Previous Acute Coronary Syndrome Research Articles

Clinical profile and prognosis of Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) in patients with previous Acute Coronary Syndrome (ACS)

Abstract Introduction Myocardial infarction with non-obstructed coronary arteries (MINOCA) may occur in patients with a personal history of ischaemic heart disease, making diagnosis even more difficult. In addition, the role of cardiovascular risk factors, which are well known in patients with acute myocardial infarction with obstructed arteries (MICAD), is less well defined in MINOCA. The aim of this study is to define the clinical characteristics, risk factors and long-term prognosis in patients with MINOCA and previous acute coronary syndrome (ACS). Methods A prospective, analytical, observational study was designed. Included all patients admitted to our centre with ACS between 2016 and 2023 in which a coronary angiography was performed. Patients were classified as MINOCA according to the definition of the 2020 European ACS guidelines. MINOCA patients with and without a history of previous ischaemic heart disease were compared. At follow-up, MACE was defined as all-cause death, hospitalisation, reinfarction and stroke. The median follow-up was 43 [IQR 20-71]. Results A total of 136 patients were included, of whom 17 had a history of ACS. The proportion of men was significantly higher in the group with previous ACS (82% vs 48%; p=0.008). Patients with a history of ACS had higher rates of smoking (71% vs 51%, p=0.139), more night work (80% vs 39%, p=0.017) and less stress (33% vs 61%, p=0.152). They also had more peripheral vascular disease (24% vs 3%, p=0.005), diabetes (41% vs 19%, p=0.042), dyslipidaemia (71% vs 43%, p=0.04) and a higher rate of atrial fibrillation (29% vs 9%, p=0.032). However, despite a higher rate of previous ventricular dysfunction (24% vs 3%, p=0.005), they had lower troponin levels on admission (62 [IQR 37-368] vs 152 [IQR 49-424]). We found no differences in the other comorbidities analysed (Table 1). On admission, patients with previous ACS had significantly more non-ST-segment elevation (29% vs 10%, P=0.05) and received more beta-blocker treatment (82% vs 57%, p=0.046). When analysing the mechanism of infarction, patients without previous ACS were more likely to have vasospasm and coronary embolism. However, there was a significantly higher rate of type II AMI (41% vs 18%, p=0.044) in the group with previous ACS. During follow-up, patients with a history of ACS are more likely to have a new infarction (7% vs 3%, p=0.3) or stroke (14% vs 6%, p=0.2). There was also a trend towards a higher incidence of MACE in patients with prior ACS, although this did not reach statistical significance (HR 2.379, 95% IC 0,883-6,405) (Table 2). Conclusion MINOCA patients with a history of ACS have distinct and worse epidemiological features in which classic cardiovascular risk factors play a significant role, with more ventricular dysfunction and atrial fibrillation. In addition, they appear to have a worse prognosis with increased cardiovascular complications. That might suggest a more MICAD-like profile.

Correlation Between Ischemia Time and Left Ventricular Failure After Primary Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction (STEMI) Patients.

Primary percutaneous coronary intervention (PPCI) is pivotal in treating ST-elevation myocardial infarction (STEMI) patients, yet ischemia time significantly impacts outcomes, particularly left ventricular failure (LVF). This study aimed to investigate the impact of ischemia duration and other variables associated with severe left ventricular systolic dysfunction in STEMI patients receiving PPCI treatment. This prospective cohort was carried out at Lady Reading Hospital in Peshawar, Pakistan, from January to June 2023. The study included 236 patients aged 18 to 70 with acute myocardial infarction who underwent PPCI within 12 hours of symptom onset. Patients with coronary dissection, late presenters (more than 12 hours after onset), those without stenting, and those with prior coronary artery intervention were excluded. Additionally, patients with systolic heart failure, a history of arrhythmias such as ventricular tachycardia or ventricular fibrillation, or a previous acute coronary syndrome event were excluded. Demographic information, clinical background, and ischemia duration were recorded and associated with left ventricular ejection fraction (LVEF) after PPCI. To identify predictors of severe left ventricular dysfunction, statistical analysis using SPSS Statistics version 26.0 (IBM Corp. Released 2019. IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp.) included multivariate regression, Pearson's correlation, and descriptive statistics. The patients' average age was 61.2 years (SD ± 12.3), with 35.59% of them being female (84 patients) and 64.41% of them being male (152 patients). Diabetes (33.05%, 78 patients) and hypertension (43.22%, 102 patients) were common comorbidities, and 14.41% (34 patients) had previously had a cardiac episode. Fifty-two patients (22.03%) of the total had ischemia within three hours, 94 patients (39.83%) had ischemia within six hours, 60 patients (25.42%) had ischemia within nine hours, and 30 patients (12.71%) had ischemia within 12 hours. Analysis of LVEF showed that 9.32% of patients (n=22) had LVEF <30% and 24.58% of patients (n=58) had LVEF 30-40%. Significant predictors of severe left ventricular systolic dysfunction were shown by multivariate regression to include ischemia duration (OR 1.45, p<0.001), age (OR 1.02, p=0.015), diabetes (OR 2.34, p=0.001), hypertension (OR 1.76, p=0.031), and previous cardiac events (OR 2.89, p=0.002); 20.33% of the patients (n=48) had LVF during the six-month follow-up, highlighting the therapeutic significance of prompt management in STEMI patients after PPCI. Prolonged ischemia, advanced age, diabetes, hypertension, and previous cardiac events that predict severe left ventricular dysfunction are associated with a greater risk of LVF following PPCI. Timely intervention and thorough therapy are essential for enhancing results for STEMI patients at high risk.

Pretreatment with P2Y12 inhibitors and relationship with clinical outcomes in NSTEMI: Analysis of 2 Argentinian registries

Abstract Introduction Pretreatment with P2Y12 inhibitors has been widely studied in the context of NSTEMI patients, with varying results. General consensus is that this strategy should be avoided, unless a long wait time is expected before angiography can be performed. However, it is unclear whether this strategy is associated with a reduction in clinical outcomes, or an increase in bleeding events. Purpose To analyze frequency of pretreatment in NSTEMI in our medium, and association with clinical outcomes. Methods We analyzed the results of two Argentinian acute coronary syndrome registries from 2017 and 2022. We explored incidence of pretreatment, and drug used. We evaluated first through univariate analysis the relationship between pretreatment use and a clinical composite outcome of in hospital events: Myocardial infarction + Mortality + In stent thrombosis + post MI angina + Stroke/TIA. We also explored the relationship of pretreatment with bleeding events (BARC 2 or higher). We later conducted a logistic regression with other clinical variables: Age, gender, diabetes, previous bleeding events, previous MI, aspirin use, anticoagulation, killip-kimball scale and ejection fraction. Results 1297 patients were included in the analysis, after excluding STEMI patients, patients with current use of P2Y12 inhibitors at time of event, and patients who did not undergo angiography. 75.6% were men, 25.6% diabetic, 27,1% smokers, 70.3% hypertensive, and 23.1% had a previous acute coronary syndrome. Mean age was 55.3 years old. Mean GRACE score was 113,5 and CRUSADE 23,8. 44% of patients recieved pretreatment, mostly with clopidogrel (93.5%). Patients that recieved pretreatment were more frequently hypertensive (73.8% vs 67%, p=0.01) and had a higher incidence of previous MI (27% vs 19%, p=0.002). GRACE score was significantly lower in patients that were pretreated (111,5 vs 115, p=0.04). Pretreatment use was significantly associated with a higher incidence of the composite clinical outcome, occuring in 10.1% of patients pretreated and in 6.9% of patients not pretreated (OR 1.56 (1.06-2.3) p=0.02. Bleeding events were numerically more frequent with pretreatment (8.7% vs 5.9%), though did not reach statistical significance (OR 1.51 (0.99-2.3) p=0.054). In multivariate analysis, after adjusting for multiple clinical variables, pretreatment was no longer associated with a higher incidence of clinical outcomes, though also not with a lower incidence (OR 1.4 (0.89-2.3) p=0.13). Discussion Pretreatment, mostly with clopidogrel, did not show a relationship with either benefit or harm with regard to ischemic and bleeding outcomes in NSTEMI patients.

Management of dyslipidaemia in individuals with severe mental illness: a population-based study in the Greater Copenhagen Area.

Severe mental illness (SMI) is associated with increased cardiovascular risk. Dyslipidaemia is a potentially modifiable risk factor, which may be inadequately managed in patients with SMI. To assess management of dyslipidaemia in patients with SMI versus healthy controls (HCs) in 2005 and 2015. Using Danish registers, we identified adult patients with SMI in the Greater Copenhagen Area (schizophrenia spectrum disorders or bipolar disorder) with ⩾1 general practitioner contact in the year before 2005 and 2015, respectively, and HCs without SMI matched on age and gender (1:5). Outcomes were lipid-profile measurements, presence of dyslipidaemia and redemption of lipid-lowering pharmacotherapy. Differences in outcomes between patients with SMI and controls were measured with multivariable logistic regression. We identified 7217 patients with SMI in 2005 and 9939 in 2015. After 10 years, patients went from having lower odds of lipid measurements to having higher odds of lipid measurements compared with HCs [odds ratio (OR)2005 0.70 (99% confidence interval (CI) 0.63-0.78) versus OR2015 1.34 (99% CI 1.24-1.44); p2005versus2015 < 0.01]. Patients had higher odds of dyslipidaemia during both years [OR2005 1.43 (99% CI 1.10-1.85) and OR2015 1.23 (99% CI 1.08-1.41)]. Patients went from having lower odds of receiving lipid-lowering pharmacotherapy to having higher odds of receiving lipid-lowering pharmacotherapy [OR2005 0.77 (99% CI 0.66-0.89) versus OR2015 1.37 (99% CI 1.24-1.51); p2005versus2015 < 0.01]. However, among persons at high cardiovascular risk, patients had lower odds of receiving lipid-lowering pharmacotherapy during both years, including subsets with previous acute coronary syndrome [OR2005 0.30 (99% CI 0.15-0.59) and OR2015 0.44 (99% CI 0.24-0.83)] and ischaemic stroke or transient ischaemic attack (TIA) [OR2005 0.43 (99% CI 0.26-0.69) and OR 2015 0.61 (99% CI 0.41-0.89)]. These results imply an increased general awareness of managing dyslipidaemia among patients with SMI in the primary prophylaxis of cardiovascular disease. However, secondary prevention with lipid-lowering drugs in patients with SMI at high cardiovascular risk may be lacking.

Resistin as a risk factor for all-cause (and cardiovascular) death in the general population

Serum resistin is a pro-inflammatory cytokine that has been described as a risk factor associated with mortality in several clinical sets including type 2 diabetes. Mortality studies in the general population are needed to find out the risk of death associated to this cytokine. In a follow-up study of a cohort of adult population (n = 6636) in Spain over a period of fifteen years (447 deaths/102,255 person-years), serum resistin measurements and death records were obtained. The risks of all-cause deaths, and deaths from cardiovascular and oncological diseases were estimated. Hazard ratios (HR) and its confidence intervals (CI) were calculated using multivariable Cox models, adjusting the effect of 11 traditional risk factors. The risk of all-cause mortality among participants exposed to the highest quintile of resistin was always higher than among those in the lowest quintile (HR varied between 1.55 when smoking was the adjusted factor [95% CI 1.17–2.05], and 1.68 when the adjusted factor was physical activity [95% CI 1.27–2.21]). The maximally adjusted model, accounting for the effect of all traditional factors, corroborated this higher risk of all-cause mortality among people in the highest resistin quintile (HR = 1.52; 95% CI 1.13–2.05). The effect of resistin was even higher for cardiovascular deaths (HR = 2.14; 95% CI 1.13–4.06), being exceeded only by suffering diabetes (HR = 3.04; 95% CI 1.98–4.69) or previous acute coronary syndrome (HR = 3.67; 95% CI 2.18–6.18). This findings corroborate the role of resistin as a risk factor for all-cause (and cardiovascular) death in the general population.

Antithrombotic Strategy in Secondary Prevention for High-Risk Patients with Previous Acute Coronary Syndrome: Overlap between the PEGASUS Eligibility and the COMPASS Eligibility in a Large Multicenter Registry.

Patients with previous acute coronary syndrome (ACS) are at high risk of recurrent adverse cardiovascular events. Recently, prolonged dual antiplatelet therapy (DAPT) and oral anticoagulation therapy (OAT) have been shown to reduce recurrent ischemic events to the expense of an increase in bleeding events. The number of patients potentially eligible for these therapies in real life remains to be determined. Among ACS patients from five registries and one randomized controlled trial, we assessed the proportion of patients eligible for the PEGASUS strategy only and the proportion of patients eligible for the COMPASS strategy only, and set out the proportion of patients with an overlap between the strategies. Among the 10,048 evaluable patients, we found that 5373 (53.4%) were eligible for the PEGASUS strategy and 3841 (38.2%) were eligible for the COMPASS strategy, with a group of 3444 (34.4%) overlapping between the two strategies. The number of patients eligible for the PEGASUS strategy only was 1929 (19.2%) and the number eligible for the COMPASS strategy only was 397 (4.0%); 4278 (42.6%) were eligible for neither a PEGASUS strategy nor a COMPASS strategy. In a large cohort of ACS patients, one in three patients was eligible for either a prolonged DAPT with ticagrelor 60 mg and low-dose aspirin or a dual pathway inhibition approach with rivaroxaban 2.5 mg and low-dose aspirin.

CT analysis of left ventricular function predicts short term survival in patients following transcatheter aortic valve implantation: 1-year outcome data

Abstract Introduction Contrast-enhanced cardiac CT routinely performed prior to transcatheter aortic valve implantation (TAVI), allows assessment of cardiac morphology and function. We assessed left ventricular function in CT as a predictor of survival following TAVI. Methods 500 consecutive patients referred for CT assessment of aortic root anatomy prior to TAVI were screened for inclusion in this analysis. All CT data sets were acquired using a third-generation dual source system. For assessment of aortic root anatomy, acquisitions were acquired using ECG-gated retrospective spiral acquisition and multiphase reconstructions in 10% increments of the cardiac cycle were rendered (slice thickness 0.75, increment 0.4 mm). left ventricular endocardial contours were automatically traced by a dedicated software (syngo. via, Siemens Healthineers, Forchheim, Germany) throughout the cardiac cycle and manually adjusted if required. Global left ventricular function parameters (end-diastolic and end-systolic volumes, stroke volume, cardiac output and ejection fraction) were derived by volumetric assessment. Results Out of 500 patients, 439 patients (mean age 80±6 years, 56% males, and Log EuroScore 23±14%) were included in this analysis (61 patients were excluded due to poor CT image quality or missing outcome data). Previous cardiac surgery had been performed in 15% of the patients, 50% had obstructive CAD with previous interventional or surgical revascularisation and 18% had a previous acute coronary syndrome. One-year survival was 83% (366/439 patients). Parameters of left ventricular function were as follows: mean LVEDV 172±56 ml, mean LVESV 78±62 ml, mean LV ejection fraction 59±18%, mean LV stroke volume index 51±22 ml/m2, mean LV cardiac output 6.6±3.3 L/min and LV cardiac index 3.5±1.7 l/min/m2. Cluster analysis of multiple LV-function surrogate parameters identified a group of patients with higher 1-year mortality, with LVEF identified as a predictor of 1-year survival with a cut-0ff of ≥37% associated with an OR 0f 0.52 (95% CI 0.27 to 0.98). Conclusion Assessment of left ventricular function using functional CT data sets is feasible and allows risk stratification of patients following TAVI. Among LV functional parameters, CT derived LV-ejection fraction with a cut-off ≥37% identifies patients with better short-term outcome. Funding Acknowledgement Type of funding sources: None.

Suboptimal coronary flow after PCI in STEMI patients: clinical implications and predictors

Abstract Background Even in experienced angioplasty centers, percutaneous coronary intervention (PCI) in the acute setting of ST-elevation myocardial infarctions (STEMI) is associated with a low, but still significant rate of suboptimal coronary flow. Identification of its clinical impact and potential modifiable risk factors is important. Purpose To evaluate the clinical impact of suboptimal coronary flow after PCI in STEMI patients and to access potential predictors of suboptimal coronary flow. Methods We retrospectively evaluated 103 hospitalized patients with acute STEMI who were admitted to our center between 2018 and 2019 and underwent PCI. Coronary flow was accessed using the Thrombolysis in myocardial infarction (TIMI) Flow Grading System. Patients were divided into suboptimal patency of the culprit-vessel, defined as TIMI flow ≤2 (group 1, n=8 (7,8%)) and optimal patency of the culprit-vessel defined as TIMI flow 3 (group 2, n=95 (92,2%)). Glomerular filtration rate (GFR) was calculated using the Modification of Diet in Renal Disease (MDRD) formula. Results Mean age 58,15±12,6 years and 85,4% were males. Seventy-eight patients (75,7%) had history of smoking, 45 (43,7%) dyslipidemia, 20 (19,4%) previous acute coronary syndrome, 18 (17,5%) diabetes, 17 (15,5%) were obese and 4 (3,9%) had chronic kidney disease. The revascularization strategy was primary PCI in 55 (54,4%) patients and fibrinolytic therapy with facilitated PCI in 48 (46,6%) patients. Infarct-related artery was the left anterior descending artery in 45 (45,5%) and multivessel disease was present in 38 (38,0%). Angiographic no-reflow after PCI was 3,0%. Intrahospital cardiovascular death occurred in 4 (3,9%) patients and was significantly associated with suboptimal flow (p=0,036) and there was no association with stent thrombosis. Predictors of suboptimal flow were higher blood urea nitrogen, creatinine and GFR at hospital admission (p=0,017 and p=0,012), peak creatinine (p=0,012) and stent length (p=0,038). Suboptimal flow was associated with higher Zwolle score (p=0,010) and ischemic Paris score (p=0,036). Conclusion Failure to achieve optimal culprit-vessel patency after PCI in STEMI patients, although infrequent, is associated with increased hospital cardiovascular death. Longer stents could be and important modified risk factor. Renal dysfunction is an important comorbidity that should be promptly identified and could be partially improved with medical treatment. Funding Acknowledgement Type of funding sources: None.

Risk factor recording and management in coronary heart disease patients from 32 countries: SURF CHD II

Abstract Introduction Patients with coronary heart disease (CHD) are at high cardiovascular risk, and controlling risk factors in this population is especially important to prevent CHD morbidity and mortality. SURF CHD (Survey of Risk factors in Coronary Heart Disease) II is a clinical audit on secondary prevention of CHD. The goals are to simplify and assess the recording and management of cardiovascular risk factors in patients with CHD. Methods SURF CHD II consists in a brief online survey conducted during routine outpatient visits in patients with a previous acute coronary syndrome (ACS), stable angina, percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). Information is collected electronically on demographics, risk factor history (smoking history, physical activity), risk factor measurements (blood pressure, BMI, waist circumference), laboratory values and medication. Risk factor targets were defined as follows: no prior smoking or having stopped smoking, practice of at least 30 minutes of moderate physical activity 3–5 times per week, BMI &amp;lt;25 kg/m2, waist circumference &amp;lt;94 cm in men and &amp;lt;80 cm in women, blood pressure of &amp;lt;140/90 mmHg (&amp;lt;140/85 mmHg in diabetics), LDL &amp;lt;70 mg/dL, HDL &amp;gt;40 mg/dL in men and &amp;gt;45 mg/dl in women, triglycerides &amp;lt;150 mg/dL, and HbA1c &amp;lt;7% in diabetic participants. Results 12884 patients from 32 countries participated in SURF CHD in 5 regions: 10195 in Europe, 2048 in South-East Asia (SEA), 415 in the Americas, 210 in North Africa-Eastern Mediterranean (NAEM), and 13 in Western Pacific. All centres participating were located in urban areas and 81.6% were public Women represented 24.6% of the participants, mean age 64.1 years (sd 11.2 years). 57.7% of the patients had a previous PCI, 50% ACS, 29.5% stable angina and 16.1% CAGB. The percentage of risk factor recording and target attainment by region is presented in Table 1. Risk factor recording ranged from 26.8% (waist circumference) to 94.3% for blood pressure. Target attainment varied from 25.8% with a BMI &amp;lt;25 kg/m2, to 76.3% of participants that had never smoked or had stopped smoking. The South East Asian region presented the highest percentages of risk factor target attainment for smoking, physical activity, BMI, waist circumference and LDL. 92.% of participants used antiplatelet medication, 100% antihypertensive medication and 89.4% lipid-lowering medications. Conclusion Risk factor recording was reasonable, but poor for some risk factors such as waist circumference and Hba1c. In line with earlier clinical audits, there is still substantial room for improvement in risk factor control in this high cardiovascular risk population. There were regional variations, with the highest level of attainment for most risk factors targets in South East Asia. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): SURF II is conducted within the framework of the ESC Prevention of CVD Programme, led by the European Association of Preventive Cardiology (EAPC).

Clinical presentation in EMS patients with acute chest pain in relation to sex, age and medical history: prospective cohort study

ObjectiveTo assess symptom presentation related to age, sex and previous medical history in patients with chest pain.DesignProspective observational cohort study.SettingTwo-centre study in a Swedish county emergency medical service (EMS) organisation.ParticipantsUnselected...

Efficacy and Safety of Atorvastatin 40 mg versus Rosuvastatin 20 mg in Patients with Type 2 Diabetes Mellitus and Previous Acute Coronary Syndrome: A Randomized Clinical Trial

Background: The purpose of this study was to compare the efficacy and safety of high-dose atorvastatin (40 mg) versus high-dose rosuvastatin (20 mg) in Egyptian patients with type 2 diabetes and previous acute coronary syndrome history. Materials and methods: This open-labeled prospective, randomized clinical trial compared once daily atorvastatin 40 mg (Ator®) versus once daily rosuvastatin 20 mg (Crestor®). The primary outcome was the 50% reduction in low-density lipoprotein cholesterol levels at 12 weeks. The secondary outcome was the achievement of low-density lipoprotein cholesterol level &lt; 55 mg/dL. Results: A total number of 108 patients had a significant percentage of improvement in atorvastatin arm (n = 59) and rosuvastatin arm (n = 49) in low-density lipoprotein cholesterol, total cholesterol, triglycerides, and high-density lipoprotein-cholesterol achieved (p ≤ 0.05). In atorvastatin arm, 32.2% of patients achieved fifty percent reduction in low-density lipoprotein cholesterol while 34.7% of patients in rosuvastatin arm (p &gt; 0.05). Twenty percent of patients achieved low-density lipoprotein cholesterol &lt; 55 mg/dL in atorvastatin group compared to eighteen percent only in rosuvastatin group (p &gt; 0.05). Regarding safety, the mean difference in liver transaminases was non-significant between the two groups (p &gt; 0.05). Muscular symptoms were experienced by 1.7% patients receiving atorvastatin 40 mg and 10.2% of those receiving rosuvastatin 20 mg (p &gt; 0.05). Conclusions: In Egyptian context, both high doses statin therapy were comparable regarding efficacy and safety in patients with type 2 diabetes and previous history of acute coronary syndrome. The Clinicaltrial.gov registration ID is: NCT05306990.

Safety of bariatric surgery in patients with previous acute coronary events or heart failure: nationwide cohort study.

BackgroundMetabolic (bariatric) surgery for patients with severe obesity and pre-existing heart disease has been reported to reduce the risk for cardiovascular events and mortality; however, concerns of short- and mid-term complications may limit the utility of metabolic surgery for these patients.MethodThis was an observational, nationwide, matched study, including all adult patients operated with a primary gastric bypass or sleeve gastrectomy procedure in Sweden from January 2011 until October 2020. Patients with or without previous acute coronary syndrome or heart failure were matched 1:5 using propensity scores. The primary outcome was serious postoperative complications, and secondary outcomes were the occurrence of any short-term complications, mid-term complications, weight loss, and health-related quality of life estimates after surgeryResultsOf patients who underwent metabolic surgery, 1165 patients with previous acute coronary syndrome or heart failure and 5825 without diagnosed heart disease were included in matched analyses. No difference was seen between the groups at risk for serious postoperative complications within 30 days of surgery (OR 1.33, 95 per cent c.i. 0.95 to 1.86, P = 0.094), whereas heart disease was associated with an increased risk for cardiovascular complications (incidence 1.1 per cent versus 0.2 per cent, P < 0.001). No differences in overall mid-term complications, weight loss, or improvement of health-related quality of life were seen. Pre-existing heart disease was associated with an increased risk for bowel obstruction and strictures (OR 1.89, 95 per cent c.i. 1.20 to 2.99, P = 0.006).ConclusionPatients with severe obesity and heart disease undergoing metabolic surgery have an increased risk of postoperative cardiovascular complications compared with patients with severe obesity without heart disease. A careful preoperative cardiovascular work-up is needed but patients with severe obesity and heart disease should not be excluded from undergoing metabolic surgery.

Circulating Cystatin C Is an Independent Risk Marker for Cardiovascular Outcomes, Development of Renal Impairment, and Long-Term Mortality in Patients With Stable Coronary Heart Disease: The LIPID Study.

BackgroundElevated plasma cystatin C levels reflect reduced renal function and increased cardiovascular risk. Less is known about whether the increased risk persists long‐term or is independent of renal function and other important biomarkers.Methods and ResultsCystatin C and other biomarkers were measured at baseline (in 7863 patients) and 1 year later (in 6106 patients) in participants in the LIPID (Long‐Term Intervention with Pravastatin in Ischemic Disease) study, who had a previous acute coronary syndrome. Outcomes were ascertained during the study (median follow‐up, 6 years) and long‐term (median follow‐up, 16 years). Glomerular filtration rate (GFR) was estimated using Chronic Kidney Disease Epidemiology Collaboration equations (first GFR‐creatinine, then GFR‐creatinine‐cystatin C). Over 6 years, in fully adjusted multivariable time‐to‐event models, with respect to the primary end point of coronary heart disease mortality or nonfatal myocardial infarction, for comparison of Quartile 4 versus 1 of baseline cystatin C, the hazard ratio was 1.37 (95% CI, 1.07–1.74; P=0.01), and for major cardiovascular events was 1.47 (95% CI, 1.19–1.82; P<0.001). Over 16 years, the association of baseline cystatin C with coronary heart disease, cardiovascular, and all‐cause mortality persisted (each P<0.001) and remained significant after adjustment for estimated GFR‐creatinine‐cystatin C. Cystatin C also predicted the development of chronic kidney disease for 6 years (odds ratio, 6.61; 95% CI, 4.28–10.20) independently of estimated GFR‐creatinine and other risk factors. However, this association was no longer significant after adjustment for estimated GFR‐creatinine‐cystatin C.ConclusionsCystatin C independently predicted major cardiovascular events, development of chronic kidney disease, and cardiovascular and all‐cause mortality. Prediction of long‐term mortality was independent of improved estimation of GFR.RegistrationURL: https://anzctr.org.au; Unique identifier: ACTRN12616000535471.

Risk scores in predicting adverse events after an acute coronary syndrome

Abstract Funding Acknowledgements Type of funding sources: None. Introduction ST-segment elevation myocardial infarction (STEMI) is a serious event that usually occur in patients with cardiovascular risk factors and is associated with great morbidity and mortality. PARIS ischemic risk score and TIMI score were validated to evaluate ischemic risk in STEMI patients who underwent percutaneous coronary intervention (PCI) and to estimate mortality, respectively. Despite these specific purposes, the usefulness of these scores in predicting adverse cardiovascular events (ACE) is unknown. Objectives To assess the prognostic value of PARIS and TIMI scores for cardiovascular events, coronary ischemic events and mortality in patients after STEMI. Methods Retrospective single center cohort study enrolled 103 patients with STEMI diagnosis between 2018 and 2019, during a mean follow-up period 30.30 ± 6.46 months and patients were included regardless of the reperfusion strategy. Primary endpoint (PE) was a composite of acute coronary events (ACE), admissions to the emergency department by heart failure (HF) decompensation or chronic coronary syndrome and HF hospitalization. Secondary endpoint (SE) was ACE. Cardiovascular and non-cardiovascular death was determined. PARIS ischemic risk score was calculated and patients were stratified into low (0-2), intermediate (3-4) or high (≥ 5) ischemic risk categories. TIMI score was also assessed. Results Out of 103 patients with STEMI diagnosis, the median age was 58.15 ± 12.6 years and 85,4% were male. Fifty-seven patients (55.3%) had hypertension, 45 (43.7%) dyslipidemia, 18 (17.5%) diabetes, 17 (15.5%) were obese and seventy-eight patients (75.7%) had history of smoking. Twenty (19.4%) patients had a previous acute coronary syndrome and 15 underwent PCI. Twenty-five (24.3%) patients were included in low PARIS ischemic risk category, 53 (51.5%) in intermediate risk and 20 (19.4%) in high risk category. PE occurred in 16 patient (15.5%) and SE in 7 patients (6.8%). Eight patients died during the follow-up period (7.8%), 4 of cardiovascular causes (50%), 3 of non-cardiovascular causes (37.5%) and 1 of unknown cause. PARIS ischemic risk score showed prognostic value for PE, with an area under the curve (AUC) of 0.65, 95% confidence interval (CI) 0.506-0.806 and p-value 0.039. PARIS score also had predictive value for SE (AUC 0.816, 95% CI 0.604-1.000; p 0.004) as well as TIMI score (AUC 0.738, 95% CI 0.560 – 0.917; p 0.032). Both scores showed a good prognostic value in evaluating all-cause mortality, with a slightly better predictive value for TIMI score (AUC 0.91, 95% CI 0.802 – 1.00) when compared to PARIS score (AUC 0.84, 95% CI 0.685 – 0.987). Conclusion This study revealed that PARIS and TIMI scores have a good discriminatory power to predict prognosis in STEMI patients. According to our study results, these scores could be an interesting tool to determine the likelihood of fatal and non-fatal outcomes, including ACS.

The Relationship between Hypoglycaemic Episodes and Arrhythmias in Type 2 Diabetes Subjects after Acute Myocardial Infarction with ST-Segment Elevation—A Case Series

Background and Aims: Several studies have shown that hypoglycaemia, especially a severe episode is associated with an increased mortality rate in diabetes mellitus subjects with previous cardiovascular disease or acute coronary syndrome. One of the presumed mechanisms is the proarrhythmic effect of hypoglycaemia related to the prolongation of the action potential, or the catecholamine surge that follows an episode. The aim of this case series analysis was to investigate the relationship between hypoglycaemia and glucose variability with arrhythmic events in type 2 diabetes patients who suffered an acute myocardial infarction. Materials and Methods: We selected patients admitted consecutively to the cardiology department of Clinical Emergency Hospital in Bucharest for a period of three months with acute myocardial infarction and previously diagnosed type 2 diabetes. For each patient, a retrospective continuous glucose monitoring system (CGMS) or glucose sensor (Medtronic&#174 Enlite, USA) and a dual electrocardiograph and blood pressure monitor for 24 hours were available. Also, patients had an oscillometric device (Arteriograph&#174 TensioMed Ltd) for 24 hours or non-invasive monitoring of central blood pressure, pulse wave velocity and augmentation index. The data were analysed using Medtech&#174, TensioWin&#174 and Carelink iPro&#174 softwares. We used SPSS&#174 version 20.0 (IBM) for the statistical analysis. The results are presented as median and interquartile range (IQR). Results and Discussion: Ten type 2 diabetes patients (4 males, 6 females) with anterior (4/10) and inferior acute myocardial infarction (6/10) were included. They were treated with insulin (3/10), sulphonylurea (Gliclazide) plus Metformin (4/10), Metformin monotherapy (2/10), or all three (1/10). The patients had a median age of 67.5 (3.25) years with a median disease duration of 8 (7.75) years. The median body mass index was 29.54 (5.65) kg/m2. The median HbA1c was 7.9% (3.15) % and C-peptide 3.3 (2.66) ng/ml. There were no significant differences regarding the number of atrial or ventricular premature beats, ventricular or atrial tachycardia or fibrillation, the duration of QT interval, systolic and diastolic blood pressure, aortic pressure, augmentation index, pulse wave velocity between subjects with hypoglycaemia and those without. There was a negative correlation between QTc and glucose values in patients with hypoglycaemia (Spearman coefficient correlation r = -0.232; p Conclusion: Mild hypoglycaemia in type 2 diabetes patients with systolic dysfunction after ST-elevated myocardial infarction did not increase the number of supraventricular premature beats and QTc duration. We suggest that non-severe hypoglycaemia does not increase the risk of arrhythmias in patients with type 2 diabetes.

Abstract 11341: Diabetes and Chronic Kidney Disease: Prevalence, Associated Factors and Influence on Optimal Medical Therapy in Patients with Coronary Artery Disease

Introduction: Diabetes mellitus (DM) and chronic kidney disease (CKD) are comorbidities of great therapeutic and prognostic importance in patients with coronary artery disease (CAD). Knowledge about their prevalence, associated factors and influence on optimal medical therapy are needed to best manage this population. Methods: This is a unicentric cross-sectional analysis of 869 patients enrolled in a CAD registry in Brazil. To be included, patients needed to have a previous coronary artery revascularization procedure (either percutaneous or surgical), documented previous acute coronary syndrome, or known coronary stenosis greater than 50%. CKD was defined as creatinine clearance &lt; 60 mL/min. DM was defined as prescription of glucose-lowering drugs or a HbA1c &gt; 6.5%. Results: Overall, mean age was 64.7 years, 261 (30%) were women, 528 (61%) had previous myocardial infarction, and 547 (63.4%) had a previous revascularization procedure. DM was prevalent in 449 (51.7%) patients and CKD in 280 (32.2%). Both comorbidities were concomitant in 151 (17.4%) patients. On multivariate analysis, CKD was correlated to female sex (OR 2.94; 95%CI 1.88-4.67), age (OR 1.20; 95%CI 1.16-1.23), BMI (OR 0.80, 95%CI 0.76-0.84), and HDL-cholesterol (OR 0.97; 95%CI 0.96-0.99). DM was associated with age (OR 1.02, 95%CI 1.00-1.04), BMI (OR 1.05, 95%CI 1.01-1.08), high blood pressure (OR 2.1, 95%CI 1.39-3.21), and heart rate (OR 1.02, 95%CI 1.00-1.03). Concomitant presence of CKD and DM was associated with age (OR 1.09, 95%CI 1.06-1.13) and left ventricular ejection fraction (OR 0.97, 95%CI 0.95-0.98). Patients with DM were more likely to receive ACE inhibitors or ARBs (79.3% x 67.1%, p&lt; 0.001) and calcium channel blockers (41.9% x 31.2%, p=0.001). Patients with DM and CKD had higher use of nitrates (38.4% x 25.6%, p=0.002). There was no difference in the prescription of antithrombotic drugs, beta-blockers or statins between groups. Conclusion: DM and CKD are both very prevalent comorbidities in patients with CAD. They are associated with age and risk markers such as high blood pressure and lower left ventricular ejection fraction. Although typically these populations are undertreated in others registries, this fact was not observed in our study.

STEMI treatment in remote areas – challenges of the only interventional angioplasty center located in an archipelago

Abstract Background In remote islands lack of specialized medical facilities, long distance transfer and emergency medical system organization remains a challenge and fibrinolysis is necessary to achieve revascularization in optimal timing in ST-elevation myocardial infarction (STEMI) patients. Our angioplasty center is the only one located in an archipelago composed of nine islands, six of which do not have hospital facilities and only have small family health care units. Purpose To evaluate the reality and outcomes of our interventional angioplasty center and compare cardiovascular outcomes between STEMI patients from the main island and remote islands. Methods We retrospectively evaluated 103 patients with STEMI admitted to our center between 2018 and 2019. Patients from the main island where the center is located underwent primary percutaneous coronary intervention (PCI) (group 1, n=55) and patients from remote islands underwent fibrinolytic therapy followed by transference to our center with facilitated or rescue PCI (group 2, n=48). A subanalysis of the far remote islands without hospital facilities was also performed. Primary outcome was defined as cardiovascular death or re-infarction at two years and secondary outcome as intrahospital haemorrhagic complications. Results Mean age was 58,15±12,6 years, 85,4% were males and follow up period was 30,30±6,46 months. Seventy-eight patients (75,7%) had history of smoking, 45 (43,7%) dyslipidemia, 20 (19,4%) previous acute coronary syndrome, 18 (17,5%) diabetes and 17 (15,5%) were obese. Troponin I peak was 117,42±129,06 ug/L and 14 (13,6%) were in Killip Class III/IV. Infarct-related artery was the left anterior descending artery in 45 (45,5%) and multivessel disease was present in 38 (38,0%). In group 1 reperfusion after PCI was obtained in 91,5%. In group 2, 73,5% met criteria for reperfusion after fibrinolysis and 23,6% after rescue PCI. Mean time from fibrinolysis to PCI was 558±349 minutes. Rates of successful revascularization did not differ between groups, as well as complete patency of the culprit-vessel defined as thrombolysis in myocardial infarction (TIMI) flow 3 (91,5% vs. 97,2% and 90,0% vs. 93,0% respectively for group 1 and 2). Cardiovascular death at two years occurred in 4 (3,9%) patients and re-infarction in 11 (10,7%) and were similar between groups (3 (5,5%) vs. 1 (2,1%) and 8 (14,5%) vs. 3 (6,3%) respectively) as well as haemorrhagic complications (1 (1,8%) vs. 5 (10,4%) respectively). Nineteen (18,4%) patients were from far remote islands without hospital facilities and when comparing these patients with the others there was also no difference in primary outcome. Conclusion Even in remote islands, an organized STEMI network with attempted fibrinolytic treatment and coordinated transference of patients for facilitated or rescue PCI can provide successful revascularization with cardiovascular outcomes similar to those submitted to primary PCI. Funding Acknowledgement Type of funding sources: None.

Myocardial injury in stress echocardiography: comparison of dobutamine, dipyridamole and dynamic stress echocardiography – single centre study

Abstract Background Stress echocardiography (SE) plays important role in investigation of the patients with chest pain. Adverse events rate is higher in dobutamine stress echocardiography on comparison to dobutamine stress echocardiography (ExSE) or dipyridamole stress echocardiography (DIP). Dynamic stress (ExSE) is recommended as the first-choice method according to the current guidelines. Purpose Response to the different stressors was studied in several studies with controversial results. This study aimed to investigate myocardial injury during stress echocardiography measured by the serum high sensitivity troponin (hsTnT) in a low risk population and whether there is a difference in hsTnT response between various stressors. Methods 135 patients (DSE n=46, ExsE n=46, Dip n=43) investigated for chest pain with suspicion on angina with negative diagnostic stress echocardiography were enrolled in the study. HsTnT was measured before and at 180 min. after the test was terminated. Patients with baseline elevated hsTnT levels (≥14 pg/ml), impaired LV EF (&amp;lt;50%), regional wall motion abnormalities, previous acute coronary syndrome and/or revascularisation, known epicardial coronary artery stenosis &amp;gt;50%, diabetes, prediabates (fasting glycemia at the day of the test ≥5,6 mmol/l, left ventricle hypertrophy &amp;gt;13 mm, baseline uncontrolled hypertension (BP &amp;gt;160/100 mmHg), estimated systolic pulmonary pressure &amp;gt;45 mmHg, more than moderate valvular disease, and patient who experienced dobutmine side effect (hypotension, atrial fibrillation) were excluded from the study. Results HsTnT increased in DSE and ExSE, but not in DIP group [9,4 (1,5–58,6), 1,1 (−0,9–15,7), −0,1 (−1,4–2,1) ng/L, p&amp;lt;0,001]. Similar result was found In DSE and ExSE subgroups without atropine [5,3 (0,4–45,3) vs 1,1 (−1,1–15,7) ng/L, p&amp;lt;0,001]. Adding atropine during SE triggered much greater hsTnT release in DSE [40,1 (3,7–160,3) vs 5,3 (0,4–45,3) ng/L, p&amp;lt;0,001], but not in ExSE group [0,6 (−0,9–22,7) vs 1,1 (−1,1–15,7) ng/L, p=0,786]. Moderate correlation of hsTnT rise with DSE length was observed (r=0,43). Conclusions DSE leads to significant myocardial injury multiplied when atropine is used. No injury was observed in DIP and only mild was revealed in ExSE. This finding support ExSE as the preferred stress echocardiography method. Whether significant myocardial injury is causative of the higher adverse event rates in DSE remains to be determined. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): University Hospital Hradec Kralove, Czech RepublicFaculty of Medicine Hradec Kralove, Charles University, Czech Republic hsTnT change 0–180 min. the whole grouphsTnT change 0–180 min. w/wo atropine

Atherosclerosis associated pathways are upregulated in stenotic aortic valves from patients with severe concomitant coronary artery disease

Abstract Aortic valve stenosis (AVS) share pathobiology and risk factors with atherosclerosis. However, medical treatment effective against atherosclerosis lack ability to halt the progression of AVS. The aims of this study were to (i) determine the prevalence of coronary artery disease (CAD) in surgical AVS patients and (ii) to establish predictors of CAD in AVS patients and (iii) to identify differential aortic valve transcriptomic profiles depending on concomitant CAD. The study cohort consisted of 256 consecutive AVS patients with surgically verified tricuspid aortic valves, of which 74 aortic valves were collected. CAD defined as coronary artery stenosis requiring concomitant bypass surgery or previous acute coronary syndrome or percutaneous coronary intervention Transcriptomic data were obtained from microarray analysis of tissues from three different stages of AVS process (healthy, intermediate, and calcified tissue). All comparisons were sex and tissue adjusted. Non-coding probes were removed and a variance filter was applied prior to analysis which yielded 5121 genes. The prevalence of CAD in AVS was 49%. A logistic regression model revealed male sex, claudication, diabetes and current smoking as significant predictors of CAD when age, sex, peak transaortic velocity, hsCRP, eGFR and BMI were held constant. 28 genes were significantly (q&amp;lt;0.05) differentially expressed when aortic valves from patients with (n=43) and without (n=31) CAD were compared. A comparison of patients with concomitant multi vessel disease (2–3 affected vessel territories, n=20) and patients without CAD or single vessel disease (n=54) revealed 189 significantly expressed genes and an optimal visual separation on heatmap (Figure 2). Active-subnetwork-oriented-enrichment analysis identified upregulated aortic valve atherosclerosis associated pathways in multi vessel disease patients related to reactive oxygen species and cytokine signaling. This study provides a novel observation of differential aortic valve gene expression profile depending on concomitant severe CAD. The results revealed that patients with concomitant severe CAD exhibited underlying atherosclerosis-related mechanisms to their aortic valve disease. Therefore, future precision medicine against AVS may be facilitated by assessing concomitant CAD. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Karolinska Institute - Clinical Science Training ProgrammeSwedish Heart Lung Foundation Predictors of concomitant CADDEGs in AVs stratified on severe CAD

Predictors for one-year outcomes of cardiorespiratory fitness and cardiovascular risk factor control after cardiac rehabilitation in elderly patients: The EU-CaRE study.

Studies on effectiveness of cardiac rehabilitation (CR) in elderly cardiovascular disease patients are rare, and it is unknown, which patients benefit most. We aimed to identify predictors for 1-year outcomes of cardiorespiratory fitness and CV risk factor (CVRF) control in patients after completing CR programs offered across seven European countries. Cardiovascular disease patients with minimal age 65 years who participated in comprehensive CR were included in this observational study. Peak oxygen uptake (VO2), body mass index (BMI), resting systolic blood pressure (BPsys), and low-density lipoprotein-cholesterol (LDL-C) were assessed before CR (T0), at termination of CR (T1), and 12 months after start of CR (T2). Predictors for changes were identified by multivariate regression models. Data was available from 1241 out of 1633 EU-CaRE patients. The strongest predictor for improvement in peak VO2 was open chest surgery, with a nearly four-fold increase in surgery compared to non-surgery patients. In patients after surgery, age, female sex, physical inactivity and time from index event to T0 were negative predictors for improvement in peak VO2. In patients without surgery, previous acute coronary syndrome and higher exercise capacity at T0 were the only negative predictors. Neither number of attended training sessions nor duration of CR were significantly associated with change in peak VO2. Non-surgery patients were more likely to achieve risk factor targets (BPsys, LDL-C, BMI) than surgery patients. In a previously understudied population of elderly CR patients, time between index event and start of CR in surgery and disease severity in non-surgery patients were the most important predictors for long-term improvement of peak VO2. Non-surgery patients had better CVRF control.