Previous Coronary Artery Disease Research Articles

High systemic inflammation as a novel cardiovascular risk factor and target for anti-cytokine therapy: comment regarding the triglyceride glucose index.

In the last century, there has been more than enough research that proved the association of high lipid and glucose levels with cardiovascular disease, thus establishing the current well-known traditional cardiovascular risk factors such as dyslipidemia, diabetes, and metabolic syndrome. Hence, these cardiovascular risk factors are target therapy for glucose and lipid-lowering agents to prevent adverse cardiovascular events. However, despite controlling the lipid and glucose levels, some studies demonstrated the subclinical atherosclerosis suggesting that these cardiovascular risk factors alone cannot account for the entire atherosclerosis burden. In the last years, large-scale clinical trials demonstrated the operation of the inflammatory pathway in atherosclerotic cardiovascular disease (ASCVD) by the immune system, both the innate (neutrophils, macrophages) and adaptive (T cell and other lymphocytes) limbs, contribute to atherosclerosis and atherothrombosis. In this regard, some studies that use antiinflammatory therapy targeting the immune system by modulating or blocking interleukins, also known as anti-cytokine therapy, have been shown to reduce the risk of adverse cardiovascular events in patients with previous coronary artery disease. In this regard, the U.S. Food and Drug Administration (FDA) approved the use of colchicine 0.5mg once daily for reducing cardiovascular events in patients who have established ASCVD and high residual systemic inflammation. Therefore, measuring the systemic inflammation can improve the cardiovascular risk assessment and identify the subsets of patients that will benefit from anti-cytokine therapy after diagnosis of ASCVD or after myocardial revascularization.

Paclitaxel-induced acute myocardial infarction: a case report and literature review

BackgroundPaclitaxel is a chemotherapeutic agent commonly used for ovarian, lung, breast carcinoma, and Kaposi’s sarcoma. Its common side effects include hypersensitivity reaction, bone marrow suppression, and peripheral neuropathy. However, a rare and life-threatening side effect is paclitaxel-induced myocardial infarction.Case presentationA 71-year-old man with type 2 diabetes mellitus, hypertension, heavy smoking history, previous coronary artery disease with percutaneous coronary intervention (PCI) in left anterior descending artery (LAD), and non-small lung cancer presented with non-ST elevation myocardial infarction during infusion of paclitaxel infusion. Coronary angiogram showed de novo three vessel disease with 70% stenosis in ostial to distal left main artery (LM) and 80% in-stent re-stenosis in proximal to mid left anterior descending artery.ConclusionsPhysicians should be keeping this in mind when dealing with patients on paclitaxel, especially if they have previous risk factors for coronary artery disease.

The Role of Cilostazol, a Phosphodiesterase-3 Inhibitor, in the Development of Atherosclerosis and Vascular Biology: A Review with Meta-Analysis.

Atherosclerotic cardiovascular disease (ASCVD) stands as the leading global cause of mortality. Addressing this vital and pervasive condition requires a multifaceted approach, in which antiplatelet intervention plays a pivotal role, together with antihypertensive, antidiabetic, and lipid-lowering therapies. Among the antiplatelet agents available currently, cilostazol, a phosphodiesterase-3 inhibitor, offers a spectrum of pharmacological effects. These encompass vasodilation, the impediment of platelet activation and aggregation, thrombosis inhibition, limb blood flow augmentation, lipid profile enhancement through triglyceride reduction and high-density lipoprotein cholesterol elevation, and the suppression of vascular smooth muscle cell proliferation. However, the role of cilostazol has not been clearly documented in many guidelines for ASCVD. We comprehensively reviewed the cardiovascular effects of cilostazol within randomized clinical trials that compared it to control or active agents and involved individuals with previous coronary artery disease or stroke, as well as those with no previous history of such conditions. Our approach demonstrated that the administration of cilostazol effectively reduced adverse cardiovascular events, although there was less evidence regarding its impact on myocardial infarction. Most studies have consistently reported its favorable effects in reducing intermittent claudication and enhancing ambulatory capacity in patients with peripheral arterial disease. Furthermore, cilostazol has shown promise in mitigating restenosis following coronary stent implantation in patients with acute coronary syndrome. While research from more diverse regions is still needed, our findings shed light on the broader implications of cilostazol in the context of atherosclerosis and vascular biology, particularly for individuals at high risk of ASCVD.

Long-Term Prognosis after ST-Elevation Myocardial Infarction in Patients with Premature Coronary Artery Disease.

A significant percentage of younger patients with myocardial infarction have premature coronary artery disease (CAD). The aims of this study were to analyze all-cause mortality and major adverse cardiovascular events (MACEs cardiovascular death, non-fatal reinfarction, stroke, target vessel revascularization) during eight-year follow-up in patients with ST-elevation myocardial infarction (STEMI) and premature CAD. We analyzed 2560 STEMI patients without previous CAD and without cardiogenic shock at admission who were treated with primary PCI. CAD was classified as premature in men aged <50 years and women <55 years. Premature CAD was found in 630 (24.6%) patients. Patients with premature CAD have fewer comorbidities and better initial angiographic findings compared to patients without premature CAD. The incidence of non-fatal adverse ischemic events was similar to the incidence in older patients. Premature CAD was an independent predictor for lower mortality (HR 0.50 95%CI 0.28-0.91) and MACEs (HR 0.27 95%CI 0.15-0.47). In patients with premature CAD, EF < 40% was the only independent predictor of mortality (HR 5.59 95%CI 2.18-8.52) and MACEs (HR 4.18, 95%CI 1.98-8.13). Premature CAD was an independent predictor for lower mortality and MACEs. In patients with premature CAD, EF < 40% was an independent predictor of eight-year mortality and MACEs.

Critical Assessment of the Management of Unstable Angina in a Specialized Cardiology Emergency Room.

The management of unstable angina (UA) presents a challenge due to its subjective diagnosis and limited representation in randomized clinical trials that inform current practices. This study aims to identify key factors associated with the indication for invasive versus non-invasive stratification in this population and to evaluate factors associated with stratification test results. This retrospective cohort study included patients hospitalized with UA over a consecutive 20-month period. To assess factors associated with stratification strategies, patients were divided into invasive stratification (coronary angiography) and non-invasive stratification (other methods) groups. For the analysis of factors related to changes in stratification tests, patients were categorized into groups with or without obstructive coronary artery disease (CAD) or ischemia, as per the results of the requested tests. Comparisons between groups and multiple logistic regression analyses were performed, with statistical significance set at a 5% level. A total of 729 patients were included, with a median age of 63 years and a predominance of males (64.6%). Factors associated with invasive stratification included smoking (p = 0.001); type of chest pain (p < 0.001); "crescendo" pain (p = 0.006); TIMI score (p = 0.006); HEART score (p = 0.011). In multivariate analysis, current smokers (OR 2.23, 95% CI 1.13-4.8), former smokers (OR 2.19, 95% CI 1.39-3.53), and type A chest pain (OR 3.39, 95% CI 1.93-6.66) were independently associated. Factors associated with obstructive CAD or ischemia included length of hospital stay (p < 0.001); male gender (p = 0.032); effort-induced pain (p = 0.037); Diamond-Forrester score (p = 0.026); TIMI score (p = 0.001). In multivariate analysis, only chest pain (type B chest pain: OR 0.6, 95% CI 0.38-0.93, p = 0.026) and previous CAD (OR 1.42, 95% CI 1.01-2.0, p = 0.048) were independently associated. The type of chest pain plays a crucial role not only in the diagnosis of UA but also in determining the appropriate treatment. Our results highlight the importance of incorporating pain characteristics into prognostic scores endorsed by guidelines to optimize UA management.

Prevalence of depression in postmyocardial infarction patients in a tertiary care center in Riyadh.

The coexistence of coronary artery disease (CAD) and depression is a growing concern, as both conditions lead to disability. Although depression is more prevalent in CAD patients than in the general population and has been associated with adverse cardiac outcomes, the underlying mechanisms linking depression and CAD are not yet fully understood. This study aims to assess the prevalence of depression in postmyocardial infarction (MI) patients as baseline data in Saudi Arabia. A cross-sectional study was conducted at King Saud Medical City, Riyadh. The study population included male and female patients who had survived MI from January 2022 to June 2022. A sample size of 323 patients was initially planned, but only 249 patients could be included on account of exclusions. The patients underwent screening for depression using Patient Health Questionnaire-2 (PHQ-2), and those who were positive on screening were further assessed using the PHQ-9 according to DSM-5 criteria. Sociodemographic data, comorbidities, and previous cardiac interventions were collected from medical records. The mean age of the study participants was 57.15 years, and majority (76.6%) were males. The prevalence of previously diagnosed depression was 9.2%, and 5.2% of patients reported using antidepressant medication. According to the PHQ-9 scores, 33.33% had depression, 9% had moderate depression, and 2.4% had severe depression. There were significant associations between the severity of depression and previous CAD (P < 0.05), previous coronary artery bypass graft surgery (P < 0.05), and heart failure (P < 0.05). This study reveals a high prevalence of depression in post-MI patients at King Saud Medical City. The findings highlight the need for comprehensive management of depression in this population to improve outcomes. Further research into the underlying mechanisms linking depression and CAD to develop effective interventions is required.

Changes of hospital-level variation in use of optimal medical treatment for long-term follow-up from a multi-level methodological approach

Abstract Background Contemporary guidelines documented that optimal medical therapy (OMT) should be prescribed to improve clinical outcome in patients with acute myocardial infarction (AMI). However, the changes of hospital-level variations in prescription rates of OMT for long-term follow-up are unknown. Purpose We aimed to investigate (1) impact of hospital-level variation on the use of each medication and OMT and (2) changes of hospital-level variation in prescription rates of individual medical therapy and OMT during the follow-up. Methods We examined hospital medications of 13,516 AMI patients without documented contraindications to antiplatelet agents, β-blockers (BB), angiotensin-converting enzyme inhibitors (ACE) /angiotensin II receptor blockers (ARB), or statins from the Korean Acute Myocardial Infarction Registry (KAMIR) – National Institute of Health (NIH) database. OMT was defined as use of all 4 indicated medications. Hierarchical generalized linear mixed models estimated hospital-level variation in prescription rates of OMT and each medication after adjustment for patient-level factors. Variation was explored with a median rate ratio (MRR), which estimates the relative difference in risk ratios of 2 hypothetically identical patients at 2 different hospitals. Results The prescription rates of OMT and each effective cardiac medications are presented in Figure. There were substantial decreases in the prescription rates for OMT (from 66.7% to 51.6%) and dual antiplatelet agents (from 99.1% to 50.4%) for 2 years follow-up. After adjustment for patient-level covariates, hospital-level MRR for OMT was 1.47 at discharge, indicating an 47% likelihood that 2 random hospitals would differ in treating identical AMI patients. As the prescription rates of OMT and each effective cardiac medications decreased, adjusted hospital-level MRR for OMT (from 1.47 to 1.22), BB therapy (from 1.35 to 1.15), ACE/ARB therapy (from 1.68 to 1.16), and statin therapy (from 1.19 to 1.06) decreased for 2-year follow-up, whereas MRR for dual antiplatelet therapy increased at 1 year (MRR; 1.61) and 2 years (MRR; 1.63) follow-up (Figure). Among patient-level factors, age &amp;gt;70 years, Killip class&amp;gt;2, obesity, hypertension, previous coronary artery disease, renal dysfunction, reduced ejection fraction, percutaneous coronary intervention was independently associated with the use of OMT. Conclusion Hospital-level variations in the use of OMT and each effective cardiac medications were observed at discharge, but weakened overtime, except for use of dual antiplatelet therapy.

The prognostic impact of cardio-renal anaemia syndrome in Japanese acute decompensated heart failure patients stratified by left ventricular ejection fraction

Abstract Background Cardio-renal anaemia syndrome (CRAS) has been reported to be an important prognostic factor for events in heart failure (HF) patients. Previous reports have shown that it has relatively little prognostic impact in patients with preserved left ventricular ejection fraction (LVEF), which remains controversial. We therefore investigated the prognostic impact of CRAS in Japanese acute decompensated heart failure (ADHF) patients according to LVEF. Methods We combined two registry studies of ADHF patients in Japan and examined HF events and their associated factors over a 2-year observation period. The prognostic impact of CRAS was also analysed by LVEF. The primary endpoint was defined as all-cause mortality or HF hospitalisation. Renal dysfunction was defined as eGFR &amp;lt;60 mL/min/1.73 m2 and anaemia as haemoglobin &amp;lt;13 g/dl in men and &amp;lt;12g/dl in women. CRAS was defined as the presence of both renal dysfunction and anaemia. Three groups were also created by LVEF (&amp;gt;50%, 40-49% and &amp;lt;40%) and analysed separately. Results A total of 2142 patients were enrolled. Mean age was 78.7 years and 49% of the patients was male. Previous coronary artery disease and atrial fibrillation were present in 31% and 44% of the patients, respectively. Medications included beta-blockers in 61% and renin-angiotensin system inhibitors in 53% of the patients. Renal dysfunction was present in 1676 (74%) and anaemia was seen in 1523 (67%) patients. CRAS was present in 1190 (53%) patients. During the mean follow-up period of 623±244 days, the primary endpoint was observed in 1015 patients, with 563 deaths and 737 HF hospitalisations. Multivariate analysis in a Cox proportional hazards model showed that CRAS was an independent prognostic factor in all patients (hazard ratio [HR]1.488;95% confidence interval [CI] 1.292-1.715, p&amp;lt;0.001). Multivariate analysis was also performed in three groups of patients with LVEF &amp;gt;50%, 40-49% and &amp;lt;40%. As with all patients, CRAS was an independent predictor of the primary endpoint in the three groups. (LVEF &amp;gt;50% [1273 patients]: HR1.313[95%CI 1.089-1.583], p = 0.004; LVEF 40-49% [381 patients]:HR,1.907[95%CI 1.323-2.750], p&amp;lt;0.001; LVEF &amp;lt;40% [651 patients]:HR: 1.446[95%CI 1.117-1.872]; p = 0.005) Conclusion In the present registry study of Japanese patients with ADHF, CRAS was a important prognostic factor. The results also confirmed a similar trend in patients with any LVEF.

Sex-based differences in ST-segment elevation myocardial infarction: a multicentre national registry analysis

Abstract Background Sex differences in ST-segment elevation myocardial infarction (STEMI) are not fully understood. Female patients appear to have higher mortality. Purpose To establish sex-differences in Portuguese STEMI patients. Material and methods Retrospective multicentre analysis of STEMI patients included in the Portuguese Registry on Acute Coronary Syndromes (ProACS) between October 2010 and October 2022. Two cohorts were defined according to sex. Baseline characteristics, clinical findings, treatment and mortality were compared. Multivariate analysis was performed to assess predictors of mortality. Results A total of 14470 patients were included with a mean age of 64 ± 14 years, of which 26% were female. Female patients were significantly older (p&amp;lt;0.001) and with higher prevalence of several cardiovascular risk factors such as: high blood pressure (p&amp;lt;0.001), diabetes (p&amp;lt;0.001) and dyslipidemia (p=0.015), as well as higher reported past medical history, namely ischemic stroke/transient ischemic attack (p=0.001), renal disease (p&amp;lt;0.001) and dementia (p&amp;lt;0.001). On the other hand, previous coronary artery disease was less common comparing to men. Reperfusion therapy was less frequent in females (p&amp;lt;0.001), with less cases of multivessel disease (p=0.004). Regarding inpatient medical treatment women were less frequently prescribed medical therapy and more frequently needed inotropes (p&amp;lt;0.001). Regarding discharge medication, similar tendencies were observed, and women were less frequently referred to cardiac rehabilitation programs (p&amp;lt;0.001). Concerning prognosis, women had more complications while at hospital, namely, congestive heart failure (p&amp;lt;0.001), ischemic stroke (p&amp;lt;0.001) and intra-hospital mortality (p&amp;lt;0.001). Similarly, women had higher thirty-day and one-year mortality (p&amp;lt;0.001) and non-cardiac hospital readmission (p&amp;lt;0.001). After multivariate analysis, female sex (OR=1.633; CI 95% [1.065-2.504]; p=0.025) remained as an independent factor for intra-hospital mortality but not for thirty-day and one-year mortality. Conclusions In our population, female patients had statistically significant differences in comparison to men regarding clinical characteristics, treatment and prognosis. Nevertheless, female sex was an independent risk factor only for intra-hospital mortality.

ACEi/ARB after STEMI: prognostic impact and predictors of adherence, results from the real-world FAST STEMI registry

Abstract Background The impact of adherence to angiotensin converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARBs) therapy on cardiovascular outcomes after ST-elevation acute myocardial infarction (STEMI) in real-world patients is understudied. Purpose To identify predictors of lower compliance to ACEi/ARBs and estimate its impact on cardiovascular outcomes and mortality in the first year after the index event. Methods We evaluated real-world adherence to the most common cardiovascular drugs by comparing the number of bought tablets in pharmacies to the expected tablets at 1 year and on total follow-up length. A total of 6043 patients with STEMI from 2012 to 2017 were enrolled in the FAST-STEMI registry and followed up for 4.7±1.6 years. 299 patients with intraprocedural and intrahospital deaths were excluded. The main outcomes evaluated were all-cause death, cardiovascular death, myocardial infarction, major and minor bleeding events and ischemic stroke. The optimal compliance cutoff was found by ROC curve analysis with Youden index; Kaplan Meier and Cox proportional hazard models were performed to evaluate cumulative event rates of mortality at follow-up. Predictors of lower adherence were evaluated at univariate and multivariate analysis with logistic regression. Results A total of 4167 patients with ACEi/ARBs prescription at discharge were considered: mean age was 64 ± 12 years old, 77.3% were men, 18.4% had hypertension, 12% were diabetic, 3.8% had previous coronary artery disease (CAD), mean ejection fraction (EF) was 49.21%±8.9%. Mean ACEi/ARBs adherence was 84.4% (IQR 57.5-99.8): after univariate and multivariate analysis, predictors of lower compliance were age ³75 years old (OR 0.822, 95%CI 0.697-0.970) and known ischemic cardiopathy (OR 0.592, 95%CI 0.422-0.831), whereas preserved EF (OR 1.197, 95%CI 1.048-1.368), hypertension (OR 1.339, 95%CI 1.114-1.609) and beta-blockers prescription at discharge (OR 1.442, 95%CI 1.155-1.802) were predictors of good adherence. ACEi/ARBs compliance higher than 72.06% (identified at Youden’s analysis as best cut-off) was found both at univariate and multivariate analysis as a predictor of lower cardiovascular (0.3% vs 2.6%, HR 0.17, 95%CI 0.07-0.36, p&amp;lt;0.001) and all-cause mortality (1.5% vs 5.9%, HR 0.34, 95%CI 0.23-0.51, p&amp;lt;0.001). Finally, ACEi/ARBs optimal compliance at 1-year was associated to a reduction of myocardial infarctions (7.7% vs 10.4%, p=0.02), as well as minor bleedings (0.2% vs 0.7%, p=0.01), whilst did not impact on ischemic stroke nor major bleedings. Conclusions In our large real-world registry, good adherence to ACEi/ARBs therapy after acute myocardial infarction with ST-elevation was associated with a reduction in mortality (either cardiovascular and all-cause), myocardial infarctions and minor bleedings. Older age and previous coronary artery disease resulted as predictors of poor compliance to ACEi/ARBs therapy.

Combined predictive value of pre-procedural protein-energy wasting and inflammation status for amputation and/or mortality after lower extremity revascularization in patients on hemodialysis

Abstract Background Although lower extremity revascularization has been commonly performed in chronic hemodialysis (HD) patients with peripheral artery disease (PAD), poorer prognosis after revascularization still remains major problems. Recently, protein-energy wasting (PEW) or malnutrition have been considered to be strongly associated with chronic inflammation and advanced atherosclerosis in HD patients. We investigated the association of geriatric nutritional risk index (GNRI) as a surrogate marker of the PEW, C-reactive protein (CRP) and their joint role with prediction of amputation and/or mortality after lower extremity revascularization in HD patients. Method We enrolled a total of 800 HD patients (age 67±10 years, diabetes 63.3% and critical limb ischemia 52.9%) who successfully underwent lower extremity revascularization [535 with endovascular therapy (EVT) and 265 with bypass surgery]. Patients were divided into tertiles according to pre-procedural GNRI levels; tertile 1 (T1): &amp;lt;88.1, T2: 88.1-96.7and T3: &amp;gt;96.7, and CRP levels; T1: &amp;lt;2.0mg/l, T2: 2.0-12.6mg/l and T3: &amp;gt;12.6mg/l, respectively. Primary outcome was amputation-free survival (AFS). They were followed up for up to 8 years. Results During follow-up period (median: 43 months), 56 (7.0%) patients needed major amputation and 183 (22.9%) patients died. Kaplan-Meier analysis shows that the AFS rates for 8 years were 47.0%, 56.9% and 69.5% in T1, T2 and T3 of GNRI, and were 65.8%, 58.7% and 33.2% in T1, T2 and T3 of CRP, respectively (p&amp;lt;0.0001 in both). After adjustment for male, age, previous coronary artery disease, procedure (EVT vs. bypass surgery), below-knee artery disease and ulcer/gangrene as covariates with p&amp;lt;0.05 by univariate analysis, declined GNRI [hazard ratio (HR) 2.18, 95% confidence interval (CI) 1.57-3.07, p&amp;lt;0.0001 for T1 vs. T3] and elevated CRP (HR 1.78, 95%CI 1.24-2.59, p=0.0016 for T3 vs. T1) were identified as independent predictors of amputation and/or mortality. In the combined setting of both variables, the risk of amputation and/or mortality was 3.77-fold higher (95%CI 1.97-7.69, p&amp;lt;0.0001) in the group with T1 of GNRI and T3 of CRP than in that with T3 of GNRI and T1 of CRP (Figure). Addition of GNRI and CRP in a predicting model with established risk factors improved C-statistics (0.661 to 0.716, p=0.0021) greater than that of each alone. Conclusion Among HD patients undergoing lower extremity revascularization for PAD, those with pre-procedural declined GNRI and elevated CRP frequently experienced amputation and/or mortality, furthermore, combination of both variables could more accurately stratify the risk of amputation and/or mortality.

Beta-blockers after STEMI: prognostic impact and predictors of adherence, results from the real-world FAST-STEMI registry

Abstract Background The impact of beta-blocker therapy on cardiovascular outcomes after ST-elevation acute myocardial infarction (STEMI) is debated. Adherence to beta-blockers after acute myocardial infarction and effect on long term cardiovascular outcomes are also fields with significant knowledge gaps. Purpose To identify predictors of lower compliance to beta-blocker therapy and estimate its impact on cardiovascular outcomes and mortality during the first year of follow-up after the index event. Methods We evaluated real-world adherence to the most common cardiovascular drugs by comparing the number of tablets bought in pharmacies to the expected number of tablets needed at 1 year and at the final follow-up. A total of 6043 patients with STEMI were enrolled in the FAST-STEMI registry from 2012 to 2017 and followed up for 4.7±1.6 years. 299 patients with intraprocedural and intrahospital deaths were excluded. The main outcomes evaluated were all-cause death, cardiovascular death, myocardial infarction, major and minor bleeding events, and ischemic stroke. The best compliance cut-off was found by ROC curve analysis with Youden index; Kaplan Meier and Cox proportional hazard models were performed to evaluate cumulative event rates of mortality at follow-up. Predictors of lower adherence were evaluated in univariate and multivariate analyses with logistic regression. Results A total of 4992 patients with beta-blockers prescription at discharge were enrolled: mean age was 64±12.3 years old, 76% were male, mean ejection fraction was 49±8.8%. Mean adherence to beta-blockers was 95,8% (IQR 82.2-100). After univariate and multivariate analyses, age over 75 years old (OR 0.76, 95%CI 0.63-0.91) and previous coronary artery disease (OR 0.62, 95%CI 0.44-0.87) resulted as predictors of lower compliance, whereas concomitant ACEi/ARB prescription at discharge was a predictor of good adherence (OR 1.23, 95%CI 1.04-1.46). Adherence to beta-blockers higher than 65.68% (identified as best cut-off at Youden’s analysis) was related to a lower cardiovascular (0.65% vs 1.49%, p 0.009) and all-cause mortality (1.98% vs 4.48%, p &amp;lt;0.001). At multivariate analysis, adherence to beta-blockers was significantly associated with lower cardiovascular mortality (HR 0.40, 95%CI 0.20-0.81, p 0.01) as well as EF &amp;gt;50% (HR 0.30, 95%CI 0.14-0.63, p 0.002), while age over 75 years old (HR 4.72, 95%CI 2.23-9.98, p &amp;lt;0.001) and history of atrial fibrillation (HR 2.63, 95%CI 1.02-6.80, p 0.04) were associated with a higher risk of cardiovascular death. Finally, optimal adherence to beta-blockers did not reduce the number of myocardial infarctions, strokes, or bleeding events. Conclusions In our large real-world registry, optimal adherence to beta-blockers after STEMI was associated with a reduction in both cardiovascular and all-cause mortality. Older age and previous coronary artery disease resulted as predictors of poor compliance to beta-blocker therapy.Kaplan Meier on all-cause and CV deathMultivariate analysis on CV death

The effect of sodium-glucose co-transporter-2 inhibitors following anterior ST-segment elevation myocardial infarction

Abstract Background Sodium-glucose co-transporter-2 (SGLT-2) inhibitors have been clearly demonstrated to be associated with lower rate of new-onset heart failure(HF) in patients under risk of HF. In addition, due to lower rehospitalisation and better functional status in HF patients, SGLT-2 inhibitors have became the cornerstone of treatment regardless of the diabetes status. New-onset HF is very common in survivors of anterior ST-segment elevation myocardial infarction(STEMI) and requires preventive strategies, however the role of SGLT-2 inhibition in this population is not well established yet. Purpose In this study, we aimed to demonstrate the role of the SGLT-2 inhibitors in patients with anterior STEMI. Methods We prospectively enrolled patients with diabetes mellitus who had anterior STEMI, which was managed with primary percutaneous coronary intervention. Patients with previous myocardial infarction, heart failure, under SGLT-2 inhibitor treatment and chronic kidney disease were excluded. Patients were divided into two groups according to SGLT-2 inhibitor treatment; group 1 patients treated with empaglifosine or dapaglifosine and group 2 received other classes of diabetes medicine. Comorbidities regarding smoking history (p: 0.871), hypertension (p: 0.064), previous cerebrovascular accident(p: 0,348) and coronary artery disease(p: 0.201) were comparable between groups. Presence of multivessel coronary artery disease (p: 0.259) and left main coronary artery involvement (p: 0.062) were also similar between groups. Glucose level on admission was similar (p: 0.782) between groups, however HBa1C level was significantly higher in group 1(p: &amp;lt;0.001). Left ventricular ejection fraction which was calculated prior to hospital discharge was also similar between groups(p: 0.297). Mean follow-up duration was 12 months and new-onset heart failure was significantly lower in group 1 patients(p:&amp;lt;0.001). In line with the rate of new onset-heart failure, pro-BNP levels at the 12th month visit were lower in group 1 patients (p: 0.042) which was similar during the STEMI hospitalization (p: 0.668). Multivariate analyses demonstrated that the use of SGLT-2 inhibitors independently associated with lower rate of new-onset HF. Conclusion Our results indicate that SGLT-2 inhibitors decrease the rate of new-onset heart failure during the follow-up in patients with previous myocardial infarction.Baseline characteristicsUnivariate and multivariate analysis

Impact of coronary artery disease phenotype on treatment in chronic coronary syndromes: the EURECA registry

Abstract Background The EURECA registry aimed to assess the use of stress ECG and cardiac imaging in the diagnostic process of patients with chronic coronary syndrome (CCS). To which extent the coronary artery disease (CAD) phenotype, defined by the diagnostic process, may influence the management of these patients in clinical practice is not known. Purpose In the present analysis we aimed to evaluate the impact of the CAD phenotype on downstream therapeutic choices in the EURECA population. Methods Among the 5156 patients enrolled in the EURECA registry between May 2019 and March 2020, early treatment choices (within 6 months from enrolment) could be defined in 4874 patients (mean age 63.5 years, 59.7% males). They were categorized as: 1. no treatment change; 2. optimized medical treatment (OMT, i.e. new therapy or increase of previous therapy); 3. revascularization. The CAD phenotypes were defined in 3771 patients as: 1. no CAD; 2. non-obstructive CAD; 3. obstructive CAD without documented ischemia (including patients with no stress test performed); 4. obstructive CAD with documented ischemia. Results In 3049/4874 patients (63%) treatment was unchanged, in 1204 (24%) medical treatment was optimized and in 621 patients (13%) revascularization was performed. At the end of the diagnostic process, the disease phenotype was no CAD in 1409/3771 patients (37%), non-obstructive CAD in 1463 (39%), obstructive CAD without documented ischemia in 374 (10%) and obstructive CAD with documented ischemia in 525 patients (14%). In patients with non-obstructive CAD, medical treatment was optimized more frequently than in those with no CAD (34% vs 19%, P&amp;lt;0.001) but in 65% of these patients treatment was unchanged. In patients with obstructive CAD revascularization frequency was similar in patients without or with documented ischemia (60% vs 61%, P=NS) as well as OMT alone (21% and 18%, P=NS) (Figure 1). Revascularization or OMT alone were associated with enrolment in cardiology departments, older age, male gender, typical symptoms, higher frequency of risk factors, history of previous CAD and positive results of any non-invasive test (Figure 2). At multivariate analysis independent predictors of more intense treatment were enrolment in cardiology department (OR 1.55, 95% CI 1.30-1.83), typical angina (OR 1.96, 95% CI 1.69-2.27), hypertension (OR 1.29, 95% CI 1.11-1.49) and positivity of any non-invasive test. Conclusions In patients with CCS the diagnosis of non-obstructive CAD is associated with a suboptimal medical treatment. On the other hand, the diagnosis of anatomical obstructive CAD drives revascularization procedures, independently of documenting inducible ischemia. The intensity of treatment management depends on the overall estimation of patient risk based more on clinical variables and positivity of any diagnostic test than on specific disease phenotypes.Treatment according to CAD phenotypePredictors of revascularization or OMT

Abstract 12552: Unmasking Unstable Angina: The Crucial Influence of Chest Pain Perception in Hospital Management Strategies

Introduction: Managing unstable angina (UA) poses a significant challenge due to its subjective diagnosis and underrepresentation in pivotal clinical trials that have greatly influenced current practices. The aim of this study is to determine the key variables that impact the management of UA in a referral cardiology hospital. Hypothesis: In addition to prognostic scores, other factors such as the nature of chest pain may have a relevant role in the management of UA. Methods: This retrospective cohort study enrolled patients consecutive hospitalized with a diagnosis of UA from July 16, 2018 to February 28, 2020. The primary objective was to analyze the factors associated with the utilization of either an invasive or non-invasive strategy. The secondary objective sought to identify the factors associated with the presence of obstructive coronary artery disease (CAD) or ischemia, as determined by the results of complementary tests. Between-group comparisons were performed using multiple logistic regression analysis, with statistical significance set at a 5% level. Results: A total of 729 patients were included in the study, with a mean age of 62.9 years, with a male predominance (64.6%). Factors significantly associated with an invasive strategy were smoking (p = 0.001), type of chest pain (p &lt; 0.001), angina "in crescendo" (p = 0.006), TIMI risk (p = 0.006), and HEART score (p = 0.011). In the multivariate analysis, current smokers (OR 2.23, CI 95% 1.13-4.8) and type A chest pain (OR 3.39, CI 95% 1.93-6.66) were independently associated with the invasive strategy. Regarding the presence of obstructive CAD or ischemia, male gender (p = 0.032), exertional chest pain (p = 0.037), Diamond-Forrester (p = 0.026) and TIMI risk (p = 0.001) showed significant associations. In the multivariate analysis, the type of chest pain (type B chest pain: OR 0.6, CI 95% 0.38-0.93, p = 0.026) and presence of previous CAD (OR 1.42, CI 95% 1.01-2.0, p = 0.048) were independently associated with obstructive CAD or ischemia. Conclusion: Chest pain type is not only instrumental in diagnosing UA but also critical in shaping the suitable treatment approach. Our study emphasizes the significance of integrating pain traits with guidelines-endorsed scoring systems for optimal management.

Different prognostic significance of coronary artery and aortic valve calcium in patients with chest pain.

Coronary artery calcification (CorCa) identifies high cardiovascular risk in the general population. In this setting, aortic valve calcification (AoCa) showed contradictory results. Our goal has been to assess the prognostic power of CorCa and AoCa in patients with chest pain who underwent an ECG-gated cardiac multidetector CT (cardiac-MDCT). A total of 528 patients without previous known coronary artery disease, with chest pain who underwent a cardiac-MDCT multidetector, were retrospectively recruited. The primary endpoint included death, acute coronary syndrome, stroke, and heart failure. A total of 61 patients (11.6%) had an event during a mean follow-up of almost 6years (5.95 ± 2.98). The most frequent event was acute coronary syndrome (6.4%). Total mortality was 4.5%. Patients with CorCa > 0 had more events than those without CorCa (17.3% versus 4.3%; p < 0.001). Likewise, when only patients without AoCa were considered (n = 118), clinical events were more frequent in those with CorCa (12.7% versus 3.6%; p = 0.004). After excluding patients with coronary artery disease, events were more frequent in those with CorCa (12.6% versus 4.3%; p = 0.004). The higher the Agatston score, the more frequent the events. Patients with AoCa > 0 had more events than those without (16.5% versus 7.3%; p < 0.001), but in patients without CorCa, no difference in events was seen (6.2% versus 3.6%; p = 0.471). A Cox regression analysis showed age, smoking, prior stroke, and CorCa but not AoCa to be independently related to events. In summary, CorCa, but not AoCa, is related to cardiovascular events in patients with chest pain who undergo a cardiac-MDCT. We show that coronary artery calcification, but not aortic valve calcification, detected in a coronary CT scan is tightly related to cardiovascular events. Although this is a message already shown by other groups in the general population, we do believe that this work is unique because it is restricted to patients with chest pain sent to coronary CT. In other words, our work deals with what we face in our routine everyday practice. • The presence and the amount of coronary artery calcification are associated with cardiovascular events in patients with chest pain. • Aortic valve calcification is not associated with cardiovascular events in patients with chest pain.

Age-Specific Cardiovascular Risk Factors for Major Adverse Cardiac Events in Patients Undergoing Myocardial Perfusion Imaging.

The prevalence of traditional cardiovascular risk factors shows different age-specific patterns. It is not known whether the prognostic impact of risk factors is similarly age-specific. We evaluated the profiles of cardiovascular risk factors and their prognostic impact on coronary artery disease (CAD) in relation to age. We included 3667 patients with suspected or known CAD undergoing stress myocardial perfusion imaging (MPI). We evaluated the risk for major adverse cardiac events (MACE) within three years from the index MPI in patients belonging to three groups according to age tertile distribution: <59, 59-68, and >68 years. Gender, body mass index, diabetes, hypertension, dyslipidemia, family history of CAD, smoking, angina, dyspnea, previous CAD, and MPI outcome were assessed as risk factors by a multivariable Cox's regression. The three-year risk of MACE increased progressively with age and was 9%, 13%, and 18% for each group, respectively (p < 0.0001). Dyspnea and abnormal MPI outcome were significant risk factors for all age groups. Diabetes and smoking were significant from the age of 59 onwards, while hypertension resulted significant for patients older than 68 years. The number of risk factors was significantly associated with the occurrence of MACE increase with age. It is noteworthy that a personal history of CAD was not useful for risk stratification, while MPI results were.

Guideline-Directed Low-Density Lipoprotein Cholesterol Management After Acute Ischemic Stroke: Findings from a National Health Care Service

Patients with ischemic stroke are at high risk for future cardiovascular events and should be treated intensively with lipid-modifying agents. Combination lipid-lowering therapies are often needed to achieve updated guideline-directed treatment goals. However, real-world data on intensification of lipid-lowering therapies and attainment of low-density lipoprotein cholesterol (LDL-C) targets early after ischemic stroke are limited. We extracted data from the largest healthcare provider in Israel on patients hospitalized with acute ischemic stroke between January 2020 and February 2022. Included were 3,027 patients surviving ≥1 year after stroke, with documented LDL-C levels and lipid-lowering medications at 2 time periods (0 to 3months and 6 to 12months after discharge). Participants were classified according to preexisting stroke and/or coronary artery disease. The use of combination lipid-lowering therapy (ezetimibe and/or proprotein convertase subtilisin/kexin type 9 [monoclonal antibodies] inhibitor plus statin) in the study population increased between the 2 timepoints from 3.6% to 5.1%, reaching 10.5% in those with previous coronary artery disease and stroke. LDL-C levels <70 and <55mg/100ml were attained by 42.3% and 22.9% of patients early after hospitalization, and in 49.5% and 27.1% during 6 to 12months after hospitalization, respectively. Attainment of guideline-recommended LDL-C goals was higher in patients treated with combination lipid-lowering therapies and in those with preexisting cardiovascular disease. In conclusion, despite the advances in drug development and the availability of several mechanisms to lower cholesterol levels, the attainment of guideline-recommended LDL-C targets after acute ischemic stroke is suboptimal. Intensification of treatment with combination lipid-lowering therapies after hospitalization is uncommonly performed in clinical practice, even in those with preexisting cardiovascular disease.

Incidence and Prognostic Associations of Early Postoperative Stroke and Death Among Patients Undergoing Inner Branched Thoracic Endovascular Repair of Aortic Arch Pathologies: A Systematic Review and Meta-Analysis.

The objective of this systematic review was to assess the incidences and associations of early postoperative stroke and death among patients undergoing inner branched thoracic endovascular aortic repair (TEVAR) of arch pathologies. Electronic bibliographic sources (PUBMED, EMBASE, and CENTRAL) were searched up to February 2022 using a combination of thesaurus and free-text terms to identify the studies using branched TEVAR to treat aortic arch disease. The systematic review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. All observational studies investigating the prognosis of inner branched TEVAR in the treatment of aortic arch pathologies were included. Independent extraction of articles was performed by two authors using predefined data fields, including study quality indications. All pooled analyses were based on a random-effects or fixed model according to the heterogeneity. A total of 23 case series totaling 532 participants were included after screening. After optimized selection (largest sample size, most detailed data, lowest risk of bias) from the overlapping data, 12 studies with 289 participants were included in data synthesis. The pooled incidence of 30-day postoperative stroke was 10.6% (95% CI 7.0%-14.2%; p=.41, I2=3%). Pooled 30-day mortality was 4.9% (95% CI 2.0%-7.8%; p=.38, I2=7%). Combined early stroke/death was 15.7% (95% CI 11.2%-20.3%; p=.30, I2=15%). Subgroup analyses of 11 studies (without data missing) showed that a higher incidence of 30-day postoperative stroke was found in studies with aged participants (age≥71.3 years, p=.010), the higher percentage of COPD (≥30%, p= .011) and non-dissection-related pathologies (≥60.8%, p=.011). The higher 30-day postoperative mortality was found in studies with a high percentage of previous coronary artery disease (≥34.5%, p=.023). This review demonstrated that there were acceptable rates of 30-day postoperative stroke and death among patients undergoing inner branched TEVAR. It is strongly necessary to perform a rigorous risk assessment of aortic plaque embolism and coronary artery disease when the surgical plan of the inner branched TEVAR is determined. Treatment arch pathologies with inner branched TEVAR provides acceptable early stroke rate and mortality. Aortic pathology mainly influenced the early stroke rate, and early recognizing high-risk patients for aortic plaque embolism is of supreme importance for reducing the early stroke rate. In addition, the history of coronary artery disease was strongly associated with early mortality, and attention should be paid to the coronary artery assessment and perioperative management of these patients.

Baseline Cardiovascular Risk Factor Control in Patients With Type 2 Diabetes and Coronary Disease Versus Stroke: Secondary Analysis of Cardiovascular Outcome Trials.

Patients with type 2 diabetes (T2D) and cardiovascular disease are at increased risk for recurrent ischemic events. Cardiovascular risk factor control is vital for secondary prevention, but how this compares among individuals with different T2D macrovascular complications is unknown. We aimed to determine if there might be differences in risk factor control in patients with T2D with previous stroke versus coronary artery disease (CAD). Cross-sectional analyses were performed on 12 856 patients with T2D with prior history of stroke with or without CAD from 3 diabetes cardiovascular outcome trials: CARMELINA (The Cardiovascular and Renal Microvascular Outcome Study With Linagliptin), EMPA-REG OUTCOME (Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients), and CAROLINA (The Cardiovascular Outcome Study of Linagliptin vs Glimepiride in Type 2 Diabetes). Risk factors at baseline assessed included dyslipidemia, hypertension, smoking, and current antiplatelet/anticoagulant therapy. Control, respectively, was defined as LDL (low-density lipoprotein)-C <100 mg/dL or statin use, systolic blood pressure <140 and diastolic blood pressure <90 mm Hg, not currently smoking, and use of an antiplatelet/anticoagulant medication. The odds ratio of 3 to 4 (or good) versus 0 to 2 (or suboptimal) risk factors controlled was analyzed by logistic regression models. The odds for good versus suboptimal risk factor control in patients with CAD alone was higher than in those with stroke alone across all 3 trials odds ratios (95% CI): CARMELINA, 2.05 (1.67-2.51), EMPA-REG OUTCOME, 2.50 (2.10-2.99), and CAROLINA, 1.63 (1.21-2.20). The respective odds ratios were lower (and rendered nonsignificant in CAROLINA) when cardiovascular risk factor control in patients with both CAD and stroke were compared with those with stroke alone: CARMELINA, 1.45 (1.13-1.87); EMPA-REG OUTCOME, 1.62 (1.25-2.08); and CAROLINA, 1.16 (0.74-1.83). In contemporary populations of patients with T2D, there was significant discordance in control of cardiovascular risk factors between patients with stroke versus CAD, with the former having less optimal control. The intermediate results in patients with both CAD and stroke suggest that these differences could be related at least in part to clinician factors. URL: https://www. gov; Unique identifiers: NCT01243424, NCT01131676, NCT01897532.