Predictor Of Major Adverse Cardiac Events Research Articles

Number of inflamed coronary vessels in prediction of cardiac death and MACE among patients undergoing routine CCTA: the Oxford Risk Factors And Non-Invasive Imaging (ORFAN) Study

Abstract Background Coronary inflammation can be assessed by the changes in perivascular adipose tissue on routine coronary CT angiograms (CCTA). Fat attenuation index score (FAI Score) quantifies the degree of inflammation in each epicardial coronary artery, and adjusts for age, sex, scan technical parameters, biological and anatomical factors. Coronary inflammation assessment in a single coronary artery was previously shown to be predictive of cardiac events in the CRISP-CT study. However, the impact of inflammation in multiple coronary arteries on clinical outcome remains unclear. Purpose To evaluate the prognostic value of the number of inflamed coronary arteries with high inflammation in the risk of cardiac death, and major adverse cardiac events (MACE). Methods In a nested cohort within the Oxford Risk Factors And Non-invasive imaging (ORFAN) study, consecutive patients (n=3,393) who underwent routine clinical CCTA were followed up over a median(IQR) 7.7(6.4-9.1) years for cardiac mortality, and MACE (including myocardial infarction, new onset heart failure, cardiac mortality). FAI Score was calculated for each of the 3 epicardial coronary arteries. Results The number of inflamed arteries (FAI Score >75th centile) showed an additive impact on cardiac mortality compared with no inflamed arteries (all vessels FAI Score <25th centile), with hazard ratio 29.8 (95% CI 13.9-63.9, p<0.001) for 3 inflamed arteries, HR 20.4 (95% CI 9.4-44.7, p<0.001) for 2 inflamed arteries, and HR 13.0 (95% CI 5.9-28.8, p<0.001) for 1 inflamed artery. (Panel A) Similarly, patients with multiple inflamed arteries showed progressively higher risk for MACE (HR 7.2, 8.3 and 12.6 for 1-, 2- and 3-inflamed arteries respectively compared to patients with no inflamed artery). (Panel B) Patients with no inflamed arteries showed very low event rates for cardiac mortality and MACE. In patients with no obstructive CAD (n=2,651), similar trends were observed whereby patients with 3-inflamed arteries showed highest risk for cardiac mortality (Panel C) and MACE (Panel D), with intermediate risk for those with 1 or 2 inflamed arteries. Conclusion The number of coronary arteries with high inflammation, measured by FAI Score from routine CCTA, is associated with adverse cardiovascular events and cardiac mortality in an additive dose-response manner.

Extra cellular volume by computed tomography is useful for prediction of prognosis in cardiac sarcoidosis

Abstract Background Extracellular volume (ECV) fraction on magnetic resonance imaging (MRI) has been useful in evaluating the degree of myocardial fibrosis and has been reported to help diagnose and evaluate the prognosis of cardiomyopathy. However, there are also several contraindications in the cardiac MRI, and the performance of it takes time. Computed tomography (CT) helps screen for coronary artery disease, is more versatile than cardiac MRI, and is also useful in screening for coronary artery disease. Myocardial extracellular volume (ECV) analysis on CT has been recently eligible and has shown a good correlation with ECV on MRI. We hypothesized that ECV on CT, a new fibrosis indicator, would be useful in predicting prognosis in patients with cardiac sarcoidosis (CS). Purpose The purpose of this study is to evaluate the utility of ECV analysis on CT for predicting major adverse cardiac events (MACEs) in cases with cardiac sarcoidosis (CS). Methods As a single-center study, 48 patients (18 males, 67 ± 11 years old) diagnosed with CS based on the 2016 Japanese Circulation Society criteria and who underwent cardiac CT using 320-row detector CT or 256-row detector CT, and including late-phase images from December 2008 to January 2024 were analyzed retrospectively. We evaluated the ECV of left ventricular myocardium (LVM) using commercially available software (Figure A). The primary endpoint was MACEs, a composite of all-cause death, heart failure hospitalization, and fatal ventricular arrhythmia. Results Among all 48 patients, 14 combined events (10 fatal ventricular arrhythmias, three heart failure hospitalizations, and one all-cause death) were observed during a follow-up of 56 ± 57 months. ECV of LVM on CT was significantly higher in patients with MACEs than the others (37 ± 5.6% vs 33 ± 4.6%, P = 0.0087). The best cut-off value of ECV of LVM on CT for prediction of MACEs was 34.97%, and the sensitivity and specificity of LV-ECV to predict MACEs were 71% and 76% at the best cut-off, and the area under the curve was 0.73 based on the receiver operating characteristics curve analysis (P = 0.009) (Figure B). The cases with ECV ≥ 34.97% (n = 18) had significantly higher MACEs than the cases with ECV < 34.97% based on the Kaplan-Meier analysis (P = 0.0031) (Figure C). In the multivariate Cox proportional hazard model, ECV on LVM (Hazard ratio 1.11, 95% confidence interval 1.00-1.21, p=0.0493) and history of VT ablation (Hazard ratio 27.7, 95% confidence interval 4.27-180, p=0.0011) were the significant predictors of MACEs. Conclusion Adverse events mainly caused by fatal ventricular arrhythmia are relatively common in CS. Evaluation of ECV by CT may be useful for the prediction of MACEs in cases with CS.

Extra-cellular volume fraction analysis on cardiac CT is useful for predicting the prognosis of hypertrophic cardiomyopathy

Abstract Introduction Extra-cellular volume (ECV) fraction on magnetic resonance imaging (MRI) can evaluate the degree of myocardial fibrosis and has been reported to help diagnose and evaluate the prognosis of cardiomyopathy. In hypertrophic cardiomyopathy (HCM), ECV analysis on MRI is reported to help predict ventricular arrhythmias. However, the performance of cardiac MRI takes time, and there are also several contraindications. Cardiac computed tomography (CT) is more versatile than cardiac MRI and is also useful in screening coronary artery disease. ECV analysis on CT is now available, and a good correlation with ECV on MRI has been reported. We hypothesized that ECV on CT, a new fibrosis indicator, would be useful in predicting prognosis in HCM patients. Purpose To determine the utility of ECV analysis on CT to predict the prognosis in patients with HCM. Methods One hundred and three HCM patients (68 males, 66 ± 11 years old) who underwent cardiac CT using 320-row detector CT or 256-row detector CT, from 2008 to 2021 at our two hospitals were analyzed. We measured left ventricular (LV) ECV (LV-ECV) on CT and collected patient characteristics, transthoracic echocardiographic, and other CT findings. We investigated the relationship between these findings and the major adverse cardiac events (MACEs) (cardiac death, fatal arrhythmia, and heart failure hospitalization) after CT. Results All patients were followed for 64 ± 54 months after cardiac CT, and 15 patients (14.6%) had MACEs (ten heart failure hospitalization cases, two ventricular fibrillation cases, two sustained ventricular tachycardia cases, and one sudden cardiac death case). The patients with MACEs had a significantly higher LV-ECV, sudden cardiac death (SCD) risk score and lower LV ejection fraction (LVEF) than those without MACEs（42.0 ± 8.3% vs. 33.7 ± 6.1%, P < 0.001, 2.4 ± 0.39 vs 1.95 ± 0.16, P= 0.047, and 57.7 ± 11.9% vs. 66.7 ± 6.9%, P = 0.004). The percentage of dilated phase HCM was significantly higher in the patients with MACEs than those without MACEs (21% vs 0%, p=0.002). LV-ECV was the only significant predictor of MACEs based on the multivariate analysis by Cox proportional hazard model (hazard ratio 1.23, 95% confidence interval 1.09-1.41, P<0.001). The optimal threshold of LV-ECV to predict MACEs was 37.6% based on the receiver operating characteristic analysis. The sensitivity and specificity of LV-ECV to predict MACEs were 73% and 78% at the best cut-off, and the area under the curve was 0.79 (Figure A). The patients with LV-ECV ≥ 37.6% (30 patients) had significantly higher MACEs than those with LV-ECV < 37.6% during the follow-up periods (P < 0.001) (Figure B). Conclusion LV-ECV on CT of 37.6% is a good prognostic indicator in HCM cases. ECV analysis on CT helped predict MACEs in HCM cases.

Corrected timi frame count : time to replace the TIMI flow?

Abstract Background Thrombolysis In Myocardial Infarction (TIMI) flow grade had been widely accepted method for evaluating coronary artery perfusion following Percutaneous Coronary Intervention (PCI). Besides, TIMI flow used to predicts outcome in ST Elevation Acute Coronary Syndrome (STEACS) underwent Primary PCI (PPCI). However, its subjective nature has led to the exploration of more objective measures such as the Corrected TIMI Frame Count (CTFC), which quantifies coronary flow by counting the number of cine frames required for contrast to reach distal coronary landmarks. Purpose This study aims to assess the predictive value of CTFC in comparison with TIMI flow grades for clinical outcomes in STEACS undergoing PPCI, and whether CTFC could serve as a superior prognostic tool. Methods We retrospectively analyzed data from electronic medical record, involving STEACS patients underwent PPCI. Post-procedure, patient with TIMI flow grades 3, CTFC was measured. Patients were followed up during hospitalization for major adverse cardiac events (MACE), including death, myocardial infarction, and revascularization. Statistical analyses were performed to correlate CTFC with clinical outcomes. Result A total of 263 patients with TIMI flow 3 were analyzed, 54.5% patient with CTFC ≤27 and >27 respectively. MACE was 5.3% and 21% in the CTFC ≤27 and >27In the regression model analysis indicates a significant relationship between CTFC and MACE was found. The correlation coefficient (R) was observed at 0.417, with the model explaining 17.4% of the variance in MACE occurrence (R Square = .174), and an Adjusted R Square of .171, indicating a modest but significant predictive power. The ANOVA confirmed the model's statistical significance with an F value of 55.067 (p < .001). This suggests that CTFC is a significant predictor of MACE in patients post-PPCI with TIMI 3 flow, underscoring its potential utility in clinical prognostication. Conclusion CTFC appears to be a promising tool in assessing coronary flow post-PCI and may be considered as a additional for TIMI flow grading in predicting clinical outcomes in ACS patients. Further large-scale studies are warranted to validate these findings and to explore the integration of CTFC into clinical practice

Examining prognostic scores for short-term major adverse cardiovascular events prediction following primary PCI: a comparative analysis

Abstract Background Accurately predicting short-term MACE (major adverse cardiac events) following primary PCI remains a clinical challenge. This study aims to assess the effectiveness of four established risk scores in predicting short-term MACE after primary PCI (percutaneous coronary intervention). Methodology We enrolled a cohort of consecutive adult patients diagnosed with STEMI (ST elevation myocardial infarction) undergoing primary PCI in this prospective observational study. Patients were followed at the interval of 3 months up for up to 12 months, and MACE events were recorded. Additionally, we obtained TIMI, PAMI, CADILLAC, and GRACE scores. Results A total of 2839 patients (79.3% male, mean age 55.6 ± 11.2 years) were included. Over a median follow-up of 244 days, the composite MACE rate was 18.3% (519). All-cause mortality was 13.5% (384), re-infarction requiring revascularization was 4.3% (121), heart failure-related re-hospitalization was 2.6% (74), stent thrombosis occurred in 5.6% (160), and CVA (cerebrovascular accident) events were documented in 1% (28). The AUC (area under the curve) for TIMI, PAMI, CADILLAC, and GRACE scores were 0.658 [0.630-0.685], 0.658 [0.632-0.684], 0.669 [0.644-0.695], and 0.675 [0.649-0.701], respectively, for the prediction of MACE. On multivariable Cox regression, medium and high-risk categories based on GRACE score were independent predictors of MACE with adjusted HR (hazard ratio) of 1.52 [1.21-1.92]; p<0.001 and 1.92 [1.34-2.75]; p<0.001, respectively. Conclusion A significant proportion of patients experienced short-term MACE after primary PCI. While none of the assessed scores demonstrated significant predictive power, the GRACE score exhibited comparatively better predictive ability than TIMI, PAMI, and CADILLAC scores

Location-specific prognostic significance of plaque burden, stenosis, and plaque morphology in coronary artery disease

Abstract Background The prognostic significance of coronary plaque localization, percentage atheroma volume (PAV), stenosis, and plaque morphology has been underexplored. Purpose To investigate the prognostic significance of plaque localization beyond plaque burden, presence of stenosis and plaque morphology. Methods Patients with no cardiac history who underwent coronary CTA were included. PAV, maximum diameter stenosis, and plaque morphology were assessed and classified into proximal, mid, or distal segments of the coronary tree. Major adverse cardiac events (MACE) were defined as death or non-fatal myocardial infarction. Results Among 2819 patients 267 events (9.5%) occurred during a median follow-up of 6.9 years. PAV of the proximal segments was strongly correlated to PAV localized at of the mid (R= 0.76) and distal segments (R = 0.74, p < 0.01 for both). When adjusted for traditional risk factors and presence of plaque on other locations, only proximal PAV was independently associated with MACE (3rd quartile HR 2.08, 95% 1.17–3.71, p=0.01 and 4th quartile HR 2.29, 95% CI 1.21–4.34, p=0.01). Similar results were seen for presence of stenosis. Proximal, mid, and distal PAV as a solitary metric (unadjusted) had similar predictive value for MACE with an AUC of 0.73 (95% CI 0.69-0.76) for proximal PAV and 0.72 (95% CI 0.68-0.76) for both mid and distal localized plaque). Similar results were obtained using diameter stenosis instead of PAV. The presence of low-attenuation plaque (LAP) in the proximal segments had additional prognostic value. Calcified or noncalcified PAV did not provide additional value beyond total location-specific PAV and presence of low-attenuation plaque. Conclusions Proximal located PAV is an independent predictor of death and non-fatal MI, while there was no incremental prognostic value of plaque localized at the mid or distal coronary segments. The presence of LAP in the proximal segments provided additional prognostic value for prediction of MACE.

Left atrial volume assessed by echocardiography identifies patients with high risk of adverse outcome after acute myocardial infarction

BackgroundThe left atrial (LA) volume has been demonstrated to be an important predictor of adverse outcome in patients with various cardiac conditions, including acute myocardial infarction (AMI). However, new treatment strategies in patients with AMI have led to better patient outcomes. We hypothesised that increased LA size could still predict mortality in patients with AMI despite improved treatment strategies.MethodsWe included patients with AMI in a prospective multicenter cohort study and the study patients were enrolled from 2014 to 2022. We recorded echocardiographic and clinical data during their index hospitalisation. Indexed LA volume (LAVi) was assessed in all patients and was used as a continuous variable in the univariate and multivariate Cox regression analysis. The study took place over a period of five years and median follow-up time was 3.8 years (range 3.1 to 5.0 years). The primary study outcomes were all-cause mortality and major adverse cardiac events (MACE). MACE was defined as hospital readmission due to myocardial infarction, cardiac arrest, stroke, heart failure, or onset of new atrial fibrillation.ResultsWe included 487 patients (69 ± 12 years old, 26% female) with AMI. During the follow-up period all-cause mortality was 50 (10.3%) and patients who reached the primary outcomes were 153 (31.4%). The deceased patients had higher LAVi compared to survivors (40.0 ± 12.9 mL/m2 vs. 29.7 ± 11.2 mL/m2, p < 0.001). Factors associated with all-cause mortality and MACE were age, year of enrollment, left ventricular (LV) ejection fraction, LV global longitudinal strain (GLS), LV filling pressure, moderate or severe mitral regurgitation and LAVi. GLS and EF were segregated into two distinct models due to their moderately high correlation (r = 0.57, p < 0.001). LAVi remained as an independent echocardiographic predictor of primary outcomes after adjusting for the covariates above in two separates multivariable Cox regression models (hazard ratio 1.02/1.02 mL/m2 [95% CI 1.01–1.03/1.01–1.03], p = 0.006/0.003).ConclusionsOur study demonstrated that LA dilatation is an independent echocardiographic predictor of mortality and MACE in patients with AMI despite improved treatment strategies. This finding highlights the potential of using LAVi as a marker for prognostication in these patients.

Predictive role of peak VO2 for short- and long-term major adverse cardiac events in patients with high cardiovascular risk.

The objective of this study was to assess the accuracy of VO2 measurements in predicting long-term major adverse cardiac events (MACEs) in patients with high cardiovascular risk. Based on a10-year atherosclerotic cardiovascular disease risk score, 333 patients with high cardiovascular risk were included in this retrospective analysis. The study endpoint was MACEs, comprising all-cause mortality, cardiovascular mortality, non-fatal myocardial infarction or stroke, and coronary revascularization. The study cohort was divided into two groups according to the frequency of MACE occurrence. Measurements of VO2 were assessed for the prediction of MACEs. The best predictive accuracy for 1‑year MACEs was determined to be aVO2 max value of ≥ 20.3 mL/kg/min, with 60% specificity and 60% sensitivity (area under the curve [AUC]: 0.61; 95% confidence interval [CI]: 0.51-0.71; p < 0.001), and for 5‑year MACEs it was ≥ 19.9 mL/kg/min, with 69% specificity and 64% sensitivity (AUC: 0.69; 95% CI: 0.62-0.76; p < 0.001). Multivariable Cox regression analysis, after adjusting for univariable factors, showed that VO2 max was independently associated with both short- and long-term MACEs in patients at high cardiovascular risk (hazard ratio [HR]: 0.900, 95% CI: 0.858-0.943, p < 0.001). According to the results of this pilot study, VO2 max can predict both short- and long-term MACEs in patients at high cardiovascular risk.

Cardiac MRI in infarct-like myocarditis: transmural extension of late gadolinium enhancement is associated with worse outcomes

ObjectivesTo assess the prognostic value of cardiac MRI (CMR) parameters for the occurrence of major adverse cardiac events (MACE) in patients with infarct-like myocarditis.MethodsIn this retrospective single-center study, patients with CMR-confirmed acute myocarditis with infarct-like presentation were identified (2007–2020). Functional and structural parameters were analyzed including late gadolinium enhancement (LGE). The primary endpoint was the occurrence of MACE up to 5 years after discharge.ResultsIn total, 130 patients (mean age, 40 ± 19 years; 97 men, 75%) with infarct-like myocarditis were included. CMR was conducted a median of 3 days (interquartile range [IQR], 1–5) after symptom onset. MACE occurred in 18/130 patients (14%) during a median follow-up of 19.3 months (IQR, 4.5–53). The median extent of LGE was 7% (IQR, 4–10). LGE affected the subepicardium in 111/130 patients (85%), the midwall in 45/130 patients (35%), and both the subepicardium and midwall in 27/130 patients (21%). Transmural extension of non-ischemic LGE lesions was observed in 15/130 patients (12%) and septal LGE in 42/130 patients (32%). In univariable Cox regression analysis, a significant association was found between the occurrence of MACE and both, quantified LGE extent and transmural LGE pattern. In multivariable analysis, transmural extension of LGE was an independent predictor for MACE (hazard ratio, 6.34; 95% confidence interval: 2.29–17.49; p < 0.001). Patients with the transmural extension of LGE had a shorter event-free time on Kaplan–Meier analysis (log-rank p < 0.001).ConclusionsMACE occurred in 14% of patients with infarct-like myocarditis during follow-up. A transmural extension of non-ischemic LGE was associated with a worse long-term prognosis.Critical relevance statementCMR-based assessment of transmural extension of non-ischemic LGE holds the potential to serve as an easily assessable marker for risk stratification in patients with infarct-like myocarditis.Key PointsThe prognostic value of CMR was studied in patients with infarct-like myocarditis.The extent of LGE and transmural extension were linked to adverse cardiac events.Transmural non-ischemic LGE can serve as an easily assessable prognostic marker.Graphical

PROVISIONAL STENTING IN LEFT MAIN STEM DISEASE: LONG-TERM OUTCOMES AND IMPACT ON SIDE BRANCH PERFUSION

Left main stem disease (LMSD) is a severe form of coronary artery disease (CAD) that involves a significant risk of mortality if not treated effectively. Traditionally, coronary artery bypass grafting (CABG) has been the primary method for revascularization in LMSD. However, percutaneous coronary intervention (PCI), especially provisional stenting using drug-eluting stents (DES), has gained popularity for its minimal invasiveness and comparable clinical outcomes. Provisional stenting allows treatment of the main vessel with additional side branch stenting only when needed, reducing complications and stent usage. Objective: The primary objective of this study is to evaluate the long-term outcomes of provisional stenting in patients with LMSD, focusing on its impact on side branch perfusion, in-stent restenosis (ISR), and major adverse cardiac events (MACE). Methods: This retrospective cohort study was conducted at a tertiary care hospital specializing in cardiology between January 2023 and December 2023. A total of 284 patients who underwent provisional stenting for LMSD were included. Fractional flow reserve (FFR) and quantitative coronary angiography (QCA) were used to assess side branch perfusion, with follow-up data including clinical outcomes such as ISR, MACE, and survival rates. Multivariate regression analysis was used to identify predictors of poor outcomes, and Kaplan-Meier survival curves were generated to compare outcomes based on side branch perfusion status. Results: The study found that 77.5% of patients achieved adequate side branch perfusion (FFR &gt; 0.80) after provisional stenting, while 22.5% had impaired perfusion (FFR ≤ 0.80). The incidence of MACE was 10.6%, and ISR was reported in 7.0% of patients during the one-year follow-up period. Kaplan-Meier analysis showed a significant survival benefit for patients with adequate side branch perfusion (Log-Rank p &lt; 0.001). Age and diabetes mellitus were significant predictors of MACE. Conclusion: Provisional stenting in LMSD provides favourable long-term outcomes, particularly in terms of side branch perfusion and reduced MACE. However, a subset of patients, particularly those with diabetes, may require additional interventions. Future studies should focus on improving outcomes in patients with impaired side branch perfusion and exploring the role of advanced imaging techniques in optimizing stenting strategies.

Incremental prognostic value of 18F-FDG myocardial ischemic memory imaging for major adverse cardiovascular events in patients with suspected unstable angina

BackgroundThe additional prognostic value of 18F-FDG PET myocardial ischemic memory imaging for patients with suspected unstable angina (UA) is not well established. This study aimed to determine whether 18F-FDG PET imaging provides incremental prognostic information for predicting major adverse cardiac events (MACE) compared to clinical risk factors, GRACE score, and coronary artery calcium score (CACS) in suspected UA patients. MethodsIn this post-hoc analysis of a prospective study, 265 suspected UA patients (62.3% male, mean age 65.0±9.4 years) were enrolled. 18F-FDG positive was defined as focal or focal on diffuse uptake patterns. MACE included cardiovascular death, acute myocardial infarction, heart failure, rehospitalization for UA, and stroke. Multivariable Cox regression was used to identify predictors of MACE, and the incremental prognostic value of 18F-FDG PET imaging was assessed using C-index, net reclassification improvement (NRI), and integrated discrimination improvement (IDI). ResultsOver a median follow-up of 25 months, 51 patients (19.2%) experienced MACE. 18F-FDG positive (HR=3.220, 95% CI: 1.630-6.360, P<0.001) , as well as 18F-FDG standardized uptake ratio (SUR) (HR=1.330, 95%CI: 1.131-1.564, P=0.0006) and Extent (HR=1.045, 95%CI: 1.028-1.062, P<0.0001), were independent predictors of MACE. The addition of 18F-FDG PET imaging significantly improved risk stratification beyond clinical factors, the GRACE score, and CACS, with improved C-index (0.769 vs 0.688, P=0.045), NRI (0.324, P=0.020), and IDI (0.055, P=0.027). Conclusion18F-FDG PET myocardial ischemic memory imaging significantly improves prognostic assessment for suspected UA patients, providing valuable additional risk stratification beyond clinical risk factors, GRACE score, and CACS.

Dark papillary muscles sign is a new prognostic indicator in patients with dilated cardiomyopathy: A multi-center study

ObjectivesThe prognostic value of left ventricular (LV) papillary muscle anomalies in dilated cardiomyopathy (DCM) patients is unclear. The objective of this study was to evaluate the prognostic significance of LV papillary muscle anomalies in DCM patients using cardiac magnetic resonance (CMR). Methods369 DCM patients who underwent CMR at two Chinese medical facilities from January 2019 to June 2023 were retrospectively and consecutively included in total. The various features of the LV papillary muscles were taken into consideration: thickness, attachment, supernumerary papillary muscles, angles, and signal intensity. The end-systolic signal hypointensity of both papillary muscles in early post-contrast cine CMR images was identified as Dark-Paps. Major adverse cardiac events (MACEs) were assessed, and all patients were followed up. Results119 patients (32.2 %) had Dark-Paps and 141 patients (38.2 %) experienced MACE during a median follow-up of 22 months. According to Kaplan-Meier curve analysis, patients who had Dark-Paps had a lower survival rate free from MACE (log-rank, p < 0.001). Dark-Paps maintained an independent predictor of MACE in a multivariate model that included left ventricular ejection fraction (LVEF) and late gadolinium enhancement (LGE) extent (HR: 3.49; p < 0.001). Furthermore, adding Dark-Paps to the multivariate model greatly enhanced the prognostic role of endpoint events (C-statistic improvement: 0.652–0.777, Delong test: p < 0.001). ConclusionDark-Paps is a potent independent indicator of major adverse cardiac events in dilated cardiomyopathy patients. In addition, Dark-Paps can provide additional prognostic value over the multivariable baseline clinical model.

Myocardial contrast echocardiography evaluation of coronary microvascular dysfunction to Predict MACEs in patients with heart failure with preserved ejection fraction follow-up

BackgroundCMD refers to the abnormalities of the tiny arteries and capillaries within the coronary artery system, which result in restricted or abnormal blood flow. CMD is an important mechanism involved in ischemic heart disease and secondary heart failure. CMD can explain left ventricular dysfunction and poor prognosis.The European Association of Cardiovascular Imaging recommends the use of MCE for the assessment of myocardial perfusion. Myocardial contrast echocardiography (MCE) is used to evaluate the accuracy of Coronary microvascular dysfunction (CMD) for predicting major adverse cardiac events (MACEs) in patients with heart failure with preserved ejection fraction (HFpEF) at follow-up.MethodsThe clinical data of 142 patients diagnosed with HFpEF in our hospital from January 2020 to January 2022 were retrospectively summarized and stratified into 77 cases (> 1) in the CMD group and 65 cases (= 1) in the non-CMD group based on the perfusion score index (PSI) of the 17 segments of the left ventricle examined by the admission MCE, and the perfusion parameters were measured at the same time, including the peak plateau intensity (A value), the curve slope of the curve rise (βvalue) and A × β values. At a median follow-up of 27 months till October 2023, MACEs were recorded mainly including heart failure exacerbation, revascularization, cardiac death, etc.ResultsIncreasing age, hypertension, diabetes, and coronary artery disease in the CMD group resulted in decreased left ventricular ejection fraction (LVEF), increased plasma NT-B-type natriuretic peptide (BNP) and left ventricular global longitudinal strain (LVGLS), decreased A-values and A × β-values, and an increased incidence of MACEs (P < 0.05). Univariate and multivariate Cox regression analyses showed that LVGLS (HR = 1.714, 95% CI = 1.289–2.279, P < 0.001) and A × β values (HR = 0.636, 95% CI = 0.417 to 0.969, P = 0.035) were independent predictors of MACEs in patients with HFpEF. The receiver operating characteristic curve (ROC) showed that the area under the curve (AUC) of LVGLS combined with A × β value for diagnosis of MACEs was 0.861 (95% CI = 0.761 ~ 0.961, P < 0.001), which was significantly higher than that of LVGLS or A × β value (P < 0.05). The Kaplan-Meier survival curves showed that the cumulative survival rate in CMD group was significantly lower than non-CMD group (logrank χ2 = 6.626, P = 0.010), with the most significant difference at 20 months of follow-up.ConclusionMCE can evaluate CMD semi-quantitatively and quantitatively, LVGLS combined with A × β value has good performance in predicting the risk of developing MACEs in patients with HFpEF at 3 years of follow-up, and CMD can be used as an important non-invasive indicator for assessing clinical prognosis.

Prognostic value of transient ischemic dilatation by 13N-ammonia PET MPI for short-term outcomes in patients with non-obstructive CAD

Abstract Objective Transient ischaemic dilatation (TID) had incremental diagnostic and prognostic value in obstructive coronary artery disease (CAD), but its clinical significance in patients with non-obstructive CAD remains unknown. We aimed to explore the prognostic value of TID in patients with non-obstructive CAD by 13N-ammonia PET imaging. Methods We retrospectively studied 131 consecutive patients with non-obstructive CAD undergoing one-day rest-stress 13N-ammonia PET myocardial perfusion imaging (MPI). TID was automatically generated using CardIQ Physio software. The receiver operative characteristic (ROC) curve was used to determine the optimal threshold of TID. The follow-up outcome was major adverse cardiac events (MACE), a composite of re-hospitalization for heart failure or unstable angina, late revascularization, non-fatal myocardial infarction, and cardiac death. Cardiac event-free survivals for normal and abnormal TID were compared using Kaplan–Meier plots and log-rank tests. Results During a median follow-up of 42.08 ± 17.67 months, 22 (16.7%) patients occurred MACE. The optimal cut-off value of TID was 1.03 based on MACE. Our preliminary outcome analysis suggests that TID-abnormal subjects had a lower overall survival probability. Furthermore, our multivariate analysis reveals abnormal TID was the only independent predictor for MACE in non-obstructive CAD. In the subgroup analysis, an abnormal TID was an independent predictor for MACE in patients with abnormal perfusion patterns. Conclusion Among patients with non-obstructive CAD, PET-derived TID ≥ 1.03 may identify those with a high risk of subsequent MACE independently. It was also an independent risk factor for poor prognosis in patients with abnormal perfusion. Graphical abstract CAD coronary artery disease, PET positron emission tomography, MPI myocardial perfusion imaging, TID transient ischaemic dilatation, MACE major adverse cardiac events, ROC receiver operative characteristic.

Artificial intelligence-assisted measurements of coronary computed tomography angiography parameters such as stenosis, flow reserve, and fat attenuation for predicting major adverse cardiac events in patients with coronary arterial disease.

Advancements in artificial intelligence (AI) offer promising tools for improving diagnostic accuracy and patient outcomes in cardiovascular medicine. This study explores the potential of AI-assisted measurements in enhancing the prediction of major adverse cardiac events (MACE) in patients with coronary artery disease (CAD). We conducted a retrospective cohort study involving patients diagnosed with CAD who underwent coronary computed tomography angiography (CCTA). Participants were classified into MACE and non-MACE groups based on their clinical outcomes. Clinical characteristics and AI-assisted measurements of CCTA parameters, including CT-derived fractional flow reserve (CT-FFR) and fat attenuation index (FAI), were collected. Both univariate and multivariable logistic regression analyses were performed to identify independent predictors of MACE, which were used to build predictive models. Statistical analyses revealed three independent predictors of MACE: severe stenosis, CT-FFR ≤ 0.8, and mean FAI (P < 0.05). Seven predictive models incorporating various combinations of these predictors were developed. The model combining all three predictors demonstrated superior performance, as evidenced by the receiver operating characteristic (ROC) curve, with an area under the curve (AUC) of 0.811 (95% confidence interval [CI] 0.774 - 0.847), a sensitivity of 0.776, and a specificity of 0.726. Our findings suggest that AI-assisted CCTA analysis, particularly using fractional flow reserve (FFR) and FAI, could significantly improve the prediction of MACE in patients with CAD, thereby potentially aiding clinical decision making.

Systemic immune-inflammation index, and neutrophilto-lymphocyte and platelet-to-lymphocyte ratios can predict clinical outcomes in patients with acute coronary syndrome.

Inflammatory mechanisms play an important role in the pathogenesis of atherosclerosis and myocardial infarction. The clinical and prognostic importance of inflammatory parameters, such as neutrophil-lymphocyte (NLR) and platelet-lymphocyte ratios (PLR) in complete blood counts in acute myocardial infarction and other cardiovascular diseases has been demonstrated. However, systemic immune-inflammation index (SII) calculated from neutrophils, lymphocytes and platelets in the complete blood cell count has not been studied sufficiently and is thought to provide a better prediction. This study investigated whether haematological parameters such as SII, NLR and PLR were associated with clinical outcomes in acute coronary syndrome (ACS) patients. We included 1 103 patients who underwent coronary angiography for ACS between January 2017 and December 2021. The association between major adverse cardiac events (MACE) that developed in hospital and at 50 months of follow up and SII, NLR and PLR was compared. Long-term MACE were defined as mortality, re-infarction and target-vessel revascularisation. SII was calculated using the formula: NLR × total platelet count in the peripheral blood (per mm3). Of the 1 103 patients, 403 were diagnosed with ST-elevation myocardial infarction and 700 with non-STelevation myocardial infarction. The patients were divided into a MACE and a non-MACE group. In hospital and during the 50-month follow up, 195 MACE were observed. SII, PLR and NLR were found to be statistically significantly higher in the MACE group (p < 0.001). SII, C-reactive protein level, age and white blood cell count were independent predictors of MACE in ACS patients. SII was found to be a strong independent predictor of poor outcomes in ACS patients. This predictive power was greater than that of PLR and NLR.

Efficacy of revascularization in CTO patients based on hibernating myocardium therapy.

The effectiveness of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) is still uncertain, especially for patients with ischemic left ventricular dysfunction. This study aimed to assess hibernating myocardium (HM), as determined by single-photon emission computed tomography (SPECT) and 18F-FDG positron emission tomography (PET), and to compare the benefits of PCI and optimal medical therapy (OMT). A retrospective study collected data from 332 patients with CTO and ischemic left ventricular dysfunction. The study compared patients who underwent PCI or OMT via propensity score matching (PSM) analysis which was performed with a 1:2 matching protocol using the nearest neighbour matching algorithm. The primary endpoint of the study was the occurrence of major adverse cardiac events (MACE), defined as a composite of cardiac death, readmission for worsening heart failure (WHF), revascularization and myocardial infarction (MI). After PSM, there were a total of 246 individuals in the PCI and OMT groups. Following Cox regression, hibernating myocardium/total perfusion defect (HM/TPD) was identified as an independent risk factor (hazard ratio (HR): 1.03, 95% confidence interval (CI): 1.008-1.052, p = .007). The cut-off value of HM/TPD was 38%. The results of the subgroup analysis suggest that for patients with HM/TPD >38%, the OMT group had a greater risk of MACE (p = .035). A sensitivity analysis restricting patients with single-vessel CTO lesions, HM/TPD remained an independent predictor (HR 1.025, 95% CI 1.008-1.043, p = .005). HM/TPD is an independent predictor of MACE, and for patients with HM/TPD > 38%, CTO-PCI had a lower risk of MACE compared with OMT. However, further validation is still needed through large-scale studies.

Location-Specific Prognostic Significance of Plaque Burden, Stenosis, and Plaque Morphology in Coronary Artery Disease.

To investigate the location-specific prognostic significance of plaque burden, diameter stenosis and plaque morphology. Patients without a documented cardiac history who underwent coronary computed tomography angiography (CCTA) for suspected coronary artery disease were included. Percentage atheroma volume (PAV), maximum diameter stenosis, and plaque morphology were assessed and classified into proximal, mid, or distal segments of the coronary tree. Major adverse cardiac events (MACE) were defined as death or non-fatal myocardial infarction. Among 2819 patients 267 events (9.5%) occurred during a median follow-up of 6.9 years. When adjusted for traditional risk factors and presence of PAV on other locations, only proximal PAV was independently associated with MACE. However, PAV of the proximal segments was strongly correlated to PAV localized at the mid (R= 0.76) and distal segments (R=0.74, p<0.01 for both). When only adjusted for cardiovascular risk factors, the area under the curve (AUC) to predict MACE for proximal PAV was 0.73 (95%CI 0.69-0.76), which was similar compared to mid PAV (AUC 0.72, 95%CI 0.68-0.76) and distal PAV (AUC 0.72, 95%CI 0.68-0.76). Similar results were obtained using diameter stenosis instead of PAV. The presence of proximal low-attenuation plaque had borderline additional prognostic value. Proximal PAV was the strongest predictor of MACE when adjusted for cardiovascular risk factors and plaque at other locations. However, when presence of plaque was only adjusted for cardiovascular risk factors, proximal, mid, and distal plaque localization showed a similar predictive ability for MACE.

Long-term prognostic value of CT-based high-risk coronary lesion attributes and radiomic features of pericoronary adipose tissue in diabetic patients

To investigate the long-term prognostic value of coronary computed tomography angiography (CCTA)-derived high-risk attributes and radiomic features of pericoronary adipose tissue (PCAT) in diabetic patients for predicting major adverse cardiac event (MACE). Diabetic patients with intermediate pre-test probability of coronary artery disease were prospectively enrolled and referred for CCTA. Three models (model-1 with clinical parameters; model-2 with clinical factors+CCTA imaging parameters; model-3 with the above parameters and PCAT radiomic features) were developed in the training cohort (835 patients) and tested in the independent validation cohort (557 patients). 1392 patients were included and MACEs occurred in 108 patients (7.8%). Multivariable Cox regression analysis revealed that HbA1c, coronary calcium Agatston score, significant stenosis and high-risk plaque were independent predictors for MACE whereas none of PCAT radiomic features showed predictive value. In the training cohort, model-2 demonstrated higher predictive performance over model-1 (C-index=0.79 vs. 0.68, p < 0.001) whereas model-3 did not show incremental value over model-2(C-index=0.79 vs. 0.80, p = 0.408). Similar findings were found in the validation cohort. The combined model (clinical and CCTA high-risk anatomical features) demonstrated high efficacy in predicting MACE in diabetes. PCAT radiomic features failed to show incremental value for risk stratification.

Prognostic Value of Coronary Angiography–Derived Index of Microcirculatory Resistance in Non–ST-Segment Elevation Myocardial Infarction Patients

BackgroundThe index of microcirculatory resistance is a reliable measure for evaluating coronary microvasculature, but its prognostic value in patients with non–ST-segment elevation myocardial infarction (NSTEMI) remains unclear. ObjectivesThis study aimed to evaluate the prognostic impact of postpercutaneous coronary intervention (PCI) angiography-derived index of microcirculatory resistance (angio-IMR) in patients with NSTEMI. MethodsThe culprit vessel’s angio-IMR was measured after PCI in 2,212 NSTEMI patients at 3 sites. The primary endpoint was 2-year major adverse cardiac events (MACEs), defined as a composite of cardiac death, readmission for heart failure, myocardial reinfarction, and target vessel revascularization. ResultsThe mean post-PCI angio-IMR was 20.63 ± 4.17 in NSTEMI patients. A total of 206 patients were categorized as the high post-PCI angio-IMR group according to maximally selected log-rank statistics. Patients with angio-IMR >25 showed a higher rate of MACEs than those with angio-IMR ≤25 (32.52% vs 9.37%; P < 0.001). Post-PCI angio-IMR >25 was an independent predictor of MACEs (HR: 4.230; 95% CI: 3.151-5.679; P < 0.001) and showed incremental prognostic value compared with conventional risk factors (AUC: 0.774 vs 0.716; P < 0.001; net reclassification index: 0.317; P < 0.001; integrated discrimination improvement: 0.075; P < 0.001). ConclusionsIn patients undergoing PCI for NSTEMI, an increased post-PCI angio-IMR is associated with a higher risk of MACEs. The addition of post-PCI angio-IMR into conventional risk factors significantly improves the ability to reclassify patients and estimate the risk of MACEs. (Angiograph-Derived Index of Microcirculatory Resistance in Patients With Acute Myocardial Infarction; NCT05696379)