MACE Rate Research Articles

The impact of statin intensity on long-term outcomes in elderly patients with acute myocardial infarction who have undergone percutaneous coronary intervention

Abstract Background The data regarding long-term clinical outcomes according to statin intensity in elderly patients who have undergone percutaneous coronary intervention (PCI) for acute myocardial infarction (MI) is unclear. Purpose We aimed to investigate the long-term clinical benefit of high intensity statin versus moderate to low intensity statin in elderly patients underwent PCI for acute MI. Methods Among 13104 patients with acute MI who have undergone PCI in a nationwide, prospective, and real-world registry, 4294 elderly (defined as ≥70 years) patients prescribed statin at discharge were included. 1136 patients were prescribed with high intensity statin, and 3158 patients were prescribed with moderate to low intensity statin. The major adverse cardiac events (MACE; all-cause death, recurrent MI, any revascularization, stroke, readmission due to heart failure [HF], or definite/probable stent thrombosis [ST]) and the components of MACE were compared in multivariable Cox regression, propensity score (PS) matched, and underwent PS-adjusted analyses. Results During a median follow-up of 998 days, MACE, all-cause death, and cardiac death occurred in 1297 patients (30.2%), 737 patients (17.2%), and 460 patients (10.7%), respectively. The risks of MACE (entire: 26.9% vs. 31.4%, hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.73-0.95, p=0.005; PS-matched: n=2186, 25.3% vs. 30.8%, HR 0.79, 95% CI 0.67-0.94, p=0.008), all-cause death (entire: 14.4% vs. 18.1%, HR 0.78, 95% CI 0.65-0.93, p=0.005; PS-matched: 13.8% vs. 18.9%, HR 0.69, 95% CI 0.57-0.92, p=0.002), cardiac death (entire: 9.5% vs. 11.4%, HR 0.81, 95% CI 0.67-0.97, p=0.042; PS-matched: 8.7% vs. 11.3%, HR 0.77, 95% CI 0.61-0.96, p=0.031), and readmission due to HF (entire: 5.5% vs. 7.5%, HR 0.72, 95% CI 0.55-0.95, p=0.021; PS-matched: 5.7% vs. 8.1%, HR 0.78, 95% CI 0.59-0.96, p=0.017) were significantly decreased in the patients received high intensity statin compared to in those received moderate to low intensity statin. There were no significant differences in the risks of recurrent MI, any revascularization, stroke, and definite/probable ST between the groups. In patients ≥80 years, compared to the moderate to low intensity statin group, high intensity statin group had the reduced rates of MACE, all-cause death, cardiac death, recurrent MI, any revascularization, stroke, readmission due to HF, or definite/probable ST, but insignificantly. Conclusions From the nationwide registry, we noted that in elderly patients after PCI for acute MI the administration of high intensity statin versus moderate to low intensity statin was contributed to the improved long-term clinical outcomes.

Angiographic definition, incidence, predictors and clinical impact of early coronary graft failure in patients undergoing coronary artery bypass graft surgery

Abstract Introduction Coronary graft failure (CGF) may occur early after coronary bypass graft surgery (CABG), potentially leading to adverse clinical outcomes. However, data regarding incidence, diagnostic strategies and identification of individuals at risk of developing early CGF are scarce. Purpose The aim of this study was to establish a definition of early CGF based on invasive coronary angiography (CAG), to identify clinical and perioperative risk factors of early CGF and to define the clinical impact of early CGF in terms of major adverse cardiovascular events (MACE: death, myocardial infarction and revascularisation) at 5-years follow-up. Methods This retrospective observational study included CABG patients who underwent CAG prior to post-surgery discharge between 2012-2022 in a tertiary center. The decision to perform a CAG was based on clincal criteria indicative of myocardial ischemia. All CAGs were reviewed by two interventional cardiologist and a thoracic surgeon. Early CGF was defined as a dysfunctional coronary graft resulting from any of the following angiographic findings: stenosis of proximal or distal anastomosis, stenosis of the bypass conduit, bypass occlusion, reduced bypass flow (TIMI<1) and kinking/tenting/dissection of the bypass leading to lumen reduction. Clinical data and ECG recordings during hospitalization were collected. Comparisons between patients with vs. without early CGF were performed. Kaplan-Meier analysis was performed to estimate cumulative survival free of MACE at 5-years follow-up. Multivariate analysis was performed to identify predictors of early CGF. Results A total of 92 patients (79% male, 66.1±10 years-old) were included. CGF was present in 55 patients (60%). Compared to the patients without graft failure (n=37 (40%), there were no differences in baseline demographics and intra- and postoperative technical and clinical parameters. At 5-years follow-up, MACE was observed in 57 patients (18 death, 34 myocardial infarction, 42 revascularization). There were 50 revascularization procedures performed in 42 patients (46%). Of them, 35 (83%) were performed in patients with early CGF vs. 7 (17%) in patients without CGF (p<0.001). Patients with early CGF showed a significantly lower MACE-free five-year survival rate (p<0.001) (Figure) 1). On multivariate analysis, venous grafts (p=0.006), Y-graft configuration (p<0.001) and the need of inotropic agents for hemodynamic support (p=0.029) showed a significant association with early CGF. Conclusion In CABG patients undergoing clinically indicated CAG prior to discharge, early CGF was observed in 60%. Most patients underwent new revascularisation. Patients with early CGF showed a higher rate of MACE at 5-years follow-up, emphasizing the necessity to recognize and treat CGF. Venous grafts, Y-graft configuration and the need of inotropic agents for hemodynamic support 12h postoperatively were associated with early CGF.

Effect of a restrictive vs. liberal blood transfusion strategy among patients with acute myocardial infarction and anemia according to heart failure. A subgroup analysis of the REALITY trial

Abstract Background/Introduction The optimal Red Blood Cell (RBC) transfusion strategy in patients with acute myocardial infarction (MI) and anemia remains debated. In REALITY, the largest randomized trial to date in this population (n=666), a restrictive compared with a liberal transfusion strategy resulted in a noninferior rate of major adverse cardiovascular events (MACE; composite of all-cause death, stroke, recurrent myocardial infarction, or emergency revascularization prompted by ischemia) at 30 days, but did not achieve non-inferiority at 1 year. One of the main concerns with RBC transfusion is the risk of fluid overload and acute heart failure (HF). Therefore, the balance of benefit and risk of transfusions strategies may differ between patients with and without heart failure. Purpose We aimed to evaluate the potential interaction between HF and RBC transfusion on outcomes in REALITY. Methods HF was defined as either a history of heart failure or Killip class > 1 at randomization (data available for 658 patients). All events until day 30, including HF, were adjudicated by a Critical Event Committee blinded to the transfusion arm and hemoglobin levels. The primary clinical outcome was MACE at 30 days. Secondary endpoints included MACE at one year, individual components of MACE and new onset of heart failure at 30 days and 1 year. Results Among 658 patients, 311 (47.3 %) had HF. HF patients had a higher rate of MACE and a higher rate of new HF than patients without HF at 30 day and at 1 year (Fig 1). There was no interaction between HF and the effect of randomized assignment on the primary outcome or on new HF. In contrast, a liberal strategy was associated with increased all-cause death at 30 days and at 1 year in patients with HF but not in pts without HF (interaction p = 0.0088 and p = 0.049 respectively, Fig 1). Conclusion(s) Heart failure is frequent in MI patients with anemia (nearly half of the patients) and is associated with higher risks of MACE and of HF. While no interaction was observed between HF and transfusion strategies on the primary outcome of MACE, a liberal transfusion strategy was associated with higher all-cause mortality than a restrictive strategy both at 30-days and 1 year. The mechanism of this interaction deserves further investigation.

Long-term outcomes of beta-blocker use in elderly patients without left ventricular systolic dysfunction after percutaneous coronary intervention for acute myocardial infarction

Abstract Background The use of beta-blocker for elderly patients without left ventricular systolic dysfunction (LVSD) after percutaneous coronary intervention (PCI) for acute myocardial infarction (MI) was uncertain. Additionally, limited data was available on long-term outcomes of beta-blocker use in elderly patients who have undergone PCI for acute MI and without LVSD. Purpose We aimed to investigate the long-term clinical benefit of beta-blocker use in elderly patients underwent PCI for acute MI and without LVSD. Methods Among 13104 patients with acute MI who have undergone PCI in a nationwide, prospective, and real-world registry, 2566 elderly (defined as ≥70 years) patients without LVSD (defined as EF <50%) were included. 2063 patients were prescribed with beta-blocker, and 503 patients were not. The major adverse cardiac events (MACE; cardiac death, recurrent MI, any revascularization, readmission due to heart failure [HF], stroke, or definite/probable stent thrombosis [ST]) and the components of MACE were compared in multivariable Cox regression, propensity score (PS) matched, and underwent PS-adjusted analyses. Results During a median follow-up of 998 days, MACE, all-cause death, and cardiac death occurred in 560 patients (21.8%), 374 patients (14.6%), and 224 patients (8.7%), respectively. The beta-blocker group had significantly lower rates of MACE (entire: 20.9% vs. 25.4%, hazard ratio [HR] 0.66, 95% confidence interval [CI] 0.58-0.76, p=0.03; PS-matched: n=986, 20.3% vs. 25.8%, HR 0.69, 95% CI 0.61-0.78, p<0.001), all-cause death (entire: 12.9% vs. 21.5%, HR 0.55, 95% CI 0.44-0.69, p<0.001; PS-matched: 11.8% vs. 20.9%, HR 0.58, 95% CI 0.47-0.72, p<0.001), and cardiac death (entire: 7.7% vs. 13.1%, HR 0.54, 95% CI 0.41-0.72, p<0.001; PS-matched: 7.3% vs. 13.5%, HR 0.57, 95% CI 0.43-0.79, p<0.001) than the no beta-blocker group. There were no significant differences in the risks of recurrent MI, any revascularization, readmission due to HF, stroke, and definite/probable ST between the groups. The lower risk of MACE in the beta-blocker group than in the no beta-blocker group was consistently observed in the subgroup analyses. In patients ≥80 years, beta-blocker versus no beta-blocker groups showed the reduced rates of MACE, all-cause death, cardiac death, recurrent MI, any revascularization, readmission due to HF, stroke, and definite/probable ST, but insignificantly. Conclusions We showed that from nationwide registry, the use of beta-blocker was associated with improved long-term clinical outcomes compared to the no use of beta-blocker in elderly patients without LVSD after PCI for acute MI.outcomes

Outcomes of drug eluting stents vs. drug eluting balloons. A single center experience

Abstract Introduction Drug eluting stents (DES) are considered the default treatment option in the current era of percutaneous coronary interventions (PCI). Nevertheless, the use of drug eluting balloons (DEB) remains highly relevant, especially in the setting of in stent restenosis (ISR), and de-novo small vessel disease or bifurcation lesions. Material and method Among 17,630 consecutive PCI procedures performed in our tertiary medical center between 2010 and 2021, we identified 16,435 procedures performed using DES and 1,195 using DEB. Endpoints included mortality and major adverse cardiac events [MACE: death, myocardial infarction (MI), target vessel revascularization (TVR), and coronary artery bypass surgery (CABG)] at 1 year. Propensity score matching was used to create a well-balanced cohort. Results and discussion: Mean age was similar (65.7±12.1 vs. 65.8±11.1, p=0.85), but less female patients (16.7% vs. 21.2%, p<0.01) were observed in the DEB group. DEB patients presented with higher rates of diabetes, hypertension, and prior CABG (62.1% vs. 48.1%, 84.9% vs. 73.2% and 18.3% vs. 10.1% respectively, p<0.01 for all), as compared to DES patients. There were also higher rates of PCI for bifurcation lesions and in-stent restenosis (18.3% vs. 15.1% and 56.0% vs. 7.8% respectively, p<0.01 for both) in the DEB group. After propensity and adjustment for confounders, 370 matched pairs were compared. 1-year MACE rates were significantly higher (HR-1.51, 95%CI 1.04-2.18, p=0.03) in the DEB group, as compared to the DES group. This was driven by higher MI (6.8% vs. 1.9%, p<0.01), TVR (20.5% vs. 11.4%, p<0.01) and CABG (12.2% vs. 7.3%, p=0.02) rates in the DEB group. Adjusted rates of 1-year mortality (HR-1.20, 95%CI 0.75-1.67, p=0.45) did not differ between the two groups. Conclusions Treatment with DEB was associated with increased MACE at 1-year, driven by higher rates of MI, TVR and CABG, as compared to DES.Freedom from MACE

Impact of atrial fibrillation on mortality and non-fatal cardiovascular outcomes in 145 293 patients admitted with COVID-19: a statewide population-linkage study

Abstract Background Atrial fibrillation (AF) is common in COVID-19 patients. The impact of AF on major-adverse-cardiovascular-events (MACE defined as all-cause mortality, myocardial infarction, ischaemic stroke, heart failure or revascularisation), recurrent admission with AF and venous thromboembolism in patients hospitalised with COVID-19 is not well-defined. Purpose This study aims to examine the impact of AF on long-term clinical outcomes including fatal and non-fatal cardiovascular outcomes in patients admitted with COVID-19. Methods Patients admitted with COVID-19 (1 January 2020 to 30 September 2021) were identified from the Admitted-Patient-Data-Collection database in New South Wales, the largest state of Australia, stratified by AF status (No-AF vs Prior-AF or New-AF during index COVID-19 admission) and followed up until 31 March 2022. A linkage look-back to year 2001 was performed to identify prior-AF history. Multivariable Cox regression was performed to assess the impact of AF status on MACE. To account for the competing risk of death and assess the impact of AF on non-fatal cardiovascular outcomes, Fine-Gray competing risk analysis was performed. Results The cohort comprised 145 293 COVID-19 patients (median age 67.4 years; 49.7% males): New-AF, n=5 140 (3.5%); Prior-AF, n=23 204 (16.0%) (Table 1). During a median follow-up of 9 months, Prior-AF and New-AF patients had significantly higher MACE rates (Prior-AF: 44.7% vs New-AF: 36.2% vs No-AF: 18.0%), including all-cause mortality (Prior-AF: 36.0% vs New-AF: 28.7% vs No-AF: 15.2%) compared to No-AF patients (both logrank P<0.001). After adjusting for age, gender, intensive-care-unit admission and Charlson comorbidity index, compared to No-AF status, New-AF and Prior-AF status were independently associated with MACE (adjusted hazard ratio[aHR]=1.17, 95% confidence interval [CI]=1.11-1.22; aHR=1.36, 95%CI=1.33-1.40 respectively; both P<0.001). Competing risk analyses showed that rehospitalisation rates for ischaemic stroke, heart failure and AF but not venous thromboembolism were significantly higher in COVID-19 patients with New-AF and Prior-AF (P<0.001) (Table 2). In a separate competing risk analysis incorporating patient’s CHA2DS2VASc status, New-AF patients had a higher rehospitalisation rate for ischaemic stroke, independent of CHA2DS2VASc group (CHA2DS2VASc=0 vs CHA2DS2VASc≥1: subdistribution HR [sHR]=3.57 and 1.61 respectively), whereas patients with Prior-AF had a higher rehospitalisation rate for ischaemic stroke only if CHA2DS2VASc≥1 (sHR=1.34) (all P<0.05). Conclusions COVID-19 patients with AF are at high risk of MACE and other adverse clinical outcomes. Such patients could be targeted for increased surveillance and additional post-discharge support. Efficacy of early anticoagulation for COVID-19 patients with new-AF to prevent stroke regardless of CHA2DS2VASc score requires further study.Table 1.Baseline characteristicsTable 2.Non-fatal CV outcomes

Abstract 16946: The Optimal Surgical Procedure of Mitral Valve Repair According to Risk Analysis of Postoperative Functional Mitral Stenosis

Background: Functional mitral stenosis (FMS) after mitral valve repair (MVr) is associated with pulmonary hypertension in the late period, increasing the risk of re-operation and deterioration of long-term outcomes. However, the risk factors for FMS after MVr, especially the impact of surgical procedures, have not been thoroughly investigated. Hypothesis: We hypothesize that procedures of valve repair, including prosthetic ring orifice area (ROA), may be associated with FMS in the late period. Methods: We retrospectively evaluated 205 patients who underwent MVr using full annuloplasty rings between 2011 and 2021 at our institution. FMS was defined as mean trans-mitral pressure gradient (TMPG) ≥8 mmHg measured by annual echocardiography. ROA was determined by calculating the internal area of each valve type and size. Perioperative factors such as repair techniques, ROA, and ROA divided by BSA (ROAi) were used to analyze risk factors for FMS. The mean follow-up period was 4.8±0.4 years. Results: MVr was performed using artificial chordae in 110 cases and intervention in valve leaflet in 83 cases (resection suture: 43, cleft closure: 26, plication: 12, and edge-to-edge repair: 8). We also utilized semi-rigid full ring in all cases (26 or less: 15, 28: 53, 30: 73, 32: 49, 34 or more: 15). We identified postoperative FMS in 23 cases (11.2%, 2.5±0.9 years after MVr) with TMPG of 9.0 ± 0.7 mmHg. In the FMS group, decreasing TR-PG in the late period was not achieved after MVr. TR-PG in the late period was also significantly higher in the FMS group (28.3 ± 5.8 vs. 20.3 ± 2.1 mmHg, p=0.01). The freedom from re-operation for MV and re-hospitalization for heart failure rate was not significantly different in the two groups (93.6% vs. 95.5%, p=0.32, 87.7% vs. 90.6%, p=0.36, respectively). However, the freedom from MACE rate was lower in the FMS group (81.4% vs. 86.3%, p=0.11). Univariate analysis demonstrated that intervention in valve leaflet (OR 2.53, p=0.04) and ROAi (OR 0.98, p=0.005) were significant risk factors for FMS. Conclusion: Although further follow-up is mandatory, these results suggested that the use of sufficiently large prosthetic ring and avoidance of intervention in valve leaflet are efficient for preventing FMS and improving clinical outcomes after MVr.

Abstract 12711: Stent Length as a Predictor of Target Vessel Revascularization in Patients Treated With Drug-Eluting Stents

Background: While several factors have been shown to increase the risk of stent thrombosis, most cases of target vessel revascularization (TVR) are due to in-stent restenosis (ISR) and have not been fully evaluated. Objectives: Our aims were to identify predictors of early and late TVR after drug-eluting stents (DES) implantation in a large prospective registry, focusing on stent length. Methods and Results: We analyzed rates of TVR according to stent length in a prospective registry of 14,447 all-comers treated with angioplasty and DES implantation in our institution. Patients were divided into quartiles according to stent length - mean 21mm - percentile 25 (Q1) 15mm, 50 (Q2) 18mm, 75 (Q3) 26mm and 100 (Q4) 32mm. At baseline patients had similar rates of diabetes mellitus, congestive heart failure and left ventricular ejection fraction. Patients in the first quartile tend to be older, more commonly of female gender, with higher rates of GFR<60, anemia, and unprotected LM angioplasty. At 4 years follow-up, rates of TVR and MACE were higher in patients with longer stents; 8.5%, 9.8%, 10.4% and 16.1% (p<0.001) and 25.3%, 26.6%, 27% and 28.4% (p=0.031); for TVR and MACE in Q1, Q2, Q3 and Q4 groups of patients; respectively. There were no significant differences in the rates of all-cause death amongst patients in different quartiles. Furthermore, at multivariate Cox-regression analysis length of stent was found to be a significant independent predictor for TVR (OR 1.25 95.0% CI 1.11 - 1.42; p<0.001). Conclusion: From the analysis of a large cohort of all-comer angioplasty patients who were treated with DES, stent length emerged as an independent predictor of TVR and MACE.

Abstract 12768: Recurrent Hyperkalemia is Associated With Higher Rates of Cardiovascular Outcomes and All-Cause Mortality in Patients With Chronic Kidney Disease: The Revolutionize III Study

Introduction: The impact of recurrent hyperkalemia (rHK) on the time to cardiovascular (CV) outcomes and mortality in patients with chronic kidney disease (CKD) has not been well studied. This real-world study described and compared rates of CV outcomes and all-cause mortality between patients with rHK and matched patients without HK (nonHK). Methods: Patients with rHK were matched 1:1 to nonHK controls via exact and propensity score matching with the date of rHK or nonHK as index. Patients were adults with stage 3 or 4 CKD identified from Optum’s de-identified Market Clarity Data spanning 1/2016 to 8/2022. For each outcome sample, the corresponding CV events in baseline were excluded. CV outcomes included major adverse cardiovascular events plus (MACE+; all-cause mortality or inpatient [IP] heart failure, myocardial infarction, or stroke) and IP cardiac arrhythmia. Rates of CV outcomes and mortality were compared between matched cohorts using cause-specific Cox proportional hazard models and reported as hazard ratios (HR) with 95% confidence intervals (CI). Subgroups analyses were conducted by renin-angiotensin-aldosterone system inhibitor (RAASi) use at index. Results: Of 6,337 matched pairs, mean age was 73.3 years and 47.7% of patients were female. Patients with rHK compared to nonHK had higher rates of CV outcomes, including MACE+ (N = 5,258, HR=1.53 95% CI=[1.43, 1.65]) and IP arrhythmia (N = 5,485, 1.94 [1.74, 2.16]) (all p<0.001, Figure 1 ). Results were consistent in the RAASi subgroup (MACE+: 1.46 [1.31, 1.63]; IP arrhythmia: 1.84 [1.57, 2.16], both p<0.001). Patients with rHK also had higher rates of mortality (Overall: N = 6,337; 1.29 [1.20, 1.38]; RAASi subgroup: 1.25 [1.11, 1.41], both p<0.001) compared to nonHK controls. Conclusions: This study demonstrates that patients with CKD and rHK had significantly higher rates of mortality, MACE+, and IP cardiac arrhythmia compared to matched patients with CKD and nonHK.

Abstract 11432: Association of Cardiac Biomarkers With Long-Term Cardiovascular Events in the Community

Introduction: Biomarkers can facilitate the prediction of events in primary prevention. Few studies have been conducted in the community setting with analyses that incorporate many biomarkers. Hypothesis: We tested whether a multi biomarker model would outperform clinical factors and individual biomarkers for predicting MACE and Stroke/MI in subjects without known CAD. Methods: A retrospective cohort study assessed composite outcomes MACE (MI, CABG, PCI, stroke, and death) and Stroke/MI. Cox proportional hazard models were fit for individual biomarkers, adjusted for age, gender, BMI, hypertension, CAD, and GFR. Multi biomarker models were developed based on AIC values from the single-biomarker models. Bootstrap tests compared survival C-statistics and relative Integrated Discrimination Index (IDI). Results: 1131 patients in Olmsted County, MN were studied. Median age was 63.1 years, 97.5% were Caucasian, and 52.2% were female. Median BMI was 27.8. Kaplan Meier rates of MACE and Stroke/MI were 29.2% (CI = 26.5-31.8%) and 12.3% (CI = 10.3% - 14.3%), at 10 years. Adjusted NT proBNP models showed a 31% increased risk of MACE/death (HR = 1.31; CI = 1.17-1.46) and a 31% increased risk for stroke/MI (HR = 1.31; CI = 1.08-1.58). Adjusted Ceramide score models showed a 13% increased risk of MACE/death (HR = 1.13; CI = 1.04-1.24) and a 29% increased risk for stroke/MI (HR = 1.29; CI = 1.11-1.51). NT proBNP and the Ceramide score with clinical factors was better than clinical factors alone for MACE/Death (Relative IDI = 29.7%; p = 0.003) and Stroke/MI (Relative IDI = 36.1%; p = 0.034). This combined model did not outperform the strongest single biomarker model for Stroke/MI or MACE/Death. Other biomarkers were not significant when added to the combined model. Discussion: Ceramide score and NT proBNP alone and together improve the prediction of MACE and Stroke/MI in a community primary prevention cohort.

Abstract 13028: Estimating Cardiovascular Event Rates in US Veterans Using the SMART Risk Score

Background: There is limited data on racial differences in long term cardiovascular (CV) outcomes amongst U.S. veterans. Methods: Utilizing the VA Informatics and Computing Infrastructure and the Corporate Data Warehouse we compared 10-year predicted major adverse CV events [MACE, a composite of all-cause death and non-fatal myocardial infarction] in patients referred for cardiovascular consultation between 2003 and 2009 using the SMART risk score with observed rates across racial groups. The SMART risk score classified patients into low 0-9.9%, intermediate 10-19.9%, high 20-29.9%, and very high >=30% risk groups. Results: 473,136 patients including white (74.7%), African American (15.5%), and other (9.8%) made the study cohort. Observed event rates were significantly higher in African Americans compared with Whites across all SMART risk groups [p<0.001], and highest in the other races, inclusive of Hispanics. These results are depicted in Figure 1 . Conclusion: There is a significantly higher observed 10-year MACE rate in African American veterans compared with their white counterparts across all predicted SMART risk score groups.

Abstract 13105: Applying Proteomic CV and Kidney Prognosis Risk in T2D Patients to Identify High-Risk Patients

Background: The interdependence of cardiovascular and kidney health in T2D requires understanding the combination of disease risk. Proteomic surrogate models for cardiovascular risk and kidney prognosis have been developed and validated, but not in a combined manner in T2D patients. Hypothesis: Combining the results of independent proteomic risk models for 4-year cardiovascular risk and kidney prognosis will identify patients at highest risk for MACE, better than eGFR. Methods: Plasma from 1,220 participants with T2D from the Atherosclerosis Risk in Communities (ARIC) study visit 5 were assayed for >5,000 proteins using the SomaScan® assay; 34.2% had incident MACE (MI, stroke, HF hospitalization, or death). Predictions from a validated proteomic CV risk model were calculated, as well as a de novo kidney prognosis model developed and validated in the Chronic Renal Insufficiency Cohort and Fenland cohort. Patients were stratified by predefined CV risk bins and sub-stratified by 2x kidney prognosis risk, and compared to eGFR stratification. Log-odds of Kaplan-Meier (KM) event rates were compared between strata. Results: Proteomic kidney risk predictions did not sub-stratify patients at low/medium CV risk (p > 0.05), but did stratify high-risk CV patients, with highest CV and kidney risk patients (5.6% of patients; p < 0.05) having a KM-estimated 63.4% 4-year MACE rate, more than 8 times the low CV risk group. Conversely, stratification using a corresponding eGFR threshold did not significantly stratify high-risk CV patients. High CV risk MACE types were different depending on proteomic kidney risk sub-stratification (chi-square p < 0.015), and participants with increased kidney risk had more HF hospitalizations (39.7% of MACE). Conclusions: Among patients with T2D and elevated proteomic markers for CV risk, an independent proteomic risk model for kidney prognosis can be applied to identify a significantly larger proportion of patients at risk for MACE.

Comparative cardiovascular safety with janus kinase inhibitors and biological disease-modifying antirheumatic drugs as used in clinical practice: an observational cohort study from Sweden in patients with rheumatoid arthritis

ObjectivesTo compare the incidence of cardiovascular (CV) events in rheumatoid arthritis (RA) treated with janus kinase inhibitors (JAKi), tumour necrosis factor inhibitors (TNFi), or other biological disease-modifying antirheumatic drugs (bDMARDs),...

Procedural and clinical impact of intravascular lithotripsy for the treatment of peri-stent calcification

BackgroundUse of intravascular lithotripsy (IVL) for treating peri-stent calcification is increasing. However, this indication remains ‘off-label’. We aimed to investigate the efficacy and clinical outcomes of in-stent IVL. MethodsPatients from five European centers who underwent in-stent IVL were included between 2019 and 2023. Demographic, clinical, procedural and follow-up data were collected from electronic hospital records. Angiographic and intracoronary imaging (ICI) data were analyzed in a centralized core-laboratory. ResultsOf 101 patients (71.2 ± 9.2 years), 56(55 %) received in-stent IVL for late stent failure (median 109 days post-PCI) due to calcific neoatherosclerosis or extra-stent calcification(late-IVL), while 45(45 %) underwent bail-out IVL due to stent infraexpasion (immediate-IVL). Both late-IVL and immediate-IVL significantly improved angiographic %diameter stenosis (73.7[59.6–89.8]% to 16.4 [10.4–26.9]%;p < 0.0001 and 28.6[22.5–43.3]% to 14.1[10.3–29.4]%;p < 0.0001, and minimum lumen area (MLA) (3.4 ± 1.2 to 8.6 ± 2.5 mm2;p < 0.002 and 5.4 ± 1.9 to 7.3 ± 1.9;p < 0.0001).Device(98 %) and procedural success(80 %) were high. MACE rates in-hospital (2 %), 30-days (3 %),6-months(5 %) and 1-year(7 %) were low and comparable in both groups. Acute diameter gain was lower in immediate-IVL (2.1 ± 0.7 mm vs. 0.5 ± 0.4 mm;p < 0.0001). This, however, was explained by significant differences in pre-IVL angiographic and ICI parameters (%diameter stenosis 73.7[59.6–89.8] vs. 28.6[22.5–43.3]%; p < 0.0001 and MLA (3.4 ± 1.2 vs 5.4 ± 1.9 mm2; p < 0.0001), whereas post-IVL percentage diameter stenosis (16.4(10.4–26.9) vs. 14.1(10.3–29.4);p = 0.914) and MLA (8.6 ± 2.5vs. 7.4 ± 1.9 mm2;p = 0.064) in late- and immediate-IVL were comparable. ConclusionsIVL in-stent due to peri-stent calcification is an effective strategy, both late and immediately after stent implantation. Overall, MACE rates at short- and mid-term were low and comparable in both groups, although clinical findings should be taken with caution.

Outcomes of chronic total occlusion percutaneous coronary intervention from the RAIAN (RAjaie - Iran) registry

ObjectiveWhile most of the evidence in CTO interventions emerge from Western and Japanese studies, few data have been published up today from the Middle East. Objective of this study was to evaluate technical success rates and clinical outcomes of an Iranian population undergoing CTO PCI in a tertiary referral hospital. Moreover, we sought to evaluate the efficacy of our CTO teaching program. MethodsThis is a retrospective single-center cohort study including 790 patients who underwent CTO PCI performed by operators with different volumes of CTOs PCI performed per year. According to PCI result, all patients have been divided into successful (n = 555, 70.3 %) and unsuccessful (n = 235, 29.7 %) groups. Study endpoints were Major Adverse Cardiovascular Events and Health Status Improvement evaluated using the Seattle Angina Questionnaire at one year. ResultsA global success rate of 70 % for antegrade and 80 % for retrograde approach was shown despite the lack of some CTO-dedicated devices. During the enrollment period, the success rate increased significantly among operators with a lower number of CTO procedures per year. One-year MACE rate was similar in both successful and unsuccessful groups (13.5 % in successful and 10.6 % in unsuccessful group, p = 0.173). One year patients’ health status improved significantly only in successful group. ConclusionsNo significant differences of in-hospital and one-year MACE were found between the successful and unsuccessful groups. Angina symptoms and quality of life significantly improved after successful CTO PCI. The RAIAN registry confirmed the importance of operator expertise for CTO PCI success.

Safety and Efficacy of Uninterrupted Oral Anticoagulation in Patients Undergoing Catheter Ablation for Atrial Fibrillation with Different Techniques.

The safety and efficacy of an uninterrupted direct anticoagulation (DOAC) strategy during catheter ablation (CA) for atrial fibrillation (AF) has not been fully investigated with different ablation techniques. We evaluated consecutive AF patients undergoing catheter ablation with three different techniques. All patients were managed with an uninterrupted DOAC strategy. The primary endpoint was the rate of periprocedural thromboembolic and bleeding events. The secondary endpoints of the study were the rate of MACE and bleeding events at one-year follow-up. In total, 162 patients were enrolled. Overall, 53 were female and the median age was 60 [55.5-69.5] years. The median CHA2DS2-VASc and HAS-BLED scores were 2 [1-4] and 2 [1-2], respectively. In total, 16 patients had a past stroke or TIA while 11 had a predisposition or a history of bleeding. The CA procedure was performed with different techniques: RF 43%, cryoballoon 37%, or laser-balloon 20%. Overall, 35.8% were on rivaroxaban, 20.4% were on edoxaban, 6.8% were on apixaban, and 3.7% were on dabigatran. All other patients were all naïve to DOACs; the first anticoagulant dose was given before the ablation procedure. As for periprocedural complications, we found three groin hematomas not requiring interventions, one ischemic stroke, and one systemic air embolism (the last two likely due to several catheter changes through the transeptal sheath). Five patients reached the secondary endpoints: one patient for a myocardial infarction while four patients experienced minor bleeding during 1-year follow-up. Our results corroborate the safety and the efficacy of uninterrupted DOAC strategy in patients undergoing CA for AF, regardless of the ablation technique.

Cardiac risk after elective endovascular repair for infrarenal abdominal aortic aneurysm: Results from the Italian Collaborators for EVAR multicenter registry

ObjectiveMajor adverse cardiac events (MACEs) were common complications after endovascular aortic repair (EVAR) causing significant postoperative morbidity and mortality. The aim of the study was to evaluate the cardiac risk after elective EVAR for uncomplicated noninfected infrarenal abdominal aortic aneurysm in a large multicenter cohort. MethodsThis is a multicenter, retrospective, financially unsupported physician-initiated observational cohort study conducted by four academic tertiary referral hospitals from January 2018 to March 2021. Baseline, perioperative, and postoperative information of elective EVARs was evaluated. The primary outcome was the incidence of MACEs after EVAR, which was defined as acute coronary syndrome, non-ST-elevation myocardial infarction, unstable angina pectoris, de novo atrial fibrillation, hospitalization for heart failure, and revascularization as well as cardiovascular death. Secondary outcomes were 1-year overall survival (all-cause mortality) and freedom from aorta-related mortality. Comparative analysis was conducted between MACE and overall population, and univariate and multivariate logistic regression analyses were used to analyze factors associated with the risk of the MACE occurrence and early 1-year mortality. ResultsThe study has enrolled 497 patients (35 females, 7%) with a mean age of 75.3 ± 7.8 years. The MACE rate was 6.4% (32/497, events/patients), and the majority of the events were recorded in the postoperative period (24/32, 75%; overall 24/497, 4.8%). One-year survival from all-cause mortality was 94% (95% confidence interval [CI]: 91-96), and the MACE population showed a significantly lower survival estimation rate (Overall - MACEs, 95.8% [95% CI: 93-97] - 67.9% [95% CI: 47-82], log-rank 41.950, P = .0001). Freedom from aorta-related mortality was 99.3% (95% CI: 98-100). The perioperative need for red blood cell transfusions was strongly related to the MACE occurrence (odds ratio: 2.67, 95% CI: 1.52-4.68, P = .001) and 1-year mortality (hazard ratio: 2.14, 95% CI: 1.48-3.09, P = .0001). ConclusionsMACEs represent a common complication in the postoperative and early period after elective EVAR. Blood loss requiring red blood cell transfusions is associated with increased postoperative MACEs and early mortality, suggesting that all the efforts should be carried out to reduce the bleeding during and after elective interventions.

Spotty calcium deposits within acute coronary syndrome (ACS)-causing culprit lesions impact inflammatory vessel-wall interactions and are associated with higher cardiovascular event rates at one year follow-up: Results from the prospective translational OPTICO-ACS study program

Background and aimsSpotty calcium deposits (SCD) represent a vulnerable plaque feature which seems to result - as based on recent invitro studies - from inflammatory vessel-wall interactions. SCD can be reliably assessed by optical coherence tomography (OCT). Their prognostic impact is yet unknown. Therefore, the aims of this translational study were to comprehensively characterize different plaque calcification patterns, to analyze the associated inflammatory mechanisms in the microenvironment of acute coronary syndrome (ACS)-causing culprit lesions (CL) and to investigate the prognostic significance of SCD in a large cohort of ACS-patients. MethodsCL of the first 155 consecutive ACS-patients from the translational OPTICO-ACS-study program were investigated by OCT-characterization of the calcium phenotype at ACS-causing culprit lesions. Simultaneous immunophenotyping by flow-cytometric analysis and cytokine bead array technique across the CL gradient (ratio local/systemic levels) was performed and incidental major adverse cardiovascular events plus (MACE+) at 12 months after ACS were assessed. ResultsSCD were observed within 45.2% of all analyzed ACS-causing culprit lesions (CL). Culprits containing spotty calcium were characterized by an increased culprit ratio of innate effector cytokines interleukin (IL)-8 [2.04 (1.24) vs. 1.37 (1.10) p < 0.05], as well as TNF (tumor necrosis factor)-α [1.17 (0.93) vs. 1.06 (0.89); p < 0.05)] and an increased ratio of circulating neutrophils [0.96 (0.85) vs. 0.91 (0.77); p < 0.05] as compared to culprit plaques without SCD. Total monocyte levels did not differ between the two groups (p = n.s.). However, SCD-containing CLs were characterized by an increased culprit ratio of intermediate monocytes [(1.15 (0.81) vs. 0.96 (0.84); p < 0.05)] with an enhanced surface expression of the integrin receptor CD49d as compared to intermediate monocytes derived from SCD-free CLs [(1.06 (0.94) vs. 0.97 (0.91)] p < 0.05. Finally, 12 months rates of MACE+ were higher in patients with, as compared to patients without SCD at CL (16.4% vs. 5.3%; p < 0.05). ConclusionsThis study for the first time identified a specific inflammatory profile of CL with SCD, with a predominance of neutrophils, intermediate monocytes and their corresponding effector molecules. Hence, this study advances our understanding of ACS-causing CL and provides the basis for future personalized anti-inflammatory, therapeutic approaches to ACS.

Effect of diabetes mellitus on young female patients with acute coronary syndrome

BackgroundDiabetes mellitus (DM) is one of the most important risk factors of acute coronary syndrome (ACS). There have been many studies on the relationship between DM and ACS. However, the effect of DM on young females with ACS is still unclear. ObjectiveTo explore the effect of DM on coronary arteries lesions in young females with ACS. Methods1278 young females (age ≤ 44 years) undergoing coronary angiography were divided into DM group (n = 197) and control group (n = 1081) according to whether they had diabetes. Based on whether the patient has ACS, each group was further divided into DM-ACS subgroup and Non-DM-ACS subgroup to compare the characteristics and severity of coronary artery lesions and follow-up outcomes. ResultsThe prevalence of diabetes was 15.41% (197/1278). Overweight (58.88%) and depression or anxiety (11.17%) in the DM group was significantly higher than those (32.22% and 6.20%) in the control group (P < 0.05). The prevalence of ACS (85.28%) in the DM group was significantly higher than that (25.35%) in the control group (P < 0.05). The proportion of type A lesions in the DM-ACS subgroup was lesser than that in the Non-DM-ACS subgroup (P < 0.05). The type C lesions in the DM-ACS subgroup were significantly higher than that in the Non-DM-ACS subgroup (P < 0.01). The number of stents implantation in the DM-ACS subgroup was no significant difference compared with the Non-DM-subgroup (P > 0.05). The length of stent implantation in the DM-ACS subgroup was significantly longer than that in the Non-DM-ACS subgroup (P < 0.05). The rate of MACE was not statistically significant between the two subgroups (P > 0.05), but the rate of all-cause death (2.98%) in the DM-ACS subgroup was significantly higher than that (0.36%) in the Non-DM-ACS subgroup (P < 0.05). ConclusionsDM is an important risk factor in young females with ACS. Young women with diabetes are prone to coronary heart disease. The coronary artery lesions in DM patients were more severe than those in Non-DM patients, despite the protective effect of estrogen on the cardiovascular system. Therefore, young women with DM should be treated to prevent ACS and future events activelyandpurposefully.

HEART Score and Its Implementation in Emergency Medicine Departments in the West Balkan Region-A Pilot Study.

Chest pain represents a prevalent complaint in emergency departments (EDs), where the precise differentiation between acute coronary syndrome and alternative conditions assumes paramount significance. This pilot study aimed to assess the HEART score's implementation in West Balkan EDs. A retrospective analysis was performed on a prospective cohort comprising patients presenting with chest pain admitted to EDs in Sarajevo, Zenica, and Belgrade between July and December 2022. A total of 303 patients were included, with 128 classified as low-risk based on the HEART score and 175 classified as moderate-to-high-risk. The low-risk patients exhibited younger age and a lower prevalence of cardiovascular risk factors. Laboratory and anamnestic findings revealed higher levels of C-reactive protein, ALT, and creatinine, higher rates of moderately to highly suspicious chest pain history, a greater number of cardiovascular risk factors, and elevated troponin levels in moderate-to-high-risk patients. Comparatively, among patients with a low HEART score, 2.3% experienced MACE, whereas those with a moderate-to high-risk HEART score had a MACE rate of 10.2%. A moderate-to-high-risk HEART score demonstrated a sensitivity of 91.2% (95%CI 90.2-93.4%) and specificity of 46.5% (95%CI 39.9-48.3%) for predicting MACE. This pilot study offers preliminary insights into the integration of the HEART score within the emergency departments of the West Balkan region.