Predictor Of Ischemic Events Research Articles

Predictors of ischemic and hemorrhagic complications in patients with myocardial infarction at 18-month follow-up: a single-center registry study

Aim. To identify predictors of ischemic and hemorrhagic events in patients with myocardial infarction (MI) after 18 months of follow-up.Material and Methods. The single-center prospective study included 478 patients with MI. The exclusion criteria were as follows: age < 18 years; MI as a complication of myocardial revascularization; atrial fibrillation; intake of anticoagulants after MI. During inpatient treatment, the risk of ischemic and hemorrhagic events was calculated according to the PRECISE-DAPT score, GRACE hospital discharge risk score, CRUSADE bleeding score. After 18 months, we evaluated the rate of ischemic (cardiovascular death, unstable angina, life-threatening arrhythmia, non-fatal MI and stroke, acute decompensated heart failure, elective repeated and/ or emergency revascularization) and haemorrhagic events and the amount of corresponding therapy.Results. At 18 months post-MI, patients were at high risk of developing both ischemic events (cardiovascular death: 32.0%; recurrent MI: 16.3%; repeated myocardial revascularization: 18.5%; unstable angina: 13.8%; stroke: 3.6%) and hemorrhagic events (bleeding rate of 39.7% according to the TIMI score), most of which occurred during the first 12 months post-MI. Double antiplatelet therapy (DAPT) was prescribed to 86.5% patients upon discharge (including a triple antithrombotic therapy in 8.6% patients). Patient adherence to treatment was 66.7% and 60.6% at 6 and 12 months of follow-up, respectively. After 18 months, DAPT was prescribed exclusively to patients suffered from recurrent ischemic events or those who underwent repeated myocardial revascularization (17.4% patients in total). The main reason to cancel DAPT was bleeding, although it was minor in most cases. Predictors of ischemic events (fatal and non-fatal) at 18 months of follow-up were PRECISE- DAPT score (odds ratio (OR) = 1.108, 95% confidence interval (CI) = 1.054-1.164, р < 0.001), GRACE score (OR = 1.032, 95% CI = 1.016-1.048, р < 0.001), left ventricular ejection fraction (LVEF) < 40% (OR = 4.256, 95% CI = 1.510-12.001, р = 0.006). Predictors of hemorrhagic events at 18-month follow-up were PRECISE-DAPT score (OR = 1.025, 95% CI = 1.009-1.041, р = 0.002), peripheral artery disease (PAD) (OR = 2.459, 95% CI = 1.365-4.428, р = 0.003), intake of sulfonylurea for diabetes mellitus (OR = 2.523, 95% CI = 1.266-5.028; р = 0.009), unsuccessful percutaneous coronary intervention (PCI) or conservative treatment of MI (OR = 3.792, 95% CI = 1.799-7.996, р < 0.001).Conclusion. Predictors of ischemic events (fatal and non-fatal) in the long-term period after MI include PRECISE-DAPT and GRACE scores, and LVEF below 40%. Predictors of hemorrhagic events at 18-month follow-up were PRECISE- DAPT scores, PAD, taking sulfonylurea for diabetes mellitus, unsuccessful PCI or conservative treatment of MI.

Cerebral oximetry monitoring by means of INVOS-4100 as a predictor of ischemic events during carotid endarterectomy.

Several methods have been proposed to monitor cerebral perfusion during carotid endarterectomy (CEA), with the purpose of minimizing the risk of perioperative stroke. The INVOS-4100 is able to detect cerebral oxygen saturation providing an intraoperative real-time monitoring system of cerebral oximetry. The aim of this study was to evaluate the performance of the INVOS-4100 in predicting cerebral ischemia during CEA. Between January 2020 and May 2022, 68 consecutive patients were scheduled for CEA either under general anesthesia or regional anesthesia with deep and superficial cervical block. Vascular oxygen saturation was recorded continually through INVOS before and during clamping of the ICA. Awake testing was performed in the group of patients undergoing CEA under regional anesthesia. Sixty-eight patients were included; 43 were males (63.2%). Severe stenosis of the artery was present in 92%. Forty-one (60.3%) patients were monitored by INVOS, while 22 (39.7%) underwent awake testing. Mean clamping time was 20 ± 6.6 min. Patients undergoing awake testing had a lower hospital stay and ICU stay during admission (p = 0.011 and p = 0.007 respectively). Comorbidities correlated with a higher ICU stay (p < 0.05). The INVOS monitoring was able to predict ischemic events with a sensitivity of 98% (AUC = 0.976). The present study demonstrates that cerebral oximetry monitoring was a strong predictor of cerebral ischemia, although it was not possible to determine the non-inferiority of cerebral oximetry compared to awake testing. Nonetheless, the use of cerebral oximetry evaluates only perfusion in the superficial brain tissue and an absolute rSO2 value corresponding to significant cerebral ischemia has not been established. Therefore, larger prospective studies that correlate cerebral oximetry with neurologic outcomes are needed.

Coronary Stenting in High Bleeding Risk Patients With Small Coronary Arteries Followed by One-Month Dual Antiplatelet Therapy: Onyx ONE Clear.

Small reference vessel diameters (RVDs) are a predictor of ischemic events after coronary stenting. Among patients at high bleeding risk (HBR) precluding long-term dual antiplatelet therapy (DAPT), those with small vessel disease (SVD) constitute an especially high-risk subgroup. Here, we evaluated the results of a durable-polymer, coronary zotarolimus-eluting stent (ZES) for the treatment of patients with SVD at HBR with 1-month DAPT. In the prospective, multicenter Onyx ONE (One-Month DAPT) Clear study, 1506 patients at HBR treated with a ZES that discontinued DAPT at 30 days were included. The clinical outcomes of patients undergoing treatment of lesions with an RVD of ≤2.5 mm (SVD group, as determined by the angiographic core laboratory) were compared with patients without SVD. The primary end point was the composite of cardiac death or myocardial infarction between 1 and 12 months. Small vessel diameter treatment was performed in 489 (32.5%) patients. Patients with SVD were more likely to be women, have undergone a previous percutaneous intervention, and have multivessel coronary artery disease than patients without SVD. There were no significant differences in lesion, device, or procedural success between the groups. The Kaplan-Meier rate estimate of the primary end point was 8.5% and 6.8% in patients with SVD and those without SVD, respectively (P = .425). No significant differences were found in any secondary end point. The Kaplan-Meier rate of stent thrombosis was 0.6% and 0.8% in patients with SVD and those without SVD, respectively (P = .50). Among patients at HBR treated with a ZES and 1-month DAPT, those with SVD had favorable 12-month ischemic and bleeding outcomes, which were comparable with those of patients with larger caliber vessels.

Association of fluid-attenuated inversion recovery vascular hyperintensity with ischaemic events in internal carotid artery or middle cerebral artery occlusion

Background and purposeIndividuals with intracranial artery occlusion have high rates of ischaemic events and recurrence. It has been challenging to identify patients who had high-risk stroke using a simple, valid...

Predictors of ischemic events in patients with unilateral extracranial vertebral artery dissection: A single-center exploratory study.

ObjectiveExtracranial vertebral artery dissection (EVAD) is one of the main causes of stroke in young and middle-aged patients. However, the diagnosis is challenging. This study aimed to identify the characteristics of EVAD on color duplex ultrasonography (CDU) and high-resolution magnetic resonance imaging (hrMRI), hoping to improve the accuracy and determine the relative contribution of vessel findings and clinical factors to acute ischemic events.MethodsPatients with unilateral EVAD were recruited and divided into ischemia and non-ischemia groups. Clinical features of patients and the lesion location; a variety of signs which indicate dissection, including the presence of an intimal flap, double lumen, intramural hematoma, dissecting aneurysm, intraluminal thrombus, and irregular lumen; and other quantitative parameters of each dissected segment on CDU and hrMRI were reviewed, respectively. Multiple logistic regression was performed to explore the association between clinical, imaging characteristics, and ischemic events in patients with unilateral EVAD.ResultsNinety-six patients with unilateral EVAD who met the inclusion criteria were enrolled during a six-year period. Overall, 41 cases (42.7%) were confirmed as ischemic stroke (n = 40) or transient ischemic attack (n = 1) during the 48 h after the onset of symptoms. Men, infections during the last week, and smoking were more common in the ischemia group. Intraluminal thrombus and occlusion on CDU were more prevalent in patients with cerebral ischemia than in those without (36.6 vs. 5.5%; p < 0.001, and 39.0 vs. 9.1%; p = 0.001, respectively). On hrMRI, intraluminal thrombus and occlusion were also more frequent in the ischemia group than in the non-ischemia group (34.1 vs. 5.5%; p < 0.001, and 34.1 vs. 9.1%; p = 0.003, respectively). In addition, lesion length on hrMRI was significantly longer for patients with ischemia (81.5 ± 41.7 vs. 64.7 ± 30.8 mm; p = 0.025). In multivariable logistic regression analysis, male gender, infections during the last week, and the presence of intraluminal thrombus on CDU and hrMRI were independently associated with acute ischemic events.ConclusionMale sex, infections during the last week, and the presence of intraluminal thrombus due to dissection are associated with an increased risk of ischemic events in patients with unilateral EVAD.

Impact of renal function on the prognostic value of mineral metabolism in patients with chronic ischaemic heart disease patients with chronic ischaemic heart disease

BackgroundParathormone (PTH) is a component of the Mineral Metabolism (MM) system that has been shown recently to add prognostic value in pts. with stable coronary artery disease (SCAD) and average renal function. However, the influence of renal function on the prognostic role of PTH in pts. with SCAD has not been shown yet. PurposeTo assess the influence of estimated glomerular filtration rate (eGFR) on the prognostic role of PTH and other MM markers in pts. with SCAD. MethodsWe analyzed the prognostic value of MM markers (PTH, klotho, phosphate, calcidiol [25-hydroxyvitamin D], and fibroblast growth factor-23 [FGF-23]) in 964 pts. with SCAD and eGFR < 60 mL/min/1.73 m2 (LGFR) vs pts. with eGFR ≥ 60 mL/min/1.73 m2 (HGFR) included in five hospitals of Madrid. The main outcome was the combination of death with ischemic events (any acute coronary syndrome, ischemic stroke or transient ischemic attack). eGFR was calculated by the Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI). ResultsAge was 60.0 (52.0–72.0) years, 76.2% of patients were men, and eGFR was 80.4 (65.3–93.1) ml/min/1,73 m2. Median follow-up was 5.39 (2.81–6.92) years. There were 790 pts. with HGFR and 174 with LGFR. In HGFR pts., predictors of ischemic events or death were plasma levels of calcidiol [HR = 0.023 (0.94−0.99) P = .023], FGF-23 [HR = 1.00 (1.00–1.003) P = .036], non-HDL cholesterol [HR = 1.01 (1.00−1.01) P = .026] and high sensitivity troponin I [HR = 5.12 (1.67–15.59) P = .004], along with age [HR = 1.03 (1.01−1.05) P = .01], treatment with statins [HR = 0.36 (0.19−0.68) P = .002], nitrates [HR = 1.13 (1.07−2.79) P = .027], dihydropyridines [HR = 1.71 (1.05−2.77) P = .032], verapamil [HR = 5.71 (1.35–24.1) P = .018], and proton-pump inhibitors [HR = 2.23 (1.36−3.68) P = .002]. In the LGFR subgroup, predictors of death or ischemic events were PTH plasma levels, [HR = 1.01 (1.00−1.01) P = .005], eGFR [HR = 0.96 (0.94−0.99) P = .004], age [HR = 1.06 (1.02−1.10) P = .003], caucasian race [HR = 0.04 (0.004−0.380) P = .005], and treatment with insulin [HR = 2.6 (1.20–5.63) P = .015]. ConclusionsIn pts. with SCAD, PTH is an independent predictor of poor outcomes only in those with eGFR < 60 mL/min/1.73 m2, while in pts. with eGFR ≥ 60 mL/min/1.73 m2 calcidiol and FGF-23 become the only components of MM that may predict prognosis. Then, renal function influences the predictive power of MM markers in pts. with SCAD.

Impacto de la función renal en el valor pronóstico del metabolismo mineral en pacientes con cardiopatía isquémica crónica

BackgroundParathormone (PTH) is a component of the Mineral Metabolism (MM) system that has been shown recently to add prognostic value in pts. with stable coronary artery disease (SCAD) and average renal function. However, the influence of renal function on the prognostic role of PTH in pts. with SCAD has not been shown yet. PurposeTo assess the influence of estimated glomerular filtration rate (eGFR) on the prognostic role of PTH and other MM markers in pts. with SCAD. MethodsWe analyzed the prognostic value of MM markers (PTH, klotho, phosphate, calcidiol [25-hydroxyvitamin D], and fibroblast growth factor-23 [FGF23]) in 964 pts. with SCAD and eGFR<60ml/min/1.73 m2 (LGFR) vs pts. with eGFR≥60ml/min/1.73 m2 (HGFR) included in five hospitals of Madrid. The main outcome was the combination of death with ischemic events (any acute coronary syndrome, ischemic stroke or transient ischemic attack). eGFR was calculated by the Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI). ResultsAge was 60.0 (52.0-72.0) years, 76.2% of patients were men, and eGFR was 80.4 (65.3-93.1) ml/min/1,73 m2. Median follow-up was 5.39 (2.81-6.92) years. There were 790 pts. with HGFR and 174 with LGFR. In HGFR pts., predictors of ischemic events or death were plasma levels of calcidiol [HR=0.023 (0.94-0.99) p=0.023], FGF23 [HR=1.00 (1.00-1.003) p=0.036], non-HDL cholesterol [HR=1.01 (1.00-1.01) p=0.026] and high sensitivity troponin I [HR=5.12 (1.67-15.59) p=0.004], along with age [HR=1.03 (1.01-1.05) p=0.01], treatment with statins [HR=0.36 (0.19-0.68) p=0.002], nitrates [HR=1.13 (1.07-2.79) p=0.027], dihydropyridines [HR=1.71 (1.05-2.77) p=0.032], verapamil [HR=5.71 (1.35-24.1) p=0.018], and proton-pump inhibitors [HR=2.23 (1.36-3.68) p= 0.002]. In the LGFR subgroup, predictors of death or ischemic events were PTH plasma levels, [HR=1.01 (1.00-1.01) p=0.005], eGFR [HR=0.96 (0.94-0.99) p=0.004], age [HR=1.06 (1.02-1.10) p=0.003], caucasian race [HR=0.04 (0.004-0.380) p=0.005], and treatment with insulin [HR=2.6 (1.20-5.63) p=0.015]. ConclusionsIn pts. with SCAD, PTH is an independent predictor of poor outcomes only in those with eGFR<60ml/min/1.73 m2, while in pts. with eGFR≥60ml/min/1.73 m2 calcidiol and FGF23 become the only components of MM that may predict prognosis. Then, renal function influences the predictive power of MM markers in pts. with SCAD.

Abstract 11883: Mineral Metabolism Predictors of Poor Outcomes in Stable Coronary Artery Disease With and Without Impaired Renal Function

Background: Parathormone (PTH) is a component of the Mineral Metabolism (MM) system that has been shown recently to add prognostic value in stable coronary artery disease (SCAD) and average renal function. However, the influence of renal function on the prognostic role of PTH in pts with SCAD has not been shown yet. Our aim is to assess the influence of estimated glomerular filtration rate (eGFR) on the prognostic role of PTH and other MM markers in pts. with SCAD. Methods: We analyzed the prognostic value of MM markers (PTH, klotho, phosphate, calcidiol [25-hydroxyvitamin D3], and fibroblast growth factor-23 [FGF-23]) in 964 pts. with SCAD and eGFR&lt;60 ml/min/1.73 m2 (LGFR) vs pts. with eGFR≥60 ml/min/1.73 m2 (HGFR) included in five hospitals of Spain. The main outcome was the combination of death with ischemic events (any acute coronary syndrome, ischemic stroke or transient ischemic attack). eGFR was calculated by the Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI). Results: There were 790 pts. with HGFR and 174 with LGFR. Median follow-up was 5.1 years. In HGFR pts., predictors of ischemic events or death were plasma levels of calcidiol [HR= 0.023 (0.94-0.99) p=0.023], FGF23 [HR= 1.00 (1.00-1.003) p=0.036], non-HDL cholesterol [HR= 1.01 (1.00-1.01) p=0.026] and high sensitivity troponin [HR= 5.12 (1.67-15.59) p= 0.004], along with age [HR= 1.03 (1.01-1.05) p=0.01], treatment with statins [HR=0.36 (0.19-0.68) p=0.002], nitrates [HR= 1.13 (1.07-2.79) p=0.027], dihydropyridines [HR= 1.71 (1.05-2.77) p= 0.032], verapamil [HR= 5.71 (1.35-24.1) p= 0.018], and Proton-pump inhibitors [HR= 2.23 (1.36-3.68) p= 0.002]. In the LGFR subgroup, predictors of death or ischemic events were PTH plasma levels, [HR=1.01 (1.00-1.01) p=0.005], the eGFR [HR=0.96 (0.94-0.99) p=0.004], age [HR=1.06 (1.02-1.10) p=0.003], caucasian race [HR=0.04 (0.004-0.380) p=0.005], and treatment with insulin [HR=2.6 (1.20-5.63) p=0.015]. Conclusions: In pts. with SCAD, PTH is an independent predictor of poor outcomes only in those with eGFR&lt;60 ml/min/1.73 m2 , while in pts. with eGFR≥60 ml/min/1.73 m2 calcidiol and FGF-23 become the only components of MM that may predict prognosis. Then, renal function influences the predictive power of MM markers in pts. with SCAD.

Impact of Atrial Fibrillation type in Acute Coronary Syndrome and the antithrombotic strategy

Abstract Funding Acknowledgements Type of funding sources: None. INTRODUCTION Atrial fibrillation (AF) is an adverse prognostic factor during acute coronary syndrome (ACS). Current evidence recommends dual antithrombotic therapy (DAT), 1 antiplatelet drug and 1 anticoagulant drug, as the default strategy after nonST elevation ACS. AIM To identify the clinical differences and prognosis of AF type-new onset (nAF) or pre-existing (pFA)- during ACS, to evaluate antithrombotic strategy at hospital discharge (HD) and its impact on haemorrhagic and ischemic events. METHODS We performed a retrospective observational cohort study including 3241 patients (pts) with ACS (mean age 64 years, 77.5% male) admitted to a single center over a 6-year period, with 12-months follow-up. RESULTS AF rhythm was identified in 11.2% pts, of whom 63.2% presented nAF and 36.8% pAF. When AF types where compared, pts with pAF had a higher prevalence of cardiovascular (Cv) comorbidities, including hypertension (p &amp;lt; 0.001), previous ACS (p = 0.03), valvular disease (p = 0.01) or stroke (p = 0.05), had greater left atrial diameter (p &amp;lt; 0.001) and were less likely to have significant coronary lesions (p = 0.05). Pts with nAF more frequently presented with STelevation ACS (p &amp;lt; 0.001) and had a lower Hemoglobin nadir (p &amp;lt; 0.001). The independent predictors of nAF in ACS were age (OR 1.1, p&amp;lt; =0.001), LVEF ≤ 40% (OR 2.2, p = 0.001), STelevation ACS (OR 2.6, p&amp;lt; =0.001) and previous valvular disease (OR 3.5, p&amp;lt; =0.01). Compared with the population without AF, nAF was a predictor of in-hospital death (OR 2.9, p = 0.027) and in-hospital composite endpoint (death, stroke, reinfarction and cardiogenic shock) (OR 2.5, p = 0.001) in multivariate analysis, but pAF wasn’t. During 12-months follow-up of pts with ACS and AF, there was no difference regarding death or follow-up composite endpoint (death, stroke and ACS) between the AF types.Regarding antithrombotic therapy, nAF pts were less often anticoagulated (p &amp;lt; 0.001) and pAF pts where more often treated with triple antithrombotic therapy (TAT) at HD (&amp;lt;0.001). Most of the pts with TAT stopped the second antiplatelet at agent 6-months (43.8%) or 12 months (25.5%) after HD. During 12-months follow-up, pts discharged with TAT had trend towards more haemorrhagic events (TAT 6.2% vs DAT2.7%,p = 0.69) and both groups had similar ischaemic events (death, ACS, stroke) (TAT 20.9% vs DAT23.7%,p = 0.714). In multivariate analysis the choice of TAT or DAT wasn’t a predictor of ischaemic events. CONCLUSIONS In ACS, pts with nAF had worst in-hospital outcomes than pts with pAF. Regarding antithrombotic strategy at HD pts with nFA were less often anticoagulated and less often treated with TAT. In our study the choice between DAT or TAT had no statistical impact on follow-up outcomes.

Abstract P706: Age and Elevated Coronary Artery Calcium Score as a Predictor of Cerebral Ischemic Events

Introduction: Coronary artery calcium (CAC) score is a good predictor of coronary plaque burden and cardiovascular events, however its role in ischemic stroke and transient ischemic attacks (TIA) has been sparsely studied. Methods: Participants age ≥18 years with heart screen done from Nov 2008- Feb 2019 were selected and were assessed for documented Ischemic events (Ischemic stroke and TIA) after their heart screen. Only the most recent heart screen per person was considered. Patients were further divide into two groups based on their age. Comparisons between the two age groups was done using chi-square for categorical variables. Logistic regression was used to assess age and CAC as predictors of ischemic events and ROC curves were formed. Results: A total of 330896 individuals were included in the study over a span of 10 years, of which 53.9% were females. 894 (0.2%) patients were observed to have a documented diagnosis of ischemic stroke or TIA. Older patients (Age ≥50) were found to have significantly higher percentage of ischemic events as compared to young patients (3.5% vs 0.9%, p&lt;0.001), which was also observed among various CAC groups. There was also a significant difference in distribution of CAC where older patients had higher CAC even when splitting the cohort into distinct CAC categories (P &lt;0.001). On regression analysis elevated CAC and age were found to be a good predictors of ischemic events. Predictability of cerebrovascular ischemic events was significantly higher when elevated CAC score and patient age were considered together as compared age and CAC alone (P&lt;0.001). Conclusion: Elevated coronary artery calcium score and age are a good predictor of ischemic stroke and TIA.

Carotid intraplaque haemorrhage: pathogenesis, histological classification, imaging methods and clinical value

Vulnerable carotid atherosclerotic plaques are characterised by several risk factors, such as inflammation, neovascularization and intraplaque haemorrhage (IPH). Vulnerable plaques can lead to ischemic events such as stroke. Many studies reported a relationship between IPH, plaque rupture, and ischemic stroke. Histology is the gold standard to evaluate IPH, but it required carotid endarterectomy (CEA) surgery to collect the tissue sample. In this context, several imaging methods can be used as a non-invasive way to evaluate plaque vulnerability and detect IPH. Most imaging studies showed that IPH is associated with plaque vulnerability and stroke, with magnetic resonance imaging (MRI) being the most sensitive and specific to detect IPH as a predictor of ischemic events. These conclusions are however still debated because of the limited number of patients included in these studies; further studies are required to better assess risks associated with different IPH stages. Moreover, IPH is implicated in plaque vulnerability with other risk factors which need to be considered to predict ischemic risk. In addition, MRI sequences standardization is required to compare results from different studies and agree on biomarkers that need to be considered to predict plaque rupture. In these circumstances, IPH detection by MRI could be an efficient clinical method to predict stroke. The goal of this review article is to first describe the pathophysiological process responsible for IPH, its histological detection in carotid plaques and its correlation with plaque rupture. The second part will discuss the benefits and limitations of imaging the carotid plaque, and finally the clinical interest of imaging IPH to predict plaque rupture, focusing on MRI-IPH.

Transcranial Doppler as a Predictor of Ischemic Events in Vertebral Artery Dissection.

Transcranial Doppler (TCD) helps identify patients with carotid dissections at risk of ischemic events (IEs). There is paucity of data identifying independent predictors of IE in vertebral arterial dissection (VAD). We sought to investigate the clinical and ultrasound predictors of IE. Patients with VAD admitted between June 2017 and February 2020 were evaluated clinically and with TCD; sonographic curves, microembolic signals (MES), and the breath-holding index (BHI) test were applied. Covariates found on univariate screen (P < .25) were included in a multivariable linear regression to identify independent predictors of IEs. Of 88 patients with 100 VAD, 75 (85.2%) were females with a mean age 37.9 ± 7.5 years. All patients received antiplatelet treatment. TCD monitoring lasted an average of 21 ± 2.1 minutes. TCD was abnormal in 23 cases (26.1%); 21 patients had abnormal sonographic curves in the vertebral/basilar arteries, while in 4 cases, MES were present and in 5 (4.5%), BHI was abnormal. None of the patients with a normal TCD had an IE. Six strokes occurred during follow up. On univariate analysis, male sex, diabetes, dyslipidemia, a previous myocardial infarct, migraine, time of consultation to the ER, bilateral VAD, MES, BHI abnormalities, post stenotic flow in the basilar artery (PFB), and basilar/vertebral velocities were significantly associated with the risk of IEs. In the multivariate analysis, only the presence of PFB was a significant predictor of IE (OR: 68.6, 95% CI 5-937, <.001). TCD in VAD predicts patients at high risk of IE.

Prediction of Ischemic and Bleeding Events Using the Dual Antiplatelet Therapy Score in an Unrestricted Percutaneous Coronary Intervention Population.

The dual antiplatelet therapy (DAPT) risk score was developed from the DAPT trial to inform the optimal duration of DAPT after percutaneous coronary intervention. We assessed the performance of the DAPT score in the ADAPT-DES (Assessment of Dual AntiPlatelet Therapy with drug-eluting stents) all-comers registry and tested the utility of additional predictors of adverse events. Outcomes between 1 and 2 years were examined according to DAPT score ≥2 versus <2, adjusted for DAPT continuation as a time-dependent variable. To assess the incremental utility of variables not included in the DAPT score, baseline high platelet reactivity was added to the ischemia model, and high platelet reactivity, baseline hemoglobin, and warfarin use 1 year after percutaneous coronary intervention were added to the bleeding model. Among 8582 patients enrolled in ADAPT-DES, 5397 were event-free after 1 year. Between 1 and 2 years, ischemic (myocardial infarction or stent thrombosis) and bleeding events occurred in 75 (1.5%) and 124 (2.3%) patients, respectively. Patients with higher DAPT scores (≥2 versus <2) had higher rates of myocardial infarction or stent thrombosis (1.9% versus 1.1%; P=0.01) and similar rates of bleeding (2.2% versus 2.4%, respectively; P=0.79). For the prediction of myocardial infarction or stent thrombosis, bleeding and death, DAPT score ≥2 had sensitivities of 57%, 41%, and 56%, respectively; specificities of 58%, 57%, and 58%, respectively; positive predictive values of 1.9%, 2.2%, and 2.1%, respectively; and negative predictive values of 99%, 98%, and 99%, respectively. Addition of baseline high platelet reactivity to the DAPT score did not improve discrimination for ischemic events. Addition of high platelet reactivity and 2 other bleeding covariates to the DAPT score marginally improved discrimination. In ADAPT-DES, the DAPT score was predictive of ischemic events between 1 and 2 years after drug-eluting stents. Prediction of bleeding improved marginally after addition of variables not incorporated in the DAPT score.

Prediction of Ischemic Events after Percutaneous Coronary Intervention: Thrombelastography Profiles and Factor XIIIa Activity.

Background High plasma fibrin clot strength (MA) measured by thrombelastography (TEG) is associated with increased risk of cardiac events after percutaneous coronary interventions (PCIs). Factor XIIIa (FXIIIa) cross-links soluble fibrin, shortens clot formation time (TEG-K), and increases final clot strength (MA). Methods We analyzed platelet-poor plasma from patients with previous PCI. Kaolin-activated TEG (R, K, MA) in citrate platelet-poor plasma and FXIIIa were measured ( n = 257). Combined primary endpoint was defined as recurrent myocardial infarction (MI) or cardiovascular death (CVD). Relationship of FXIIIa and TEG measurements on cardiac risk was explored. Results FXIIIa correlated with TEG-MA ( p = 0.002) and inversely with TEG-K ( p < 0.001). High MA (≥35.35 mm; p = 0.001), low K (<1.15 min; p = 0.038), and elevated FXIIIa (≥83.51%; p = 0.011) were associated with increased risk of CVD or MI. Inclusion of FXIIIa activity and low TEG-K in risk scores did not improve risk prediction as compared with high TEG-MA alone. Conclusion FXIIIa is associated with higher plasma TEG-MA and low TEG-K. High FXIIIa activity is associated with a modest increase in cardiovascular risk after PCI, but is less sensitive and specific than TEG-MA. Addition of FXIIIa does not provide additional risk stratification beyond risk associated with high fibrin clot strength phenotype measured by TEG.

Abstract WP197: Autonomic Nervous System Parameters to Predict the Occurrence of Ischemic Events After Transient Ischemic Attack or Minor Stroke

Background: Stress response is tightly regulated by the autonomic nervous system (ANS) which can be measured by heart rate variability (HRV). Traditional risk factors and acute triggers for ischemic stroke and transient ischemic attack (TIA) are considered as chronic and acute stressors, respectively. These risk factors all contribute to the recurrent ischemic events and are related to ANS dysfunction. The moderate predictive value of ABCD2 score may be due to assessing a limited number of stressors. Aims, Objectives and Hypotheses: We proposed to 1) assess whether HRV parameters, as markers of ANS function and stress, can predict secondary ischemic events after TIA or minor stroke, and 2) compare the HRV-based predictive tools with ABCD2 score. We expected that using HRV indicators can enhance the prediction of ischemic events. Methods: This is a prospective observational study. Patients developed TIA or minor stroke within 48 hours were eligible. The main study variables included: ABCD2 score, HRV assessment from 24-hour Holter recording, and psychological stress. HRV measurement included calculations of both absolute values and changes of HRV frequency-domain parameters: high frequency (HF), normalized HF, HF +low frequency, and total power. Patients were followed for 90 days to assess the development of outcome events. Logistic regression was employed for data analyses. Area under the curve (AUC) and diagnostic tests were used to assess models’ predictive power. Results: Final analyses include data collected from 201 patients. The most useful HRV predictors were Daytime HF changes (AUC=0.70) and Morning HF value (AUC=0.61). AUCs for the Best Stress Model and the Most Practical Model were 0.82 and 0.76, respectively, which were significantly higher than AUC of ABCD2 score (AUC=0.63), p &lt;0.05. The optimal cut-off points for Daytime HF changes and Morning HF might be increase of 12.5% and 50 ms 2 , respectively. The exploratory models that involved both values and changes of HF had AUCs ≥0.82. Conclusions: Assessing the effects of stress on ANS may be an innovative way to stratify the risk of TIA or minor stroke. Models using HRV parameters, especially HF, provide superior predictive values to ABCD2 score. Future research is needed to validate these results.

Association of PCSK9 with platelet reactivity in patients with acute coronary syndrome treated with prasugrel or ticagrelor: The PCSK9-REACT study

BackgroundCirculating proprotein convertase subtilisin/kexin type 9 (PCSK9) enzyme might be associated with increased activation of platelets. We aimed to assess the relationship between PCSK9 levels, platelet reactivity and ischemic outcomes. MethodsConsecutive ACS patients receiving prasugrel or ticagrelor and undergoing percutaneous coronary intervention (PCI) were enrolled in a prospective, observational study. Adenosine diphosphate (ADP)-induced platelet aggregation was determined by Multiplate Analyzer in the maintenance phase of treatment with prasugrel or ticagrelor. Major adverse cardiovascular events (MACEs) defined as composite of cardiovascular death, myocardial infarction, unstable angina, stent thrombosis, repeat revascularization, ischemic stroke were evaluated at 12months. ResultsA direct association was found between increased PCSK9 serum levels and platelet reactivity (r=0.30; p=0.004). When assessed according to tertile values of PCSK9, there was a significant increase in platelet reactivity in the upper vs lower tertile (p=0.02). Clinical outcome was available at follow-up in 178 subjects. In the upper PCSK9 tertile 13/59 (22.03%) patients experienced a clinical MACE at one year, vs 2/59 (3.39%) patients in the lower PCSK9 tertile. At one-year follow-up, PCSK9 was independently associated with increased ischemic MACEs: hazard ratio for upper vs lower PCSK9-level tertile was 2.62 (95% confidence interval 1.24–5.52; p=0.01). ConclusionsThese findings suggest that increased PCSK9 levels are associated with higher platelet reactivity and are a possible predictor of ischemic events in ACS patients undergoing PCI.

Transcranial Doppler as a Predictor of Ischemic Events in Carotid Artery Dissection.

We aim to evaluate clinical features and transcranial Doppler (TCD) elements, as predictors of the development of ischemic events (IEs) in patients suffering from spontaneous carotid arterial dissection without stroke (CCADW). Consecutive patients with CCADW, seen in Clínica Alemana de Santiago between April 2004 and January 2015, were evaluated clinically, and with TCD, microembolic signals (MES) monitoring and breath hold Index (BHI) test were performed. Forty-one patients with 45 CCADW were included. Mean age 41.9 years, 31 male, and 12 (29.1%) patients present with multiple CCADW. At the moment of TCD evaluation, 17 (41.4%) patients were being treated with antiplatelets and the rest under Heparin. TCD monitoring lasted in average 53.3 minutes and demonstrated at the moment of evaluation, MES in four carotid arteries (11.1%) of 3 patients and 13 (28.8%) abnormal BHI in 11 patients. Six IEs occurred in 3 patients, 3 strokes, and 3 transient ischemic attacks. In the univariate analysis correlating IE with clinical and ultrasonographic findings, the degree of carotid stenosis, the presence of multiple CAD, and the presence of MES plus abnormalities of BHI were significantly associated with the risk of an IE. Multivariable analysis showed that only the presence of MES plus abnormal BHI were significant (P < .001). MES and abnormal BHI were present in the 3 patients and in four arterial territories that had IE. TCD can identify a subgroup of patients with CCADW who are at high risk of IE.

Coronary atherosclerosis features for the prediction of ischemic events (CAFE’-PIE STUDY): A CT-scan integrated score from a bi-center registry

Coronary atherosclerosis features for the prediction of ischemic events (CAFE’-PIE STUDY): A CT-scan integrated score from a bi-center registry

In Vivo and protease-activated receptor-1-mediated platelet activation in patients presenting for cardiac catheterization

Pathways of platelet activation that are not targeted by current antithrombotic therapy may be crucial for the development of ischemic events in patients undergoing coronary angiography. We therefore investigated whether in vivo and thrombin receptor activating peptide (TRAP)-stimulated platelet activation and monocyte-platelet aggregate (MPA) levels can serve as independent risk markers for adverse outcomes in aspirin-treated patients presenting for cardiac catheterization. In vivo and TRAP-stimulated platelet surface P-selectin, activated glycoprotein IIb/IIIa (GPIIb/IIIa) and MPA levels were determined in 682 consecutive patients undergoing cardiac catheterization and in 47 healthy controls. Two-year follow-up data were obtained from 562 patients. In vivo platelet surface P-selectin, activated GPIIb/IIIa and MPA levels were significantly higher in patients with angiographically-proven coronary artery disease than in healthy controls (all p≤0.02). Patients with an acute coronary syndrome (ACS; n=125) had significantly higher levels of in vivo MPA than patients without ACS (n=437; p=0.01). In the overall study population (n=562) the surface expression of P-selectin and activated GPIIb/IIIa, and the levels of MPA in vivo and in response to TRAP were similar in patients without and with subsequent ischemic events (all p>0.05). Similar results were obtained when only patients with angiographically-proven coronary artery disease (n=459), stent implantation (n=205) or ACS (n=125) were analyzed. Receiver-operating characteristic curve analyses did not reveal cut-off values for P-selectin, activated GPIIb/IIIa, and MPA levels for the prediction of ischemic events. In conclusion, in vivo and TRAP-stimulated platelet activation and MPA levels did not predict adverse ischemic outcomes in aspirin-treated patients presenting for cardiac catheterization.

Predictors of high on-clopidogrel platelet reactivity in patients with acute coronary syndrome

High on-clopidogrel platelet reactivity (HPR) is a predictor of ischemic events after percutaneous coronary intervention. We conducted a prospective cohort study to identify variables related to HPR in acute coronary syndrome patients who are at high thrombotic risk. We enrolled 463 patients undergoing urgent coronary angiography. Platelet reactivity was measured 12–36 hours after 600 mg clopidogrel loading with multiple electrode aggregometry (Multiplate® analyzer, Roche, Basel, Switzerland, 6.4 µM ADP). HPR was defined by the consensus cut-off area under the curve >46 U. The rate of HPR was 16.0%. We analyzed simple clinical and laboratory parameters with backward multivariate logistic regression and identified the following predictors of HPR: platelet count (per G/L, OR: 1.0073, 95% CI: 1.0035–1.0112, p = 0.0002), CRP level (per mg/L, OR: 1.0077, 95% CI: 1.0016–1.01372, p = 0.01), and active smoking (OR: 0.51, 95% CI: 0.29–0.89, p = 0.02). We developed and internally validated a risk prediction model demonstrating moderate discriminative capacity (area-under-the-receiver operating characteristic curve = 0.67). In conclusion, we found a relatively low rate of high on-clopidogrel platelet reactivity (16.0%) even in an acute patient cohort. HPR measured by Multiplate was associated with high platelet count and CRP level on admission and was inversely related to active smoking. The model with rapidly available simple parameters might help to identify individuals at risk for HPR in the acute setting.