation and its effects on patients with acute coronary syndrome

To assess the psychological and physiological benefits of early exercise rehabilitation in patients with acute coronary syndrome (ACS). Among 559 ACS-diagnosed patients at Fuzhou University Affiliated Provincial Hospital from January to December 2021, 200 eligible participants were assigned to two groups. The control group received standard care, while the experimental group received early exercise rehabilitation in addition to standard care. The outcomes measured included changes in depression levels (PHQ-9), fasting blood glucose, and troponin I (TnI) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels. Data were analyzed using SPSS, with t tests and chi-square tests for group comparisons. In comparison to the control group, the experimental group demonstrated significant improvements in PHQ-9 scores (P < 0.001) and lower fasting blood glucose levels before discharge (P = 0.046). Additionally, the experimental group had notably reduced TnI levels at 72 h after admission (P = 0.001), especially among non-diabetic NSTEMI patients over 60 years old, who showed decreased TnI levels at the 48-hour mark (P = 0.016). However, there were no significant differences in NT-ProBNP change values between the two groups (P > 0.05). Subgroup analysis revealed enhanced outcomes in the intervention group for ACS patients without smoking or drinking history and no heart failure (P = 0.025,P = 0.014,P = 0.018). Early exercise rehabilitation has notable benefits for ACS patients, including reduced depression, improved blood glucose control, and enhanced myocardial protection, especially in nondiabetic NSTEMI patients aged 60 and above.

Evidence for stability of cardiac troponin T concentrations measured with a high sensitivity TnT test in serum and lithium heparin plasma after six-year storage at-80 °C and multiple freeze-thaw cycles.

As high-sensitivity cardiac troponin T (hs-cTnT) is making the transition from diagnostic to prognostic use, a long-term stability study of 5th generation hs-cTnT according to EFLM CRESS recommendations was set up for investigation of frozen clinical specimens (two matrices). Study samples collected in serum tubes and lithium heparin tubes with gel from patients admitted for suspected minor myocardial damage were measured directly after completion of the study (0 years), and after 3-year and 6-year storage at-80 °C, and recovery of hs-cTnT concentrations after long-term storage (%hs-cTnT concentration compared to 0-year) was calculated. Hs-cTnT changes were also compared to decisive delta changes, such as the ones proposed in the ESC NSTEMI 0 h/1 h algorithm (<3 or >5 ng/L for ruling out and ruling in suspected NSTEMI patients). Eighty-six patients were included in the study, whereof 28 both lithium heparin plasma and serum samples were collected simultaneously, in others only serum (n=30) or plasma (n=28). Multiple aliquots per patient were made, so that 479 serum and 473 plasma samples were available for analysis. Across the overall hs-cTnT measuring range, median recovery after 6 years was 105.4 % and 106.2 % for serum and plasma, respectively. Based on these decisive delta changes, serum showed consistent results upon long term storage (max 0.8 % of samples above delta threshold of >5 ng/L) as compared to heparin plasma (up to 19.2 % of samples above threshold). Over 6 years of storage at-80 °C, recovery of hs-cTnT in serum and heparin plasma was similar and within common lot-to-lot variation. Yet, when evaluating absolute delta increments around hs-cTnT clinical decision points, long-term stored sera displayed better clinical performance compared to heparin plasma samples.

The short-term prognosis of salvianolate use during hospitalization in patients with acute myocardial infarction

Abstract Background Salvianolate, derived from Salvia miltiorrhiza Bunge, is a traditional Chinese medicine known for its potential to promote blood circulation and eliminate blood stasis, often prescribed for cardiovascular system illnesses. This study aims to explore the impact of salvianolate treatment on the prognosis of patients with myocardial infarction during hospitalization. Methods This study included an acute myocardial infarction cohort from 71 secondary or tertiary hospitals between January 1, 2010 and June 30, 2023. Patients were divided into NSTEMI and STEMI groups. Clinical outcomes included cardiac death and major adverse cardiovascular and cerebrovascular events (MACCE, composite of cardiac death, myocardial infarction, ischemic stroke) within 30 days. Cox multivariable regression analyzed the association between salvianolate use and outcomes in STEMI/NSTEMI patients. Propensity score matching (PSM) adjusted for demographic and clinical differences between salvianolate and non-salvianolate groups. The matching factors including sex, age, Killip class, previous diseases (diabetes, hypertension, stroke, and renal insufficiency), previous percutaneous coronary intervention (PCI), in-hospital aspirin, clopidogrel, ticagrelor, lipid-lowering agents, nitrates, PCI, and thrombolytic therapy. Results A total of 76,157 STEMI patients and 74,373 NSTEMI patients were assessed. Among the STEMI group, 7,636 patients used salvianolate and 68,521 did not. Multivariate Cox regression analysis revealed that salvianolate use during hospitalization reduced cardiac death (aHR = 0.707, 95%CI = 0.623-0.803, P &amp;lt; 0.001) and MACCE (aHR = 0.730, 95%CI = 0.651-0.820, P &amp;lt; 0.001) at 30 days. These findings remained consistent in the matched population (n = 15,264) (cardiac death: aHR = 0.669, 95%CI = 0.569-0.786, P &amp;lt; 0.001; MACCE: aHR = 0.679, 95%CI = 0.586-0.787, P &amp;lt; 0.001). In the NSTEMI group, 6,461 patients used salvianolate, while67,912 did not. After matching, salvianolate use during hospitalization showed no significant difference in cardiac death and MACCE compared to not use. Conclusions Patients with STEMI treated with salvianolate exhibited improved short-term cardiovascular and cerebrovascular outcomes, while NSTEMI patients did not experience significant short-term prognosis enhancement.

Thirty days clinical outcomes following stent implantation with aspirin-free prasugrel monotherapy in non-ST segment elevation myocardial infarction. Interim report from ASET-Japan pilot study

Abstract Background Dual antiplatelet therapy with a P2Y12 inhibitor, in addition to aspirin, is the standard therapy after percutaneous coronary intervention (PCI) for non-ST-segment elevation acute coronary syndrome (NSTE-ACS) to prevent ischemic cardiovascular events. The Acetyl-Salicylic Elimination Trial (ASET) pilot studies conducted in Japan in patients with NSTE-ACS investigated the safety and feasibility of a low-dose prasugrel monotherapy after PCI. Purpose To ensure the safety of the patients, enrolment in the study was implemented only after confirmation of a successful procedure. The abstract reports our interim analysis, aimed at evaluating preliminary safety and feasibility. Methods The ASET-Japan pilot study was designed to explore the feasibility and safety of a low dose of prasugrel monotherapy (3.75mg/day), without adjunctive aspirin, after optimal PCI using Everolimus eluting stent (EES) in Japanese patients with non-ST-segment elevation acute coronary syndromes. The primary endpoint in the ASET-Japan NSTE-ACS (Phase 2) is a 12-month clinical outcome. The study is currently in the follow-up phase. All the target lesions were treated with a platinum-chromium everolimus-eluting stent. The primary ischemic endpoint was the composite of cardiac death, spontaneous target vessel myocardial infarction, or definite stent thrombosis, and the primary bleeding endpoint was Bleeding Academic Research Consortium types 3 and 5 bleeding up to 12-month. If more than 3 events occurred, trial enrollment would have to be terminated by the data and safety monitoring board. Results One hundred one patients were enrolled after successful index PCI and completed a 30 days follow-up. The mean age was 69.1±12.3 years and 75.2% was male. The mean anatomical SYNTAX score was 7.9±4.7. Unstable angina (UAP) and NSTEMI were seen in 24.8% (25/101) and 75.2% (75/101) patients, respectively. According to the Braunwald classification, 8 percent of the patients were categorised as Class IA UAP, 48% as Class IB, 20% as Class IIB, 4% as Class IIIA and 20% as Class IIIB. In NSTEMI patients, the median (IQR) pre-procedural troponin value (cardiac Troponin T or I) was 2.79 (1.12 – 22.27) times the Upper Limit of Normal. According to the PRECISE DAPT score, 36.6% of patients were categorised as High Bleeding Risk (HBR) with scores above 25. At one month, the primary ischemic endpoints of cardiac death, target-vessel spontaneous MI or definite Stent thrombosis did not occur. Two patients (2.0%) had BARC type 3a bleeding. Conclusion Prasugrel monotherapy in the first 30 days following platinum-chromium everolimus-eluting stent deployment is a feasible and safe strategy in NSTE-ACS patients with simple anatomy and successful PCI.

Hair cortisol concentration, a biomarker of stress, is gradually increased in patients with acute myocardial infarction before the acute episode

Abstract Background/Introduction Chronic stress is considered to be an important element of residual cardiovascular risk and modern guidelines recommend its systematic assessment and treatment. Its pathophysiologic contribution, however, in acute myocardial infarction (AMI) was not, until recently, easy to elucidate. This arises from difficulties in objectively quantifying stress levels using conventional research methods, like questionnaires. Purpose The purpose of our study was to measure stress levels at the days preceding an acute myocardial infarction using a solid biomarker, Hair Cortisol Concentration (HCC). Methods 102 consecutive patients with AMI (71 patients with ST-elevation Myocardial Infarction [STEMI] and 31 with Non ST-elevation Myocardial Infarction) from our institution were recruited for this study. We took hair samples from them to precisely measure HCC, which reflects cumulative cortisol levels for the time period preceding the acute event. We also did full clinical, biochemical and psychological evaluation. HCC levels were then compared with 50 age-matched healthy controls. Results To assess the temporal trend of HCC in hair segments, corresponding to specific time periods, we fitted linear mixed models. The mixed effects linear model including the main effects of time and group (AMI versus controls) and their interaction showed that cortisol concentration in hair increased over time with higher rate of increase in AMI patients versus controls (beta of interaction = 3.57; 95%CI: 1.74, 5.40; p &amp;lt; 0.001) The model explained a high percentage of the variance (conditional R2=0.940). No other baseline variable had a significant effect when added to the basic model. There was no significant difference between STEMI and NSTEMI (beta of interaction = 1.15; 95%CI: -1.330, 3.59; p = 0.358) Conclusions Hair cortisol levels, presumably reflecting stress levels, were gradually increasing before an acute myocardial infarction with higher rate of increase in patients compared to healthy controls. There was no significant difference between STEMI and NSTEMI patients. Picture 1. Predicted hair concentrations of cortisol over time prior to the event, based on linear mixed models.

Antiplatelet can improve the short-term prognosis of type 2 myocardial infarction caused by acute respiratory failure

Abstract Background Type 2 myocardial infarction (T2MI) is characterized by myocardial infarction resulting from an imbalance between myocardial oxygen supply and demand, without the rupture of acute atherosclerotic plaque. Antiplatelet therapy is the cornerstone of treatment for Type 1 myocardial infarction, however, its efficacy in T2MI remains unclear. Purpose This study aimed to explore the impacts of antiplatelets on prognosis in patients with T2MI caused by acute respiratory failure. Methods The data for this study were derived from the Health and Medical Big Data Superplatform, comprising a retrospective cohort of patients admitted to and discharged from 72 secondary and tertiary hospitals from 2010 to 2023. A total of 4708 patients with T2MI due to acute respiratory failure were included. Participants were divided into two groups: those receiving antiplatelet therapy and those not. T2MI caused by acute respiratory failure was defined as NSTEMI patients caused by respiratory failure without percutaneous coronary intervention (PCI). Propensity score matching (PSM) was used to balance covariates between the groups, followed by building a multivariable Cox regression model to further adjust for potential confounders. Covariates adjusted in multivariable Cox regression included antiplatelet, anticoagulant, and lipid-lowering drug use during hospitalization, age, sex, KILLIP classification, history of diabetes, hypertension, percutaneous coronary intervention, stroke, renal insufficiency, cerebral hemorrhage, and atrial fibrillation. One-to-one matching was performed based on propensity scores using the nearest available pair matching method with a caliper width of 0.01. The primary endpoint was Net Adverse Clinical Events (NACE) within 1 month, including myocardial infarction, cardiac death, stroke and Bleeding Academic Research Consortium (BARC) criteria type 3 or 5. Results Following 1:1 propensity score matching, a total of 1418 participants were enrolled in the final study sample, with 709 patients retained in each group. Patients using antiplatelet were more likely to use ACEI/ARB, CCB, and β-blockers during hospitalization, all p&amp;lt;0.05.Compared to non-antiplatelet therapy group, the use of antiplatelet was associated with a 0.69 times risk of 1-month NACE (aHR, 0.69; p&amp;lt;0.001), a 0.69 times risk of 1-month Major Adverse Cardiovascular and Cerebrovascular Events (MACCE) (aHR, 0.69; p&amp;lt;0.001), a 0.70 times risk of 1-month cardiac death (aHR, 0.70; p&amp;lt;0.001), and a 0.70 times risk of 1-month all-cause mortality (aHR, 0.70; p&amp;lt;0.001); with no statistical significance for other clinical outcomes (p &amp;gt; 0.05) (Figure 1). Conclusions The present study suggested that patients receiving antiplatelet therapy had a lower incidence of one-month NACE, primarily due to a reduction in major cardiac death and MACCE at 1 month.

Comparing the ability of GRACE 2.0 and GRACE 3 scores for predicting in-hospital mortality in patients with and without diabetes

Abstract Background Sex-specific refinement of GRACE 2.0 was published as GRACE 3.0 (G3). The relative ability of G3 in predicting in-hospital mortality in diabetic patients has not been explored. Purpose Explore the ability of G3 in determining in-hospital mortality in patients with and without diabetes. Methods Retrospective cohort analysis of data on NSTEMI and UA patients admitted in two hospitals between 2010 and 2019 entered into the Myocardial Infarction National Audit Project database. All baseline characteristics and G2, G3 scores were recorded. In hospital death was recorded from hospital records. The discriminative power of the G2 score was determined by comparing the area under the receiver operating characteristic curve (c-statistics). Accuracy of calibration was evaluated by plotting the mean predicted vs observed mortality in each decile of predicted risk, Hosmer-Lemeshow (HL) goodness-off it test and the Nagelkerke R2 (NR2). Results G3 was calculated in 2768 patients (age 69±14yrs, 62.3% male, 877(31.7%) with diabetes. Median risk for the cohort was 1.3%, (95% CI 1.2 to 1.4). G3 risk was higher in patients with diabetes (median 2.0 IQR 0.6 to 5.5 vs 1.0 IQR 0.3 to 3.7, p&amp;lt;0.0001). In-hospital mortality occurred in 68 (2.5%) patients with no difference between the diabetes groups (3.1% and 2.2% died in the DM and non-DM groups respectively). In the whole cohort, G3 reclassified 139(7.5%) patients in low-intermediate to high risk-category and 159(17.4%) patients in high to low-intermediate category. 10.1% and 6.5% were upgraded and 16.1% and 18.1% were downgraded in DM and non-DM groups. Overall discriminatory power of G3 (AUC 0.87, 95% CI 0.86 to 0.88, p&amp;lt;0.0001) was excellent but no different from G2 (AUC 0.86 95% CI 0.85 to 0.88, p&amp;lt;0.0001) (δAUC 0.009, p=0.461). In patients with diabetes, G3 yielded higher AUC (AUC 0.85, 95% CI 0.83 to 0.87, p&amp;lt;0.0001) than G2 (AUC 0.82, 95% CI 0.79 to 0.84, p&amp;lt;0.00101) but this was not statistically significant (δAUC 0.031, p=0.142). In patients without DM, the difference was smaller (δAUC 0.002, p=0.906). Neither G2 (δAUC 0.061, p=0.185) nor G3 (δAUC 0.028, p=0.473) was better in discrimination in DM compared to non-DM groups (Fig1A,B). In the diabetic group, calibration plot for the G3 score showed suboptimal calibration with consistent overestimation of the risk across all risk deciles (Figure1C), with the HL test showing significant differences between the observed and predicted values (p &amp;lt;0.0001) and the NR2 was low 0.09. The GRACE 2 score showed better calibration (Fig1D) (HL: p=0.09, NR2 0.11). In patients without diabetes, calibration plot for the G3 (HL: p= 0.17; NR2 0.33) (Fig1E) and G2 (HL: p=0.15, NR2 0.25) (Fig1F) shows similar pattern of overestimation of the risk less so for latter. Conclusion G3 and G2 shows excellent discrimination for in-hospital mortality in both diabetic and non-diabetic patients. G2 seems to show better calibration than G3 for diabetic patients.

Comparing the ability of GRACE 2.0 scores for predicting mortality in patients with and without diabetes

Abstract Background The GRACE 2.0 (G2) was an improvement on GRACE. Neither contains DM in the model. In the GRACE, DM independently predicted in-hospital but not the 6-month post-discharge mortality. Similar analysis for GRACE 2.0 score is unavailable. Purpose Assess the ability of the GRACE 2.0 score in predicting mortality in patients with and without diabetes. Methods Retrospective cohort analysis of data on non-STEMI and UA patients admitted in two hospitals between 2010 and 2019 entered into the Myocardial Infarction National Audit Project database. All baseline characteristics of the population and G2 scores were recorded. Death at 1 year was recorded from hospital and general practice records. Follow up was censored at the last recorded contact of the patient with a medical professional. The discriminative power of the G2 score in patients with and without diabetes in predicting mortality was determined by comparing the area under the receiver operating characteristic curve (c-statistics). Accuracy of calibration was evaluated by plotting the mean predicted vs observed mortality in each decile of predicted risk. Results Of 2841 patients entered, complete data was available for 2768 patients (age 69±14yrs, 62.3% male, 877(31.7%) with diabetes). G2 risk was higher in DM (8.3, IQR 3.9 to 19.0 v 5.5, IQR 2.6 to 13.0; p&amp;lt;0.0001). 337 patients died, 156 with DM. Higher deaths occurred in DM group (17.8% vs 16.3; adjusted OR 1.81, 95% CI 1.41-2.33, p&amp;lt;0.0001) (fig 1D). G2 discriminated between events well in whole cohort (AUC 0.81, p&amp;lt;0.001) with no difference between DM and non-DM patients (AUC DM: 0.78, 95% CI 0.75 to 0.81; non-DM 0.81, 0.79 to 0.83; δAUC 0.0301, p=0.242) (fig1E). Calibration of predictions by G2 was excellent across all deciles of risk for the whole cohort (fig 1A). However, G2 underestimated mortality in DM versus non-DM (fig1B,C), especially in the higher deciles of risk (fig 1 F,G). Conclusion(s) Discrimination of the GRACE 2.0 model was excellent for mortality at 1-year with no difference between patient with and without diabetes in our cohort of NSTEMI and UA patients. However, calibration plots suggest GRACE 2.0 underestimates mortality in diabetic compare to non-diabetic patients. This may suggest that risk stratification with GRACE 2.0 in diabetic patients may have to be considered with caution.Figure 1.

Methylome of circulating cell free DNA as a novel biomarker tool: from acute coronary syndrome to broader risk stratification of cardiovascular disease

Abstract Background Cell death during tissue injury leads to release of chromosomal DNA which is promptly degraded. However, short DNA fragments wrapped around nucleosomes survive longer in the bloodstream and can be isolated as circulating cell-free DNA (ccfDNA). Oncology field pioneered the use of cfDNA as clinical biomarker by identifying sequence modifications induced in cancer cells. Importantly, ccfDNA also retains the same epigenetic information as the tissue of origin. Despite major advances for disease diagnosis and therapy, coronary artery diseases (CAD) and associated conditions such acute myocardial infarction (AMI) or heart failure (HF) are responsible for leading number of deaths worldwide. Preventive and surveillance strategies with non-invasive testing are needed. Purpose Evaluation of ccfDNA methylation profiles as prognostic non-invasive biomarker for risk stratification of acute coronary syndromes and their potential application in preventive and surveillance strategies in other cardiovascular disorders. Methods CcfDNA isolated from citrate-plasma collected from our discovery cohort, comprising healthy controls, STEMI, NSTEMI and unstable angina (UA) patients, was analyzed applying Whole Genome Bisulfite Sequencing (WGBS) using a low-input BS-seq (PBAT) protocol. Computational analysis generated differentially methylated regions (DMRs) by tiling CpG areas and setting a threshold of minimal 25% methylation difference compared to the healthy group. To assess the validity of our findings, a selection of disease-specific DMRs were tested using targeted methylation sequencing protocol in a new set of patients. This procedure consisted in enzymatic conversion of ccfDNA methylated sites followed by probe-specific enrichment libraries and sequencing at a Novaseq 6000 platform. Results The study identified a total of 1941 DMRs and from those 486 were STEMI, 223 NSTEMI and 684 UA specific. From the identified DMRs, 74.13% from STEMI, 72.68% from NSTEMI and 61.62% from UA annotated with heart-related diseases using DisGeNET gene-disease associations. Interestingly, most of identified DMRs located within intronic regions (~60%) and also annotated as enhancers and lncRNAs. The independent validation with targeted methylation sequencing identified 566, 306 and 248 DMRs, respectively, and reduced the number of disease-specific DMRs to 171 in STEMI, 115 in NSTEMI and 82 in UA. Conclusion and Future Approaches Methylation profiles of ccfDNA showed potential as a biomarker to stratify the severity of acute coronary syndromes, a novel non-invasive detection methodology that could be extrapolated to risk stratification in other cardiovascular disease such as heart failure or coronary artery disease.

Impact of coronary CT angiography on the hospital outcome among patients admitted with AMI undergoing revascularization procedures in theUS

Abstract Background Coronary CT angiography (CCTA) is gaining popularity as a diagnostic modality for risk stratification among patients hospitalized with acute myocardial infarction (AMI). However, its impact on the hospital outcomes among this population of patients remains to be determined. Methods Using national inpatient sample database, admission cases with a diagnosis of AMI who underwent revascularization procedures were identified from 2016-2020. The prevalence of CCTA was determined among the patient population and stratified based on the type of AMI (STEMI vs. NSTEMI) and revascularization procedure (PCI vs. CABG). Hospital outcomes were compared among the study strata. Results A total of 862,064 admission cases for STEMI and 3,586,944 admission cases for NSTEMI were identified out of which 661,958 cases underwent revascularization procedures. The utilization of CCTA was roughly 10 times higher among AMI cases undergoing PCI than those undergoing CABG (0.5% vs. 0.06%, p&amp;lt;0.0001). Prior CCTA increased the odds of receiving PCI by 79.3 times and the odds of undergoing CABG by 2.8 times. Among STEMI patients undergoing PCI, prior CCTA was associated with a lower mortality rate and non-home disposition (13.8% vs. 21.2%, p&amp;lt;0.0001) compared to no CCTA (3% vs. 5.5%, p=0.01). For NSTEMI patients undergoing PCI, CCTA was associated with a lower non-home disposition (16.5% vs. 20.6%, p=0.003) but not a significantly lower mortality rate. CCTA did not demonstrate any statistically significant differences for AMI patients undergoing CABG. On the other hand, CCTA increased the cost of hospitalization by $15,130.7 for STEMI patients undergoing PCI, length of stay (9 days) and hospital cost for STEMI patients undergoing CABG ($302,802), and total hospital cost for NSTEMI patients undergoing PCI by $8,705. Conclusions Using CCTA helps in risk stratifying AMI patients for revascularization procedures, allocating PCI to those admitted with STEMI and CABG to those with NSTEMI. Although CCTA reduces the risk of death and non-home disposition among STEMI patients undergoing PCI, it also increases hospital charges for patients receiving revascularization procedures.

Rationale and design of the multicentric randomized EVAOLD trial: evaluation of a strategy guided by imaging versus routine invasive strategy in elderly patients with ischemia

BackgroundThe management of myocardial infarction without ST segment elevation (NSTEMI) in elderly patients remains challenging, in particular the benefit/risk balance of routine revascularization remains uncertain. Study designEVAOLD is s a multicenter, prospective, open-label trial with 2 parallel arms in NSTEMI patients ≥ 80 years of age. The aim of the trial is to test whether a strategy of selective invasive management guided by ischemia stress imaging (IMG group) will be non-inferior in preventing Major Adverse Cardiac and Cerebrovascular Events (MACCE, ie all-cause death, non-fatal myocardial infarction, non-fatal stroke) rates at 1 year compared with a routine invasive strategy (INV Group). Geriatric assessment and cost- effectiveness analysis will also be performed. A sample size of 1756 patients (assuming a 10% rate of patients lost to follow-up) is needed to show non-inferiority with 80% power. Non-inferiority based on exponential survival curves will be declared if the upper limit of the one-sided 97.5% confidence interval for the hazard ratio is lower than 1.24, corresponding to a non-inferiority margin of 7% in absolute difference and an event rate of 40% in the INV group. ConclusionEVAOLD is a nationwide, prospective, open-label trial testing the non-inferiority of a strategy of selective invasive management guided by ischemia stress imaging versus routine invasive strategy in elderly NSTEMI patients. ClinicalTrials.gov Identifier: NCT03289728

TCT-274 Trends and Outcomes of Impella-Supported PCI in NSTEMI Patients With Cardiogenic Shock

TCT-274 Trends and Outcomes of Impella-Supported PCI in NSTEMI Patients With Cardiogenic Shock

Implementation of Global Longitudinal Strain (GLS) in NON-ST Segment Elevation Myocardial Infarction in AL-Yarmook Teaching Hospital

Background: It would be advantageous to develop a noninvasive diagnostic tool that could more reliably distinguish between persons who would benefit from early coronary angioplasty and revascularization and those who would not in non-ST-segment elevation acute coronary syndrome. The LVGLS assessment is painless and may be completed quickly without putting patients through intense activities. Aim of study: To evaluate wall motion abnormality by (GLS) method in comparison with 2D echo and ECG changes. Material and method: A cross sectional study that included 60 patients who admitted to Al-Yarmouk teaching hospital due to new onset of acute coronary syndrome. Result: Mean GLS of patients was -13.61 ± 1.67, and the largest proportion of them were aged 56-60 yrs. regarding echo finding, 80% show hypokinetic motion wall abnormality. Patients with abnormal ECG changes, hypokenisia and low EF had significantly lower mean of GLS (p-value 0.0001, 0.0001, 0.004, respectively). The prediction value of GLS over EF was higher when comparing them according to presence of ECG changes and MWA. Conclusion: GLS is a powerful predictor of left ventricular function and appears to be a better metric than ejection fraction in NSTEMI patients.

In-Hospital Outcomes of Patients with Non-ST Elevation Myocardial Infarction Undergoing Early Invasive Percutaneous Coronary Intervention

Methodology: A cross-sectional study was conducted in the Adult Cardiology Department at the National Institute of Cardiovascular Diseases (NICVD) in Karachi, Pakistan, from August 2019 to February 2020. The study included 165 patients, both male and female, aged 40 to 75 years, who presented with NSTEMI and underwent early invasive PCI. All patients were either admitted through the emergency department or referred from outpatient services at NICVD. Comprehensive medical assessments were performed, and relevant medical history and clinical details were documented. PCI procedures were conducted under the supervision of experienced consultant cardiologists with over five years of procedural expertise. The primary outcomes evaluated were the incidence of cardiogenic shock, heart failure, and in-hospital mortality. Results: Of the 165 patients included in the study, 125 (75.8%) were male, with a mean age of 56.6±7.72 years and a mean BMI of 26.5±3.8 kg/m². Hypertension was prevalent in 100 (60.6%) patients, while 78 (47.3%) had diabetes mellitus. A history of smoking was reported in 70 (42.4%) patients. Heart failure emerged as the most common in-hospital adverse outcome, occurring in 25 (15.2%) patients, followed by cardiogenic shock in 9 (5.5%) patients, and in-hospital mortality in 20 (12.1%) patients. Conclusion: Among patients undergoing early invasive PCI following NSTEMI, heart failure was the most frequent adverse in-hospital outcome, followed by mortality and cardiogenic shock. These findings underscore the importance of vigilant monitoring and management of high-risk NSTEMI patients during the early stages of PCI intervention.

The relationship between the new inflammatory markers and disease severity in patients with acute coronary syndrome

Background Inflammation plays a crucial role in the progression of acute coronary syndrome. Aims The aim of this study was to investigate the relationship between the SYNTAX score and new inflammatory markers including albumin-globulin ratio (AGR), C-reactive protein-to-albumin ratio (CAR), fibrinogen-to-albumin ratio (FAR), neutrophil-to-albumin ratio (NAR), and neutrophil percentage-to-albumin ratio (NPAR) in STEMI and NSTEMI patients. Methods The study involved 53 STEMI and 64 NSTEMI patients, and each patient group was evaluated separately. Multivariate linear regression analysis was utilised to identify independent risk factors associated with SYNTAX scores. Results Out of the 64 NSTEMI patients, 42 had low SYNTAX score (65.6%), and 22 had high SYNTAX score (34.4%). Patients with high SYNTAX scores had significantly higher levels of age, glucose, fibrinogen, monocyte, and FAR, and lower levels of albumin and total protein. We found that FAR and monocyte levels were independent predictors of the high SYNTAX score. The study also determined that the cut-off value for FAR as 9.99, with a sensitivity of 81% and a specificity of 73% for predicting high SYNTAX score in NSTEMI patients. Out of the 53 STEMI patients, 42 had low SYNTAX score (79.2%), and 11 had high SYNTAX score (20.8%). Patients with high SYNTAX scores exhibited significantly higher total cholesterol, LDL, and glucose levels, and lower albumin and total protein levels. Conclusions The FAR level is significantly linked with the high SYNTAX score and can be a useful marker for predicting the severity of disease in NSTEMI patients.

Association between peak troponin level and prognosis among patients admitted to intensive cardiovascular care unit

IntroductionHigh-sensitivity cardiac troponin (hs-cTn) is a key biomarker for myocardial injury, yet its prognostic value in intensive cardiovascular care units (ICCU) remains poorly understood. We aimed to assess the association between peak hs-cTn levels and prognosis in ICCU patients. MethodsAll patients admitted to a tertiary care center ICCU between July 2019 – July 2023 were prospectively enrolled. Patients were divided into five groups according to their peak hs-cTnI levels: A) hs-cTnI <100 ng/L; B) hs-cTnI of 100–1000 ng/L; C) hs-cTnI of 1000–10,000 ng/L; D) hs-cTnI of 10,000–100,000 ng/L and E) hs-cTnI ≥100,000 ng/L. The primary outcome was all-cause mortality at one year. ResultsA total of 4149 patients (1273 females [30.7 %]) with a median age of 69 (IQR 58–79) were included. Group E was highly specific for myocardial infarction (97.4 %) and especially for ST segment elevation myocardial infarction (STEMI) (87.5 %). Patients in group E were 56 % more likely to die at 1-year in an adjusted Cox model (95 % CI 1.09–2.23, p = 0.014) as compared with group A. Subgroup analyses revealed that among STEMI patients, higher peak hs-cTnI levels were not associated with higher mortality rate (HR 1.04, 95 % CI 0.4–2.72, p = 0.9), in contrast to patients with NSTEMI (HR 7.62, 95 % CI 1.97–29.6, p = 0.003). ConclusionsPeak hs-cTnI levels ≥100,000 ng/L were linked to higher one-year mortality, largely indicative of large myocardial infarctions. Notably, the association between elevated hs-cTnI levels and mortality differed between STEMI and NSTEMI patients, warranting further investigation.

OMI/NOMI: Time for a New Classification of Acute Myocardial Infarction.

Forty percent of patients with acute coronary occlusion myocardial infarction (OMI) do not present with STEMI criteria, which delays their treatment and increases morbidity and mortality. The need to identify these patients promptly is crucial, and this sets the stage for the proposed reclassification. Many of these patients can be identified by other ECG and clinical features. Background/Objectives: We sought to evaluate cases of STEMI and NSTEMI that result in OMI. Additionally, we focused on the consequences of delayed revascularization in NSTEMI patients with acute coronary occlusion (NSTEMI-OMI). Methods: The study is a retrospective analysis conducted on 334 patients who underwent coronary angiography for acute coronary syndrome at UHC "Mother Teresa", Tirana, Albania, during January-May 2023. "OMI was defined as an acute culprit lesion with TIMI 0-2 flow, or an acute culprit lesion with TIMI 3 flow intervened upon and with highly elevated troponin (cTnI > 10.0 ng/mL, hs-cTnI > 5000 ng/L)". The presence or absence of STEMI criteria were determined in the final diagnosis written on the chart by a cardiologist using the third universal definition of MI. Ejection fraction (EF), total ischemia time, length of stay, and complications were compared between groups. Mechanical complications include acute ventricular failure, cardiogenic shock, rupture of the interventricular septum, rupture of the free wall, rupture of the papillary muscle, and pericarditis. Electrical complications include ventricular arrhythmias, supraventricular arrhythmias, and atrioventricular and interventricular blocks. Results: There were 334 patients included, 98 (29.3%) of whom were NSTEMI-OMI patients. Ninety-six patients (40%) of OMI patients did not fulfill the STEMI criteria. Only 11 patients (11%) of STEMI(-)OMI had PCI performed within the first 12 h vs. 76 patients (77%) with STEMI(+)OMI, p < 0.001. There was no difference in the percent of patients requiring PCI between the STEMI(+)OMI 98 patients (93%) and STEMI(-)OMI 87 patients (89%) (p = 0.496). The overall in-hospital mortality was 19 patients (5.7%), with subgroup mortality of 14 patients (4.2%) with STEMI(+)OMI, 2 patients (0.6%) with STEMI(+) NOMI, and 3 patients (0.9%) with STEMI(-)OMI, 0% STEMI(-)NOMI, (p = 0.013). Patients with mechanical complications included 67 patients (46.8%) with STEMI(+)OMI and 45 patients (46.4%) with STEMI(-)OMI. In addition, 26 patients (18.5%) with STEMI(+)OMI and 13 patients (13.1%) with STEMI(-)OMI developed electrical complications. Conclusions: STEMI(-)OMI patients had significant delays in catheterization, yet had angiographic findings, rates of PCI, and complications similar to STEMI(+)OMI. These data add further support to refocusing the paradigm of acute MI to improve recognition and rapid reperfusion of all OMIs, rather than only those with STEMI criteria.