Prior Myocardial Infarction Research Articles

Five-year Outcomes of Transcatheter Edge-to-Edge Repair in Patients with Mitral Regurgitation and Cardiogenic Shock

Objective: To analyze five-year clinical and echocardiographic outcomes in patients presenting with acute cardiogenic shock (CS) who underwent transcatheter edge-to-edge repair (TEER) for moderate or severe mitral valve regurgitation (MR). Methods: All consecutive patients who underwent TEER for MR were identified from our institutional medical records between 2015 and 2022. Patients presenting with CS undergoing TEER were included in the primary analysis. MR was diagnosed based on patient's echocardiographic findings and CS was diagnosed according to the definition in the TVT registry and/or presence of inotrope use prior to procedure and/or mechanical circulatory support prior to procedure. Kaplan-Meier survival curves were constructed to analyze outcomes. Primary outcome was five-year incidence of all-cause death. Secondary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE) and readmission for heart failure (HF). Results: A total of 35 patients were included in the study. Mean age was 81±10.4 years and 16 patients (45.7%) were male. Mean STS-score was 10.2±7.1. Nine (25.7%) patients had prior myocardial infarction (MI), 22 (62.8%) had previous atrial fibrillation, while 9 (25.7%) patients were hospitalized for HF within the past year. MR etiology was degenerative (71.4%), functional (22.9%), and mixed (5.7%). Prior to presentation with CS, NYHA classification included 2 (5,7%) patients in class I, 6 (17.1%) in class II, 13 (37.1%) in class III, and 14 (40%) in class IV. Pre-procedural mean LVEF was 56.4 ± 13%. Procedural characteristics included mean procedural time (from access to guide removal) of 2.0 ± 0.6 hours, > 1 implanted device in 14 (40.0%) patients, 1 patient had a single leaflet attachment. There was no procedural device embolism, device thrombosis, conversion to sternotomy, life threatening bleeding, stroke, MI, or death. Mean postoperative length of stay was 5.1 ± 4.4 days. During their hospital stay, a transient ischemic attack event occurred in 1 patient; however, no MI, stroke, or death were observed in any patient. During the follow-up, 13 (37.1%) patients were readmitted for HF, 1 patient needed mitral valve replacement and 1 patient needed new TEER. At 5 years, only 4 (11.4%) patients were alive. Conclusion: Despite excellent procedural and early outcomes for patients with significant MR and CS undergoing TEER, poor survival was observed after 5 years, which may be related to advanced age of this cohort.

Cardiac and Great Vessel Toxicity with Single Fraction Stereotactic Body Radiotherapy in Early-Stage Lung Cancer

The relationship between thoracic radiotherapy and cardiovascular (CV) morbidity is an area of interest. When considering stereotactic body radiotherapy (SBRT) in the management of early-stage lung cancer, reports suggest CV dose may correlate with survival. To study this association for single fraction SBRT (SF-SBRT), we performed a retrospective review of patients treated at our institution assessing for associations between this dose schedule and CV toxicity. For the interval 2010-2022, we surveyed our IRB-approved prospective registry for SF-SBRT patients with tumors within 1 cm of the heart or any of the great vessels (GVs). Distance of the tumor to these structures was stratified as: directly contacting, within 0.5 cm, from 0.5-1 cm, or > 1 cm. Medical records were reviewed post-SBRT for CV events including: myocardial infarction (MI), heart failure (HF), structural heart damage (valvular or wall abnormalities), vascular damage (aneurysm, dilation, other abnormalities), hemoptysis, and arrhythmia which were correlated with lesion location and history. Four hundred four patients treated with SF-SBRT to 34 Gy in 1 fraction were identified. 35 patients (8.7%) had 36 lesions within 1 cm of the heart or GVs. 68.6% of patients were female and 74.3% were Caucasian. The median age was 72.5 years (range: 60-91), median Charlson comorbidity score was 6, median KPS was 80, and median ASCVD score was 21.0%. 33 patients had a smoking history with a median of 50 pack years. 12 patients (34.3%) had an arrhythmia prior to SBRT, 5 (14.2%) had prior HF, and 9 (25.7%) had prior MI or CV disease. All cases were non-small cell lung cancer or radiographic malignancy with 1 case of small cell lung cancer. Median tumor size was 1.6 cm. 91.4% of patients had stage I disease. Median follow-up was 2.26 years (0.37-4.0). Seven lesions (19.4%) were abutting the heart or GVs, 14 (38.9%) were within 0.5 cm, and 15 (41.7%) were from 0.5-1 cm. 54 events were observed with a median of 1 event per patient (0-5). The most common events were arrhythmia (15), vascular damage (9), structural damage (12), heart failure (9), and MI (6). The most commonly associated vascular structure was the aortic arch, while the most commonly involved substructures of the heart were the right atrium and left ventricle. 12 events occurred in the direct contact group, 17 in the < 0.5 cm group, and 25 in the 0.5-1 cm group. Patients with heart associated lesions accounted for 8 events, while those with vessel associated tumors accounted for 46. While cardiac events are relatively common in the medically inoperable SBRT population, they did not appear to be more common with tumors directly contacting major cardiovascular structures than for those with some separation. Most events could be attributed to medical causes other than SBRT. Further study is needed to clarify the potential role of radiation in events without direct explanation.

Risk factors for major adverse cardiovascular events after coronary artery bypass grafting using radial artery grafts.

Coronary artery bypass grafting using radial artery grafts (RA-CABG) has improved long-term outcomes. However, major adverse cardiovascular events (MACE-4, including all-cause death, myocardial infarction, stroke, and repeat revascularization) after RA-CABG still occur and the predictors remain uncertain. This study aimed to detect independent risk factors of MACE-4 after RA-CABG. This is a retrospective case-control study (NCT04935086) conducted among patients who underwent primary isolated RA-CABG between 2009 and 2019 in our center. Baseline characteristics, procedure characteristics, and medication use were compared to identify the independent predictors of MACE-4, all-cause death, and myocardial infarction (MI) with univariate and then multivariate logistic regression. A total of 370 patients were analyzed using a mean follow-up duration of 48.8 ± 41.0 months. MACE-4, all-cause death, and MI occurred in 102 (27.6%), 27 (7.3%), and 66 patients (17.8%), respectively. Multivariate analysis revealed prior MI (OR = 2.12, 95%CI 1.05-4.25, P = 0.04) and RA to the left anterior descending artery (LAD) (non-left internal mammary artery to LAD) (OR = 4.87, 95%CI 1.41-16.82, P = 0.01) as independent predictors of MACE-4 after surgery. Female (OR = 4.53, 95%CI 1.06-19.41, P = 0.04), left ventricular ejection fraction (LVEF) <40% (OR = 21.00, 95%CI 1.20-368.35, P = 0.04), and RA to LAD (OR = 8.55, 95%CI 1.35-54.10, P = 0.02) were independent predictors of all-cause death. Prior MI (OR = 3.11, 95%CI 1.40-6.94, P = 0.006) emerged as an independent predictor of MI. Our data suggested that prior MI and RA to LAD were independent predictors of MACE-4 after RA-CABG. Being female, having an LVEF < 40% and RA to LAD indicated death. Prior MI indicated new MI.

Effect of Telehealth Services on Mitral and Tricuspid Regurgitation Progression: Retrospective Study.

Mitral regurgitation (MR) and tricuspid regurgitation (TR) are common cardiac conditions with high mortality risks, which can be improved through early intervention. Telehealth services, which allow for remote monitoring of patient conditions, have been proven to improve the health management of chronic diseases, but the effects on MR and TR progression are unknown. This study aimed to explore whether patients receiving telehealth services have less MR and TR progression compared with a control group. We also aimed to identify the determinants of MR and TR progression. This single-center retrospective study conducted at the National Taiwan University Hospital compared MR and TR progression (defined as either progression to moderate or greater MR and TR or MR and TR progression by ≥2 grades during the study period) between the telehealth and control groups. Patients had a minimum of 2 transthoracic echocardiograms at least 6 months apart; baseline mild-moderate MR and TR or lower; and no prior surgeries on the mitral or tricuspid valve. Telehealth patients were defined as those who received telehealth services for at least 28 days within 3 months of baseline. Basic demographics, baseline blood pressure measurements, prescribed medication, and Charlson Comorbidity Index components were obtained for all patients. A total of 1081 patients (n=226 in the telehealth group and n=855 in the control group) were included in the study analyses. The telehealth group showed significantly lower baseline systolic blood pressure (P<.001), higher Charlson Comorbidity Index (P=.02), higher prevalence of prior myocardial infarction (P=.01) and heart failure (P<.001), higher beta-blocker (P=.03) and diuretic (P=.04) use, and lower nitrate use (P=.04). Both groups showed similar cardiac remodeling conditions at baseline. Telehealth was found to be neutral for both MR (hazard ratio 1.10, 95% CI 0.80-1.52; P=.52) and TR (hazard ratio 1.27, 95% CI 0.92-1.74; P=.14) progression. Determinants for moderate or greater MR progression included older age, female sex, diuretic use, larger left atrial dimension, left ventricular end-diastolic dimension, left ventricular end-systolic dimension, and lower left ventricular ejection fraction. Determinants of moderate or greater TR progression included older age, female sex, diuretic use, presence of atrial fibrillation, LA dimension, left ventricular end-systolic dimension, and lower left ventricular ejection fraction; statin use was found to be protective. This is the first study to assess the association between telehealth services and the progression of MR and TR. Telehealth patients, who had more comorbidities, displayed similar MR and TR progression versus control patients, indicating that telehealth may slow MR and TR progression. Determinants of MR and TR progression included easy-to-measure traditional echo parameters of cardiac function, older age, female sex, and atrial fibrillation, which can be incorporated into a telehealth platform and advanced alert system, improving patient outcomes through personalized care.

Risk Factors Associated With Postoperative Cardiac Events Following Total Hip and Knee Arthroplasty

BackgroundThis study investigated the prevalence of adverse cardiac events following a total joint arthroplasty and subsequently analyzed risk factors that may increase the likelihood of these events. MethodsData for this study were extracted from a large national database. Chi-squared analyses and multivariate modelings were performed to determine the risk factors associated with 30-day perioperative troponin elevation, myocardial infarction (MI), and heart failure. We identified 80,544 total hip arthroplasty (THA) patients and 112,531 total knee arthroplasty (TKA) patients and analyzed the following cardiac risk factors: diabetes, renal insufficiency, prior MI, hypertension, and cerebrovascular disease. ResultsThere were 34% of THA patients and 52% of TKA patients who had at least one of the studied risk factors. At-risk THA patients had 2.2, 5.9, and 5.3 times the odds of troponin elevation, MI, and postoperative heart failure, respectively, within 1 month compared to the control group (P < .0001). The TKA group had 2.9, 5.3, and 5.9 times the odds of troponin elevation, MI, and postoperative heart failure within 1 month compared to the control group (P < .0001). For both procedures, prior MI had the highest odds of resulting in perioperative troponin elevation and MI. Renal insufficiency had the highest odds of resulting in perioperative heart failure. ConclusionsRisk stratification for postoperative complications in orthopedic surgery is important to minimize adverse outcomes. This study highlights the need for consideration of risk factors prior to joint arthroplasty surgery. Level of EvidenceLevel III, Prognostic.

PRIME score for prediction of permanent pacemaker implantation after transcatheter aortic valve replacement.

We sought to produce a simple scoring system that can be applied at clinical visits before transcatheter aortic valve replacement (TAVR) to stratify the risk of permanent pacemaker (PPM) after the procedure. Atrioventricular block is a known complication of TAVR. Current models for predicting the risk of PPM after TAVR are not designed to be applied clinically to assist with preprocedural planning. Patients undergoing TAVR at the University of Colorado were split into a training cohort for the development of a predictive model, and a testing cohort for model validation. Stepwise and binary logistic regressions were performed on the training cohort to produce a predictive model. Beta coefficients from the binary logistic regression were used to create a simple scoring system for predicting the need for PPM implantation. Scores were then applied to the validation cohort to assess predictive accuracy. Patients undergoing TAVR from 2013 to 2019 were analyzed: with 483 included in the training cohort and 123 included in the validation cohort. The need for a pacemaker was associated with five preprocedure variables in the training cohort: PR interval > 200 ms, Right bundle branch block, valve-In-valve procedure, prior Myocardial infarction, and self-Expandable valve. The PRIME score was developed using these clinical features, and was highly accurate for predicting PPM in both the training and model validation cohorts (area under the curve 0.804 and 0.830 in the model training and validation cohorts, respectively). The PRIME score is a simple and accurate preprocedural tool for predicting the need for PPM implantation after TAVR.

Patient and provider perspectives on barriers to myocardial infarction care among persons with human immunodeficiency virus in Tanzania: A qualitative study.

People with HIV (PLWH) have an increased risk myocardial infarction (MI), and evidence suggests that MI is under-diagnosed in Tanzania. However, little is known about barriers to MI care among PLWH in the region. In this qualitative study grounded in phenomenology, semi-structured interviews were conducted in northern Tanzania. Purposive sampling was used to recruit a diverse group of providers who care for PLWH and patients with HIV and electrocardiographic evidence of prior MI. Emergent themes were identified via inductive thematic analysis. 24 physician and patient participants were interviewed. Most participants explained MI as caused by emotional shock and were unaware of the association between HIV and increased MI risk. Providers described poor provider training regarding MI, high out-of-pocket costs, and lack of diagnostic equipment and medications. Patients reported little engagement with and limited knowledge of cardiovascular care, despite high engagement with HIV care. Most provider and patient participants indicated that they would prefer to integrate cardiovascular care with routine HIV care. PLWH face many barriers to MI care in Tanzania. There is a need for multifaceted interventions to educate providers and patients, improve access to MI diagnosis, and increase engagement with cardiovascular care among this population.

ПЕРСОНИФИЦИРОВАННЫЙ ПОДХОД К ОЦЕНКЕ РИСКА РАЗВИТИЯ ПОВТОРНЫХ СЕРДЕЧНО-СОСУДИСТЫХ СОБЫТИЙ И ХРОНИЧЕСКОЙ БОЛЕЗНИ ПОЧЕК У ПАЦИЕНТОВ С ИНФАРКТОМ МИОКАРДА И ОСТРЫМ ПОВРЕЖДЕНИЕМ ПОЧЕК

Introduction: AKI (acute kidney injury) is a common comorbid condition in patients with AMI (acute myocardial infarction), complicating its course and treatment. In the future, the prognosis of these patients after discharge from the hospital, as well as the incidence of recurrent cardiovascular events (CVS) and chronic kidney disease (CKD) are not known. The purpose of the study: to study the predictors of the development of recurrent cardiovascular events (CVS) in patients with myocardial infarction (MI) with acute kidney injury (AKI). Develop a calculator - a risk meter for repeated CCC. Materials and methods: the study was performed in the Altai Regional Cardiological Dispensary. 193 patients with MI and PCI (percutaneous coronary intervention) were included, divided into 2 groups: the first - 123 patients aged 62.8±1.1 years with MI and AKI, the second - 70 patients without AKI, age 61.3± 1.6 years. Upon admission and before discharge, the level of the KIM-1 molecule (Kidney Injury Molecule-1) and IL-18 (interleukin-18) was studied by ELISA in the urine. All patients underwent coronary angiography using low-osmolar contrast. One year after discharge, the frequency of development of repeated CCC was assessed. Statistical calculations were carried out using statistical packages STATISTICA 12.0. The level of statistical significance was taken equal to 0.05. Results. The level of KIM-1 (at admission) in the first group was statistically higher than in the second: 1998.9±147.6 versus 1289.8±126.1 pg/ml p=0.001, and IL-18 in the AKI group exceeded the corresponding parameter of the group without AKI: 179.0±12.9 versus 114.9±11.5 pg/ml p=0.007, respectively. A year later, it was found that the frequency of recurrent cardiovascular events was higher in the group with AMI and AKI: unstable angina was diagnosed in 26 (21.1%) patients in the group with AKI and 5 (7.1%) patients without AKI in history, p=0.010; 19 (15.4%) and 2 (2.8%) patients, p=0.006, 20 (16.2%) and 3 (4.2%), p=0.013 patients, respectively, had repeated myocardial infarction and progression of CHF in a year . Progression of renal dysfunction during the year was observed 5 times more often in patients with MI and AKI: CKD C2 was diagnosed in 49 (39.8%) patients of the first group and 16 (22.8%) of the second, p = 0.01; CKD C3a and C3b stages - in 34 (27.6%), p˂0.001 and 19 (15.4%) patients, p=0.002, respectively, CKD stage C4 was detected in 4 (3.2%) patients of the group with AMI and AKI in the early postinfarction period. As a result of constructing a multifactorial logistic regression model, predictors were identified that have a multiplicative effect on the development of recurrent CV events: BMI over 25 kg/m2 increases the risk of recurrent CV events by 0.91 [0.83; 0.99] times, p=0.028, history of prior MI in 3.32 [1.24; 9.86] times, p=0.022. Increase in CRP by 1.01 [1; 1.03] times, p=0.045, troponin I, 0.97 [0.94;1] times, p=0.037, and IMT-1, 1 [1;1] times, p=0.030. On the development of CKD: an increase in age is associated with an increase in the chances of developing CKD by 1.18 [1.1; 1.29], p ˂0.001; troponin I by 0.96 times [0.92; 1], p=0.030; systolic blood pressure in 1.03 [1; 1.07] times, p = 0.029. A calculator has been developed for risk stratification of the development of recurrent CV events and an algorithm for managing this category of patients after discharge from the hospital. Conclusions: thus, the identified predictors make it possible to calculate the risk of developing recurrent CV events and CKD using the developed calculator and allocate these patients to a separate group for personalized observation, taking appropriate measures of secondary prevention.

Reduced Left Ventricular Twist Early after Acute ST-Segment Elevation Myocardial Infarction as a Predictor of Left Ventricular Adverse Remodelling.

The left ventricular (LV) remodelling process represents the main cause of heart failure after a ST-segment elevation myocardial infarction (STEMI). Speckle-tracking echocardiography (STE) can detect early deformation impairment, while also predicting LV remodelling during follow-up. The aim of this study was to investigate the STE parameters in predicting cardiac remodelling following a percutaneous coronary intervention (PCI) in STEMI patients. The study population consisted of 60 patients with acute STEMI and no history of prior myocardial infarction treated with PCI. The patients were assessed both by conventional transthoracic and ST echocardiography in the first 12 h after admission and 6 months after the acute phase. Adverse remodelling was defined as an increase in LVEDV and/or LVESV by 15%. Adverse remodelling occurred in 26 patients (43.33%). By multivariate regression equation, the risk of adverse remodelling increases with age (by 1.1-fold), triglyceride level (by 1.009-fold), and midmyocardial radial strain (mid-RS) (1.06-fold). Increased initial twist decreases the chances of adverse remodelling (0.847-fold). The LV twist presented the largest area under the receiver operating characteristic (ROC) curve to predict adverse remodelling (AUROC = 0.648; 95% CI [0.506;0.789], p = 0.04). A twist value higher than 11° has a 76.9% specificity and a 72.7% positive predictive value for reverse remodelling at 6 months.

Dynamics of Non-Invasive Risk Factors of Sudden Cardiac Death after Myocardial Revascularization

Background: An attempt was made to study the effect of surgical myocardial revascularization on the processes of electrical myocardium instability underlying the occurrence of life-threatening ventricular arrhythmias, as well as the possibility of its non-invasive assessment by studying heart rate variability (HRV) and heart rate turbulence (HRT), as well as the duration and dispersion of the QT interval. Based only on the presence of viable myocardium, it is often impossible to predict the positive impact of revascularization on a patient’s prognosis, especially with reduced myocardial contractility. Moreover, given the well-studied relationship between myocardial remodeling and neurohormonal activation, non-invasive methods for assessing the autonomic regulation of cardiac activity can provide additional diagnostic information. Along with this, changes in these indicators and their prognostic role in patients with coronary artery disease after revascularization are subjects of discussion. Methods and Results: All patients underwent a comprehensive clinical and biochemical blood test, transthoracic echocardiography, tissue Doppler echocardiography, ultrasound examination of brachiocephalic arteries, selective coronary angio- and ventriculography, as well as Holter monitoring. Results show that a year after the coronary intervention, there was a significant positive trend in the frequency and structure of ventricular arrhythmias (VA). HRV indicators generally did not show significant dynamics. Only an increase in the values of the SDANN and low-frequency power (LFP) indices was noted, indicating a gradual increase in the activity of the sympathetic part of the autonomic nervous system. HRT indicators also did not show significant dynamics. A significant increase was found in the number of patients with no signs of impaired HRT. The average duration of the QT interval decreased significantly. There was also a tendency to shorten the corrected QT interval; however, it was insignificant. In terms of dispersion, both the QT interval and its corrected index, no significant dynamics were recorded in the general group of patients. Conclusion: Our study found that in patients with prior myocardial infarction, after revascularization, significant positive dynamics were recorded in life-threatening ventricular arrhythmias, but were unreliable for the indicators of autonomic regulation of cardiac activity, such as HRV and HRT.

Impact of Preprocedural Diastolic Blood Pressure on Outcomes in Patients Undergoing Percutaneous Coronary Intervention.

Recent US guidelines recommend lower blood pressure (BP) targets in hypertension, but aggressive lowering of diastolic BP (DBP) can occur at the expense of myocardial perfusion, particularly in the presence of coronary artery disease. We sought to establish the long-term impact of low DBP on mortality among patients undergoing percutaneous coronary intervention with well-controlled systolic BP. We analyzed data from 12 965 patients undergoing percutaneous coronary intervention between 2009 and 2018 from the Melbourne Interventional Group registry who had a preprocedural systolic BP of ≤140 mm Hg. Patients with ST-elevation myocardial infarction, cardiogenic shock, and out-of-hospital arrest were excluded. Patients were stratified into 5 groups according to preprocedural DBP: <50, 50 to 59, 60 to 69, 70 to 79, and ≥80 mm Hg. The primary outcome was long-term, all-cause mortality. Mortality data were derived from the Australian National Death Index. Patients with DBP<50 mm Hg were older with higher rates of diabetes, renal impairment, prior myocardial infarction, left ventricular dysfunction, peripheral and cerebrovascular disease (all P<0.001). Patients with DBP<50 mm Hg had higher 30-day (2.5% versus 0.7% for the other 4 quintiles; P<0.0001) and long-term mortality (median, 3.6 years; follow-up, 29% versus 11%; P<0.0001). Cox-regression analysis revealed that DBP<50 mm Hg was an independent predictor of long-term mortality (hazard ratio [HR], 1.55 [95% CI, 1.20-2.00]; P=0.001). In patients with well-controlled systolic BP undergoing percutaneous coronary intervention, low DBP (<50 mm Hg) is an independent predictor of long-term mortality.

Impact of age on pre-procedural TIMI flow in STEMI patients undergoing primary percutaneous coronary intervention.

Advanced age is a major determinant of impaired prognosis among patients with ST-segment elevation myocardial infarction (STEMI). However, the mechanisms associated with suboptimal reperfusion and enhanced complications are still largely undefined. The aim of the present study was to assess the impact of age on the angiographic findings and the procedural results of primary percutaneous coronary intervention (pPCI) in patients with STEMI. A consecutive cohort of patients admitted for STEMI treated with pPCI were included. Infarct-related artery (IRA) patency was defined for preprocedural TIMI flow 3. We included 520 patients, divided according to age tertiles (<61; 61-72; ≥73). Elderly patients were more often females, with hypertension, renal failure, prior myocardial infarction or PCI, with lower rates of smoking history, haemoglobin, leukocytes and cholesterol (P < 0.001), lower ejection fraction (P = 0.02), higher use of renin angiotensin system inhibitors, statins, ASA, calcium antagonists, diuretics and beta blockers. At angiography, for the IRA, percentage of thrombus (P = 0.02) and stenosis (P = 0.01), direct stenting (P = 0.02) and glycoprotein IIb-IIIa inhibitors (P = 0.04) inversely related with age, but for higher restenosis (P = 0.04). IRA patency was more common in patients aged ≥73 years (27.9% vs. 32.3% vs. 41.1%, P = 0.01). The impact of age on preprocedural TIMI flow was confirmed at multivariate analysis [adjusted odds ratio (95% confidence interval) = 0.68 (0.47-0.98), P = 0.04]. The present study shows that among STEMI patients undergoing primary PCI, more advanced age represents an independent predictor of preprocedural IRA patency. Future studies will define the implications on procedural results and long-term prognosis.

Single-Site Review of Spinal Cord Protection Protocols Including the Utilization of Spinal Drains versus Medical Management with Branched Endovascular Aortic Repair

Spinal cord ischemia (SCI) continues to be a devastating complication after repair of thoracoabdominal aortic aneurysms. The objective of this review is to present our single-center outcomes after the implementation of a standardized neuroprotective protocol following branched endovascular aortic repair. A standardized neuroprotective protocol including preoperative steroids, acetazolamide, intraoperative hemodynamic parameters, and postoperative treatment goals was initiated in November 2019. Physician-modified branched endovascular repairs were completed at a single center from 2012 to 2021 with outcomes reviewed both before (n=107) and after (n=67) the implementation of the neuroprotective protocol. The primary end point was the incidence of any SCI event at 30 days. Secondary end points included all-cause mortality, stroke, myocardial infarction, and renal failure at 30 days. Patients with Crawford extents I-III, renal failure, or necessitating emergent repair were deemed high risk for SCI events and underwent a subset analysis. Survivability after SCI was estimated using Kaplan-Meier tables. Of the 174 consecutive patients treated, the 67 patients treated following implementation of the neuroprotective protocol were more likely to have experienced a prior myocardial infarction (26.9% vs. 14%; P=0.0466) and have a history of chronic obstructive pulmonary disease (64.3% vs. 45.8%; P=0.02). This group was more likely to be treated for paravisceral aneurysms (53.7% vs. 24.3%; P=0.0002). Postprotocol implementation, spinal drain use was lower (6% vs. 38.3%; P = <0.0001) with 100% of these drains placed in urgent or unstaged thoracoabdominal aortic aneurysm repairs as a part of the protocol. Rates of any SCI event among all patients before and after implementation of the protocol were 9.3% (n=10 of 107) and 6% (n=4 of 67; P=0.57), respectively. In comparison, the protocol significantly reduced SCI rates to 0 (0% vs. 17.1%; P=0.0407) in high-risk patients. Frequency of renal failure was reduced (3% vs. 14%; P=0.018) after initiation of the protocol. Patients in the postprotocol group had significantly improved 1-year mortality rate (9% vs. 27.1%; P=0.0035) and renal failure rates (2% vs. 15%; P=0.018). Regression models indicated that patients in the postprotocol group had lower likelihood of mortality and renal failure than patients in preprotocol group (P<0.05) and that spinal drain reduced mortality (P<0.1). Implementation of a standardized neuroprotective protocol that focuses on medical management and fluid dynamics may significantly reduce risk of SCI after branched endovascular repairs, with the most significant improvement of SCI outcomes involving those at greatest risk for developing SCI. Also noteworthy, there was significant improvement to 1-year survivability after the implementation of this neuroprotective protocol.

Characteristics and outcomes in patients with a prior myocardial infarction treated with extended dual antiplatelet therapy with ticagrelor 60 mg: findings from ALETHEIA, a multi-country observational study.

Guidelines recommend extended dual antiplatelet therapy (DAPT), including ticagrelor 60mg twice daily, in high-risk post myocardial infarction (MI) patients who have tolerated 12 months and are not at high bleeding risk. The real-world utilization and bleeding and ischemic outcomes associated with long-term ticagrelor 60mg in routine clinical practice have not been well described. Register and claims data from US (Optum Clinformatics, IBM MarketScan, Medicare) and Europe (Sweden, Italy, UK, Germany) were extracted. Patients initiating ticagrelor 60mg≥12 months after MI, meeting eligibility criteria for PEGASUS-TIMI 54 trial, were included. The cumulative incidence of the composite of MI, stroke, or all-cause mortality, and of bleeding requiring hospitalization were calculated. Meta-analyses were performed to combine estimates from each source. 7035 patients treated with ticagrelor 60mg met eligibility criteria. Median age was 67 years and 29% were females; 12% had a history of multiple MIs. The majority (95%) had been treated with ticagrelor 90mg prior to initiating ticagrelor 60mg. At 12 months from initiation of ticagrelor 60mg, the cumulative incidence (95% CI) of MI, stroke or mortality was 3.33% (2.73-4.04) and was approximately three-fold the risk of bleeding (0.96%; 0.69-1.33). This study provides insights into the use of ticagrelor 60mg in patients with prior MI in clinical practice. Observed event rates for ischemic events and bleeding generally align with those in the pivotal trials, support the established safety profile of ticagrelor, and highlight the significant residual ischemic risk in this population.Clinical Trials.gov Registration NCT04568083.

Baseline characteristics of patients enrolled in the EMPACT-MI trial.

Empagliflozin has been shown to reduce the risk of adverse cardiovascular outcomes in patients with type 2 diabetes and in those with heart failure. The impact of empagliflozin in post-acute myocardial infarction (AMI) patients is unknown. The Study to Test the Effect of Empagliflozin on Hospitalization for Heart Failure and Mortality in Patients with Acute Myocardial Infarction (EMPACT-MI) trial screened 6610 participants with AMI and randomized 6522 to empagliflozin or placebo in addition to standard of care. The median (interquartile) age was 64 (56-71) years and 75.1% of patients were male. Major comorbidities included hypertension (69.1%), type 2 diabetes (31.7%), prior myocardial infarction (13.0%), and atrial fibrillation (10.9%). The majority (74.3%) of patients presented with an ST-elevation myocardial infarction. Overall, 56.9% of patients had acute signs or symptoms of congestion requiring treatment and 78.3% had left ventricular systolic dysfunction with ejection fraction <45%. Clinical characteristics, including baseline demographics, rates of revascularization, and cardiovascular medications at discharge were largely comparable to recent trials of the post-AMI population. The EMPACT-MI trial will establish the benefit and risks of empagliflozin treatment in patients with AMI.

Survival Benefit of Kidney Transplantation in Patients With End-Stage Kidney Disease and Prior Acute Myocardial Infarction.

Patients with end stage kidney disease (ESKD) and a previous acute myocardial infarction (AMI) have less access to KT. Data on ESKD patients with an AMI history who underwent first KT or dialysis between January 2007 and December 2018 were extracted from the Korean National Health Insurance Service. Patients who underwent KT (n = 423) were chronologically matched in a 1:3 ratio with those maintained on dialysis (n = 1,269) at the corresponding dates, based on time-conditional propensity scores. The 1, 5, and 10years cumulative incidences for all-cause mortality were 12.6%, 39.1%, and 60.1% in the dialysis group and 3.1%, 7.2%, and 14.5% in the KT group. Adjusted hazard ratios (HRs) of KT versus dialysis were 0.17 (95% confidence interval [CI], 0.12-0.24; p < 0.001) for mortality and 0.38 (95% CI, 0.23-0.51; p < 0.001) for major adverse cardiovascular events (MACE). Of the MACE components, KT was most protective against cardiovascular death (HR, 0.23; 95% CI, 0.12-0.42; p < 0.001). Protective effects of KT for all-cause mortality and MACE were consistent across various subgroups, including patients at higher risk (e.g., age >65years, recent AMI [<6months], congestive heart failure). KT is associated with lower all-cause mortality and MACE than maintenance dialysis patients with a prior AMI.

Ups and downs in PCSK9 inhibition in the cardiovascular arena: a review.

This article reviews PCSK9 inhibitors (PCSK9i) with a focus on clinically relevant studies published in the last 18 months. Prespecified subgroup evaluations, secondary analyses, and open-label extension studies from the two landmark trials, FOURIER and ODYSSEY Outcomes, have provided new data on the safety and efficacy of the monoclonal PCSK9 antibodies evolocumab and alirocumab. Recent studies of PCSK9i early in ACS and post percutaneous coronary intervention have explored early effects on biomarkers and plaque morphology with various imaging modalities. Two large outcome trials with PCSK9i in lower risk patients without prior myocardial infarction or stroke are ongoing and could expand the eligible population for these potent therapies. Additionally, novel methods to inhibit PCSK9 using oral administration, vaccination, and gene therapy are in various stages of clinical development. PCSK9i represent a potent class of lipid-lowering therapies that are well tolerated and effective in a wide group of patients with high-risk atherosclerotic cardiovascular disease. Ongoing studies of PCSK9i in patients at lower risk and with acute myocardial infarction have the potential to broaden their indication. Alternative methods of PCSK9i are being evaluated and could provide easier and less expensive options for this important class of medication.

Acute human defibrillation performance of a subcutaneous implantable cardioverter-defibrillator with an additional coil electrode

The subcutaneous implantable cardioverter-defibrillator (S-ICD) delivers 80 J shocks from an 8 cm left-parasternal coil to a 59 cm3 left lateral pulse generator (PG). A system that defibrillates with lower energy could significantly reduce PG size. Computer modeling and animal studies suggested that a second shock coil either parallel to the left-parasternal coil or transverse from the xiphoid to the PG pocket would significantly reduce the defibrillation threshold. The purpose of this study was to acutely assess the defibrillation efficacy of parallel and transverse configurations in patients receiving an S-ICD. Testing was performed in patients receiving a conventional S-ICD system. Success at 65 J was required before investigational testing. A second electrode was temporarily inserted from the xiphoid incision connected to the PG with an investigational Y-adapter. Phase 1 (n = 11) tested the parallel configuration. Phase 2 (n = 21) tested both parallel and transverse configurations in random order. This study enrolled 35 patients (28 males (80%); mean age 51 ± 17 years; left ventricular ejection fraction 40% ± 15%; body mass index 26 ± 4 kg/m2; prior myocardial infarction 46%; congestive heart failure 49%; cardiomyopathy 63%). Compared to the conventional S-ICD system, mean shock impedance decreased for both parallel (69 ± 15 Ω vs 86 ± 20 Ω; n = 33; P < .001) and transverse (56 ± 14 Ω vs 81 ± 21 Ω; n = 20; P < .001) configurations. Shock success rates at 20, 30, and 40 J were 55%, 79%, 97%, and 25%, 70%, 90% for parallel and transverse configurations, respectively. Defibrillation threshold testing was well tolerated with no serious adverse events. Adding a second shock coil, particularly in the parallel configuration, significantly reduced the impedance and had a high likelihood of defibrillation success at energies ≤40 J. This may enable the development of a smaller S-ICD.

Role of collateral circulation in the recovery of left ventricular function after recanalization of chronic coronary total occlusion

Aim. To obtain extended data on the impact of collateral circulation on the recovery of left ventricular (LV) function after recanalization of chronic coronary total occlusion (CTO), especially in patients with reduced left ventricle ejection fraction (LVEF).Material and methods. This single-center, prospective, non-randomized study included 20 patients with single-vessel CTO with reduced LVEF (&lt;50%), confirmed by magnetic resonance imaging (MRI), who underwent successful recanalization. All patients were divided into 2 groups depending on the severity of collateral circulation. After 1, 3 and 6 months, MRI was repeated to assess LV function recovery.Results. All patients had prior myocardial infarction, while in 70% of cases — in the area of the occluded artery. A previous attempt to recanalize CTO was noted in 30%. The mean baseline LVEF according to echocardiography was 38,80±6,72%. The most common target vessel was the right coronary artery (n=17, 85%), followed by the circumflex and anterior descending arteries — 1 (5%) and 2 (10%) patients, respectively. In the group with high collateral circulation, the initial LVEF according to MRI was higher compared to the group with mild collateral circulation (35,8±7,33% vs 30,7±8,82%, p=0,17). After 6 months, MRI showed significant changes in end-diastolic volume (from 226±71,1 ml to 203±55,2 ml) and LV endsystolic volume (from 153±72,8 ml to 118±57,6 ml), as well as mean increase in LVEF by 3,3%, 4,8% and 5,2% at 1, 3 and 6 months, respectively (p=0,01 compared with baseline). The predictors of LVEF recovery in multivariate regression analysis were the initial LVEF according to MRI, and the filling rate of distal CTO bed on coronary angiography (R2=0,63).Conclusion. Successful percutaneous coronary intervention with CTO improves LV function in patients with ischemic cardiomyopathy, regardless of the degree of collateral circulation. LV function recovery generally occurs within 3 months after revascularization.

Impact of cardiac history and myocardial scar on increase of myocardial perfusion after revascularization

PurposeWe sought to assess the impact of coronary revascularization on myocardial perfusion and fractional flow reserve (FFR) in patients without a cardiac history, with prior myocardial infarction (MI) or non-MI percutaneous coronary intervention (PCI). Furthermore, we studied the impact of scar tissue.MethodsSymptomatic patients underwent [15O]H2O positron emission tomography (PET) and FFR before and after revascularization. Patients with prior CAD, defined as prior MI or PCI, underwent scar quantification by magnetic resonance imaging late gadolinium enhancement.ResultsAmong 137 patients (87% male, age 62.2 ± 9.5 years) 84 (61%) had a prior MI or PCI. The increase in FFR and hyperemic myocardial blood flow (hMBF) was less in patients with prior MI or non-MI PCI compared to those without a cardiac history (FFR: 0.23 ± 0.14 vs. 0.20 ± 0.12 vs. 0.31 ± 0.18, p = 0.02; hMBF: 0.54 ± 0.75 vs. 0.62 ± 0.97 vs. 0.91 ± 0.96 ml/min/g, p = 0.04). Post-revascularization FFR and hMBF were similar across patients without a cardiac history or with prior MI or non-MI PCI. An increase in FFR was strongly associated to hMBF increase in patients without a cardiac history or with prior MI/non-MI PCI (r = 0.60 and r = 0.60, p < 0.01 for both). Similar results were found for coronary flow reserve. In patients with prior MI scar was negatively correlated to hMBF increase and independently predictive of an attenuated CFR increase.ConclusionsPost revascularization FFR and perfusion were similar among patients without a cardiac history, with prior MI or non-MI PCI. In patients with prior MI scar burden was associated to an attenuated perfusion increase.