Rates Of Myocardial Infarction Research Articles

Carotid endarterectomy compared with carotid artery stenting for extracranial carotid artery stenosis: a retrospective single-centre study

Aim: One of the main risk factors for an ischemic stroke is significant carotid artery stenosis, and extracranial severe carotid artery stenosis accounts for 20% of ischemic strokes. Prior to the development of carotid artery stenting (CAS), the only effective and reliable treatment for carotid artery stenosis was carotid endarterectomy (CEA). This study compares the results of CAS and CEA in patients with significant carotid artery stenosis. Methods: Between 2018 and 2022, hospital records of all patients who underwent carotid artery revascularization at the institution were retrospectively analyzed. Patients were divided into two groups depending on whether CEA or CAS was performed for carotid revascularization. Propensity score matching was performed to reduce bias by equating the baseline clinical characteristics of the groups. To compare 30-day, 1-year, and long-term outcomes, rates of transient ischemic attack (TIA), myocardial infarction, stroke, all-cause mortality, and composite endpoints were analyzed. Results: After PSM, 76 patients each in the CEA and CAS groups were compared. The mean age was 69.80 years ± 11.35 years and 121 (80%) were male. The patients were followed up for a mean of 33 months ± 6 months. The incidence of TIA in the perioperative period [9 (12%) vs. 4 (5%); P < 0.05], TIA and composite endpoint at 1-year period [11 (15%) vs. 2 (3%); P < 0.05 and 27 (36%) vs. 16 (21%); P < 0.05, respectively] were significantly higher in the CAS group than in the CEA group. No difference was observed between the groups in the long-term. Conclusions: There was no noticeable difference between the CEA and CAS groups in the examination of cases with severe carotid artery stenosis in terms of 1-month, and 1-year results (apart from TIA and composite endpoints), or long-term outcomes. Extracranial carotid artery stenosis can be treated safely and effectively also by CAS.

Causal Association Between Subtypes of Excessive Daytime Sleepiness and Risk of Cardiovascular Diseases.

Excessive daytime sleepiness (EDS), experienced in 10% to 20% of the population, has been associated with cardiovascular disease and death. However, the condition is heterogeneous and is prevalent in individuals having short and long sleep duration. We sought to clarify the relationship between sleep duration subtypes of EDS with cardiovascular outcomes, accounting for these subtypes. We defined 3 sleep duration subtypes of excessive daytime sleepiness: normal (6-9 hours), short (<6 hours), and long (>9 hours), and compared these with a nonsleepy, normal-sleep-duration reference group. We analyzed their associations with incident myocardial infarction (MI) and stroke using medical records of 355 901 UK Biobank participants and performed 2-sample Mendelian randomization for each outcome. Compared with healthy sleep, long-sleep EDS was associated with an 83% increased rate of MI (hazard ratio, 1.83 [95% CI, 1.21-2.77]) during 8.2-year median follow-up, adjusting for multiple health and sociodemographic factors. Mendelian randomization analysis provided supporting evidence of a causal role for a genetic long-sleep EDS subtype in MI (inverse-variance weighted β=1.995, P=0.001). In contrast, we did not find evidence that other subtypes of EDS were associated with incident MI or any associations with stroke (P>0.05). Our study suggests the previous evidence linking EDS with increased cardiovascular disease risk may be primarily driven by the effect of its long-sleep subtype on higher risk of MI. Underlying mechanisms remain to be investigated but may involve sleep irregularity and circadian disruption, suggesting a need for novel interventions in this population.

Heart Failure-Related Outcomes in Patients with Left Ventricular Dysfunction Undergoing Percutaneous Chronic Total Occlusion Revascularization.

The presence of a chronic total occlusion (CTO) and severe left ventricular (LV) systolic dysfunction are known negative prognostic factors in patients with coronary artery disease. Several studies have examined the effect of CTO revascularization on mortality, symptoms, occurrence of myocardial infarction (MI), and cardiac function in patients with normal or reduced LV function. However, the effect of CTO revascularization on heart failure-related events in patients with LV dysfunction, such as heart failure hospitalization (HFH), the occurrence of atrial fibrillation (AF), and a worsening renal function (WRF), has not yet been evaluated. To assess the success rate and safety of CTO percutaneous coronary interventions (PCIs) in coronary patients with LV ejection fractions of 40% and evaluate the impact of successful CTO revascularization on HFH, occurrence of AF, and WRF. Prospectively, data were collected from CTO PCIs performed at three referral centers and analyzed. From a total of 1435 CTO PCIs, 132 (9.2%) patients with a left ventricular ejection fraction (LVEF) of 40% were included in this analysis. The median follow-up duration was 23.18 months (interquartile range (IQR): 11.02-46.66 months). A successful CTO PCI was achieved in 109 of these patients, while the procedure was unsuccessful in 23 patients (82.5% procedural success rate). Overall, the intervention had an acceptable number of peri-procedural (or in-hospital) complications (9.1%). During the follow-up period, the rates of all-cause death, cardiovascular death, and non-fatal MI were not significantly different between the two groups. The rates of HFH were significantly lower in the successful PCI group, while WRF and AF did not differ between successful and unsuccessful PCI groups. Successful PCI and higher estimated glomerular filtration rate (eGFR) were independent predictors of a lower risk of HFH, while prior stroke and diabetes were independent predictors of a higher risk of HFH. In patients with reduced LV systolic function (ejection fraction, EF 40%), CTO PCI is a safe and effective procedure and successful CTO PCI is independently associated with a lower risk of HFH during follow-up. Further expansion of this cohort is necessary to confirm these results.

Prognostic value of a novel artificial intelligence-based coronary computed tomography angiography-derived ischaemia algorithm for patients with suspected coronary artery disease.

Coronary computed tomography angiography (CTA) imaging is used to diagnose patients with suspected coronary artery disease (CAD). A novel artificial intelligence-guided quantitative computed tomography ischaemia algorithm (AI-QCTischaemia) aims to identify myocardial ischaemia directly from CTA images and may be helpful to improve risk stratification. The aims were to investigate (i) the prognostic value of AI-QCTischaemia amongst symptomatic patients with suspected CAD entering diagnostic imaging with coronary CTA and (ii) the prognostic value of AI-QCTischaemia separately amongst patients with no/non-obstructive CAD (≤50% visual diameter stenosis) and obstructive CAD (>50% visual diameter stenosis). For this cohort study, AI-QCTischaemia was calculated by blinded analysts amongst patients with suspected CAD undergoing coronary CTA. The primary endpoint was the composite of death, myocardial infarction (MI), or unstable angina pectoris (uAP) (median follow-up 6.9 years). A total of 1880/2271 (83%) patients had conclusive AI-QCTischaemia result. Patients with an abnormal AI-QCTischaemia result (n = 509/1880) vs. patients with a normal AI-QCTischaemia result (n = 1371/1880) had significantly higher crude and adjusted rates of the primary endpoint [adjusted hazard ratio (HRadj) 1.96, 95% confidence interval (CI) 1.46-2.63, P < 0.001; covariates: age/sex/hypertension/diabetes/smoking/typical angina]. An abnormal AI-QCTischaemia result was associated with significantly higher crude and adjusted rates of the primary endpoint amongst patients with no/non-obstructive CAD (n = 1373/1847) (HRadj 1.81, 95% CI 1.09-3.00, P = 0.022), but not amongst those with obstructive CAD (n = 474/1847) (HRadj 1.26, 95% CI 0.75-2.12, P = 0.386) (P-interaction = 0.032). Amongst patients with suspected CAD, an abnormal AI-QCTischaemia result was associated with a two-fold increased adjusted rate of long-term death, MI, or uAP. AI-QCTischaemia may be useful to improve risk stratification, especially amongst patients with no/non-obstructive CAD on coronary CTA.

Coronary artery bypass surgery versus percutaneous interventions for women with multivessel coronary artery disease

ObjectiveTo compare outcomes in women undergoing percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery. DesignThis retrospective, propensity-score matched cohort study from the New York State cardiac registry (2012-2018) included all women with multivessel coronary artery disease undergoing PCI with everolimus-eluting stents (EES) and CABG surgery. The primary outcome was all-cause mortality. The key secondary outcome was major adverse cardiac events, defined as the composite of all-cause mortality, myocardial infarction, and stroke. ResultsPCI with EES was associated with a higher 6-year risk of mortality (25.75% vs 23.57%; adjusted hazard ratio [AHR], 1.29; 95% confidence interval [CI], 1.14-1.45). PCI also was associated with a higher rate of the composite outcome of death, myocardial infarction, and stroke (36.58% vs 32.89%; AHR, 1.28; 95% CI, 1.17-1.41), as well as myocardial infarction (14.94% vs 9.12%; AHR, 1.84; 95% CI, 1.56-2.17), but not stroke (7.07% vs 7.62%; AHR, 0.83; 95% CI, 0.67-1.03). Repeat revascularization rates also were higher for women undergoing PCI (21.53% vs 11.57%; AHR, 1.88; 95% CI, 1.63-2.17). There was no difference in mortality between the 2 interventions when PCI patients received complete revascularization or had noncomplex lesions and for women without diabetes. ConclusionsFor women with multivessel coronary artery disease, CABG surgery is associated with lower 6-year mortality, myocardial infarction, and repeat revascularization rates compared to PCI with EES.

Longitudinal outcomes of final kissing balloon inflation in coronary bifurcation lesions treated with a single stent

BackgroundFinal kissing balloon inflation (FKBI) is a percutaneous coronary intervention (PCI) technique that is considered mandatory to improve outcomes in two-stent strategies, but its use in single-stent bifurcation PCI remains controversial.MethodsIn this retrospective cohort study, we identified patients with coronary bifurcation lesions treated with one stent from January 2012 to March 2021 at a single academic medical center. Incidence rates per 1,000 patient-years (IR1000) were calculated for the outcomes of all-cause mortality, myocardial infarction (MI), stent thrombosis (ST), target lesion revascularization (TLR), coronary artery bypass graft (CABG), and cardiac readmission between patients who received FKBI and those who did not over a median follow up of 2.3 years. Studied outcomes were adjusted for all baseline clinical and procedural characteristics.ResultsThis study included 893 consecutive patients of which 256 received FKBI and 637 did not. The IR1000 for MI were 51.1 and 27.6 for patients who received FKBI and patients who did not, respectively (adjusted HR = 2.44, p = 0.001). The IR1000 for death were 31.2 and 52.3 for patients who received FKBI and patients who did not, respectively (adjusted HR = 0.68, p = 0.141). The incidence rates of ST, TLR, CABG, and cardiac readmissions were similar between patients who received FKBI and those who did not.ConclusionsThese results suggest that performing FKBI in a one-stent technique was associated with higher rates of myocardial infarction, particularly in the first 6 months, and no difference in death, ST, TLR, CABG, and cardiac readmission rates.

Monoclonal Gammopathy of Undetermined Significance and Associated Cardiovascular Outcomes in a Hospital Setting - a Fresh Perspective

Introduction: A growing body of evidence has confirmed the association between monoclonal gammopathy of undetermined significance (MGUS) and a variety of diseases including bone disease, renal impairment, autoimmune disorders, neuropathies, secondary immunodeficiencies, and infections. Recently, there has been an emerging focus on cardiovascular (CV) outcomes in patients with MGUS. However, they have not been investigated well, especially among hospitalized patients. In our study, we investigated the association between MGUS and cardiovascular outcomes in a hospital setting using the National Inpatient Sample database. Methods: MGUS patients were sampled using ICD-10 codes. Patients less than the age of 18 years, those with missing data, and those with concomitant multiple myeloma, smoldering multiple myeloma, B-cell lymphomas, non-Hodgkin lymphomas, amyloidosis, and Waldenstrom's macroglobulinemia were excluded . Patients were stratified into two cohorts based on the presence or absence of MGUS. Comorbidities and CV outcomes were collected using ICD 10 DM codes. CV outcomes were evaluated before and after 1:1 matching for age, gender, and race. Furthermore, a sensitivity analysis was performed where all individuals with a history of diabetes mellitus (DM), prior myocardial infarction, hypertension, chronic kidney disease (CKD) stage 3-5, dialysis-dependence, obesity, metabolic syndrome, cancer (all-cause), antiplatelet or oral anticoagulant use were excluded. CV outcomes were then reevaluated using multivariate logistic regression to adjust for smoking, dyslipidemia, and aspirin use. P-values &amp;lt; 0.05 was considered statistically significant. Results: Out of a total of 17,357,556 patients included in the study, 23,435 patients had MGUS (0.1%). MGUS patients tended to be older, male, smokers, and Caucasian. Additionally, MGUS patients tended to have more DM (39.2% vs 27.9%), CKD (33.6% vs 8.6%), dialysis-dependence (13.3% vs 4%), obesity (18% vs 16.5%), dyslipidemia (39.1% vs 23.3%), metabolic syndrome (18.9% vs 10.4%), and cancer (12.9% vs 8.1%) when compared to non-MGUS patients. Aspirin, antiplatelets, and anticoagulant use were more prevalent in the MGUS patients when compared to non-MGUS patients. MGUS patients had more heart failure (36.8% vs 17.2%;p&amp;lt;0.001), atrial fibrillation (10% vs 5.9%;p&amp;lt;0.001), venous thromboembolism (VTE) (2.8% vs 1.6%;p&amp;lt;0.001), aortic aneurysm (2.2% vs 1%;p=0.005), aortic stenosis (4.0% vs 1.6%;p&amp;lt;0.001), aortic regurgitation (1.2% vs 0.5%;p&amp;lt;0.001), mitral stenosis (0.3% vs 0.1%;p=0.009), mitral regurgitation (3.5% vs 1.5%;p&amp;lt;0.001), conduction disorder (6.6% vs 3.3%;p=0.002), cor-pulmonale (0.4% vs 0.2%;p&amp;lt;0.001), peripheral vascular disease (PVD) (14.4% vs 5.6%;p&amp;lt;0.001), and acute myocardial infarction (MI) (4.5% vs 3.6%;p&amp;lt;0.001). There were no significant differences in ischemic stroke/transient ischemic attack (TIA) and aortic dissection rates among both groups. The matched model corroborated several of our unmatched findings that MGUS was associated with higher heart failure, atrial fibrillation, VTE, aortic stenosis, mitral regurgitation, conduction disorder, cor-pulmonale, and PVD. Acute MI and ischemic stroke/TIA rates were negatively associated with MGUS in our matched model. Finally, sensitivity analysis showed that MGUS was still associated with higher rates of heart failure, atrial fibrillation, VTE, aortic regurgitation, and PVD, but decreased ischemic stroke/TIA and acute MI rates. Conclusion: In conclusion, our study found that patients with MGUS are at an increased risk of a wide spectrum of cardiovascular diseases in a hospital setting. MGUS patients may benefit from cardiovascular screening tools like electrocardiograms and echocardiograms at the hospital as this disease is independently associated with cardiovascular outcomes. Additional studies are needed to corroborate these findings as this will have implications on monitoring and screening of cardiovascular complications in MGUS patients.

In-hospital complications after MitraClip in patients with heart failure and preserved versus reduced ejection fraction in the United States

BackgroundThe clinical benefits of transcatheter edge to edge mitral valve repair have been well established in patients with heart failure and severe mitral regurgitation (MR) who have prohibitive surgical risk. In March of 2019, the FDA approved the MitraClip for treatment of selected patients with HF and severe secondary MR. However, the relative outcomes of patients with HFrEF and HFpEF treated with MitraClip are largely unknown. We therefore sought to investigate the incidence and characteristics of in-hospital mortality in patients with HFpEF and HFrEF following MitraClip. MethodsThe study sample analyzed was originated from the National Inpatient Sample (NIS) registry which includes data from hospitalized patients in the United States (US) between January 1, 2012 and December 31, 2020. Data were extracted from the entire NIS registry using ICD-9 codes. Patients with the primary or secondary diagnosis of MitraClip were identified. Hospitalizations for HFpEF and HFrEF were identified based on ICD-9-CM and ICD-10-CM codes. Demographics, conventional risk factors, and in-hospital outcomes were evaluated. Results23,260 hospitalizations for MitraClip implantation between 2016 and 2020 were analyzed. The HFrEF group had higher absolute rates of complications as well as a higher observed in-hospital mortality (2.4 % vs 1.7 %; OR 0.75 95 % CI 0.44–1.26; p 0.28) which did not meet statistical significance. Absolute rates of acute myocardial infarction (AMI), acute kidney injury (AKI) and respiratory failure necessitating invasive mechanical ventilation were observed to be higher among HFrEF patients. Post-procedural shock was significantly more common in patients with HFrEF (9.0 % vs 2.8 %: OR 0.34 95 % CI 0.25–0.48 p < 0.001). Significantly longer hospitalizations were observed in the HFrEF cohort (5.3 ± 11.2 days vs 4.2 ± 7.3 days; p < 0.001) as well as a higher total hospitalization cost (61,723 ± 56,728 USD vs 57,278 ± 46,143). ConclusionsIn the present study of US patients, those with HFrEF were observed to have statistically higher risk of in-hospital post-procedural shock and longer hospitalization length of stay when compared with patients with HFpEF who underwent MitraClip implantation. Additionally, patients with HFrEF undergoing MitraClip procedure were observed to have higher absolute rates of certain post-procedural complications, however these observations did not reach statistical significance. Understanding of the aforementioned differences after MitraClip implantation may be useful in-patient selection, prognostic guidance, and hypothesis generation to propel future large clinical studies.

Prognostic Significance of Peripheral Artery Disease in Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention.

Peripheral artery disease (PAD) elevates the risk of adverse outcomes. The current work aimed to evaluate the influence of PAD in acute coronary syndrome (ACS) cases administered percutaneous coronary intervention (PCI), and to determine whether PAD adds incremental prognostic value to the global registry of acute coronary events (GRACE) scale. To retrospectively analyze a single-center, prospective cohort trial, we consecutively included ACS cases administered PCI. Individuals with and without PAD were comparatively examined for clinical outcomes. The primary endpoint was major adverse cardiovascular events (MACEs), a compound item encompassing all-cause death, myocardial infarction (MI), stroke and repeat revascularization. The added value of PAD based on a reference model was examined. PAD was detected in 179 (10.4%) of the 1,770 included patients. The incidence rates of MACEs (40.3% vs. 17.9%), all-cause death (11.2% vs. 1.6%), cardiovascular death (8.9% vs. 1.4%), MI (8.4% vs. 2.2%) and repeat revascularization (30.2% vs. 15.2%) were all markedly elevated in PAD cases in comparison with the non-PAD group (p 0.001). After adjusting for other confounding variates, PAD independently predicted MACE occurrence (hazard ratio = 1.735, 95% confidence interval: 1.281-2.351). Addition of PAD resulted in remarkably increased predictive performance for MACE compared to the baseline GRACE score (Harrell's C-statistic: 0.610 vs. 0.587, p 0.001; net reclassification improvement: 0.134, p 0.001; integrated discrimination improvement: 0.035, p 0.001). In ACS cases administered PCI, PAD independently worsens clinical outcomes and adds incremental value to the GRACE risk score.

The effect of gender on clinical outcomes following routine revascularizations with polymer-free sirolimus-eluting stents.

Gender-specific outcomes after percutaneous coronary interventions were studied by a number of research groups with different endpoints and cohorts of different ethnic extractions. The purpose of this report is to use propensity score matching to determine gender-specific differences in clinical outcomes after percutaneous coronary interventions with polymer-free sirolimus-coated stents. The basis for this post hoc analysis was two large all-comers studies with prospectively enrolled patients from Europe and Asia. Data were pooled and analyzed in terms of clinical outcomes to assess the impact of gender in patients with stable coronary artery disease and acute coronary syndrome. The primary endpoint was the accumulated target-lesion revascularization rate whereas secondary endpoints consisted of the event rates for major adverse cardiac events (MACE), myocardial infarction, bleeding events and death from all causes. The purpose of these post hoc analyses was to detect potential differences in clinical outcomes between females and males in unselected and propensity-score-matched cohorts. Overall, in the unmatched cohorts, accumulated target-lesion revascularization rates did not differ between both genders (2.7% vs. 2.0%; P = 0.101), however, accumulated MACE rates were higher in females than in males (5.2% vs. 3.9%; P = 0.020). After propensity-score-matching, primarily adjusting for age, hypertension and diabetes, our data revealed similar accumulated MACE in women and men (5.5% vs. 5.2%; P = 0.749). In the unmatched STEMI subgroup, all-cause mortality was significantly higher in females driven by older age (P < 0.001). In the propensity-score-matched real-world cohorts, female gender was not a predictor for increased rates of accumulated MACE. In the unmatched STEMI subgroup, all-cause mortality was significantly higher in females due to older age. Age seems to be the determining factor for increased clinical event rates and not gender.

Cardiovascular hospitalizations and mortality among adults aged 25-64 years in the USA.

Declines in cardiovascular mortality have stagnated in the USA since 2011. There is growing concern that these patterns reflect worsening cardiovascular health in younger adults. However, little is known about how the burden of acute cardiovascular hospitalizations and mortality has changed in this population. Changes in cardiovascular hospitalizations and mortality among adults aged 25-64 years were evaluated, overall and by community-level income. Using the National Inpatient Sample, age-standardized annual hospitalization and in-hospital mortality rates for acute myocardial infarction (AMI), heart failure, and ischaemic stroke were determined among adults aged 25-64 years. Quasi-Poisson and quasi-binominal regression models were fitted to compare outcomes between individuals residing in low- and higher-income communities. Between 2008 and 2019, age-standardized hospitalization rates for AMI increased among younger adults from 155.0 (95% confidence interval: 154.6, 155.4) per 100 000 to 160.7 (160.3, 161.1) per 100 000 (absolute change +5.7 [5.0, 6.3], P < .001). Heart failure hospitalizations also increased (165.3 [164.8, 165.7] to 225.3 [224.8, 225.8], absolute change +60.0 (59.3, 60.6), P < .001), as ischaemic stroke hospitalizations (76.3 [76.1, 76.7] to 108.1 [107.8, 108.5], absolute change +31.7 (31.2, 32.2), P < .001). Across all conditions, hospitalizations rates were significantly higher among younger adults residing in low-income compared with higher-income communities, and disparities did not narrow between groups. In-hospital mortality decreased for all conditions over the study period. There was an alarming increase in cardiovascular hospitalizations among younger adults in the USA from 2008 to 2019, and disparities between those residing in low- and higher-income communities did not narrow.

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&amp;lt;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&amp;lt;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&amp;lt;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&amp;lt;0.01), TVR (20.5% vs. 11.4%, p&amp;lt;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

Ischemic burden and cardiovascular mortality in 12 middle- and high-income European countries

Abstract Background Death rates from ischemic heart disease (IHD) are consistently higher in middle-income countries (MICs) than in high-income countries (HICs) in Europe, but the reasons are unknown. Purpose The main goal of this study was to disentangle the relation between patient-specific revascularization through percutaneous coronary intervention (PCI) and risk factor burden among European women and men from HICs and MICs Methods We enrolled 22,087 patients with myocardial infarction (MI) from 40 urban hospitals in 12 European countries (6 high-income and 6 middle-income countries; HICs and MICs, respectively) and quantified their traditional risk-factor burden (hypercholesterolemia, diabetes, current smoking and hypertension), the severity of their clinical presentation (incidence of ST-segment elevation MI [STEMI]) and their 30-day cardiovascular outcomes. We calculated women to men risk ratios (RRs) using inverse probability weighting models with estimates compared by interaction test on the log scale. Results Women and men from MICs were significantly (P&amp;lt;0.001) younger than those from HICs. Rates of hypertension and diabetes were significantly (P&amp;lt;0.001) higher in MICs compared to HICs for both women and men. By contrast, we did not find significant differences between country income levels, sex and rates of hypercholesterolemia. In line with these data the use of preventive medications was significantly (P&amp;lt;0.001) more common in MICs than in HICs and in women compared with men. Despite this, the rates of STEMI on hospital presentation were remarkably (P&amp;lt;0.001) higher in MICs than in HICs. (68.8% vs 57.7% in women and 71.0% vs 57.9% in men), and accordingly the case fatality rates for MI were consistently (P&amp;lt;0.001) higher in MICs than in HICs, with women having higher rates of mortality than men (10.3% vs 5.7%; RR: 1.90; 95% CI: 1.67-2.17 and 5.5%, vs 4.2%; RR: 1.31; 95% CI: 1.06-1.63; respectively; P interaction=0.002). Contrary to what was expected, MIC hospitals had higher rates of revascularization procedures than HIC hospitals both in women (72% vs 56%) and men (80% vs 61%). Although the rates of death were consistently lower in the population undergoing revascularization, still mortality remained significantly (P&amp;lt;0.001) higher in MICs than in HICs and in women than in men (6.9% vs 3.8% and 4.3% vs 2.3%; 10.3% vs 5.7%), but the relative RRs for the two country income groups did not significantly differ each other (P interaction=0.40). Conclusions Although the rates of revascularization procedures in MI were higher in MICs, the rates of death were substantially higher in MICs than in HICs. The high burden of risk factors in MICs appears to be the reason of a substantial increased baseline ischemic risk with higher rate of STEMI as MI clinical presentation. Better control of risk factors may mitigate the observed gap in mortality from MI between MICs and HICs, especially in women.

Optimal medical management vs. percutaneous coronary intervention for patients with stable angina: from nation-wide Korean Insurance data

Abstract Background To investigate whether percutaneous coronary intervention (PCI) on top of optimal medical therapy (OMT) is superior to OMT only in patients with stable angina. Methods We enrolled patients with stable angina from 2005-2010 using the Korean national Insurance data. 68621 patients were candidate with stable angina and finally 5673 patients in PCI plus OMT and 5673 in OMT were selected with 1:1 propensity matching. Results Primary endpoint, a composite of myocardial infarction (MI), stroke, cardiac death and revascularization was significantly more common in PCI than in OMT group, 13.5/1000 vs. 11.5/1000 person year with HR, 1.182(1.059-1.319) (P=0.0027). Individual outcome rate of MI, revascularization and cardiac death was higher in PCI group then in OMT group , 2.9 vs. 2. (HR [1.376 1.085-1.744], p=0.0085), 30.3 vs. 8.1 (HR 3.638 [3.269-4.049], p&amp;lt;0.001) and 4.8 vs 3.4/1000 person year (HR 1.397 [1.155-1.69], p=0.0006) respectively. No difference was found in stroke rate. In subgroup analysis same trend of more rate of event in PCI group was detected. Conclusions PCI was associated with higher rate of primary endpoint of MI, stroke, cardiac death as compared to OMT only in patients with stable angina.Primary endpoint between PCI vs. OMT

Longer-term impact of PCSK9 inhibitors on major adverse cardiovascular events and all-cause mortality: a systematic review and meta-analysis of randomised controlled trials

Abstract Background The development of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors offers a novel treatment option for lowering cardiovascular risk profiles through significant reductions in low-density lipoprotein cholesterol. Whilst their effect on improving patients' lipid profiles has been well-established in clinical trials, their impact on major adverse cardiovascular events (MACE) and all-cause mortality in the longer-term is of interest since PCSK9 inhibitors are becoming an important addition to the current armament of lipid-lowering therapies. Purpose This systematic review and meta-analysis seeks to evaluate the longer-term effect (≥ 12 months) of PCSK9 inhibitors on MACE and all-cause mortality, compared to placebo, in patients with dyslipidaemia or atherosclerotic cardiovascular disease. Methods A systematic search of databases including PubMed, Ovid, and Cochrane Central Register of Controlled Trials was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in January 2023. Two reviewers screened for phase 3 randomised-controlled trials (RCTs) comparing the anti-PCSK9 monoclonal antibodies currently in use (alirocumab and evolocumab) to placebo in adult patients. Trials were included if they had a follow-up of at least 12 months from initiation of treatment and reported on MACE or all-cause mortality. Demographic data, clinical characteristics, MACE outcomes such as rates of myocardial infarction, coronary revascularisation, cardiovascular death, hospitalisation for heart failure, hospitalisation for unstable angina, stroke and all-cause mortality outcomes were extracted. A random effects model was used for meta-analysis with dichotomous outcomes reported as odds ratio (OR), 95% confidence intervals (CI) and I² metric to assess heterogeneity. Results The incidence of myocardial infarction and coronary revascularisation was reported in ten studies (encompassing 57,890 participants) out of the eleven RCTs that met our inclusion criteria. Meta-analysis demonstrated statistically significant reduction in myocardial infarction (OR -0.27, 95% CI -0.40 to -0.15, p &amp;lt;0.01, I² = 25.5%) and coronary revascularisation (OR -0.20, 95% CI -0.28 to -0.11, p &amp;lt;0.01, I² =12.4%) for patients on PCSK9 inhibitors compared to placebo. Heterogeneity was considered moderate and low respectively for these outcomes. No statistically significant effect was observed for other MACE or all-cause mortality. Conclusions The results of this study suggest that PCSK9 inhibitors can significantly reduce rates of myocardial infarction and coronary revascularisation in patients over the long-term (≥ 12 months). Further studies with longer-term follow-up are needed to fully evaluate the impact of PCSK9 inhibitors across MACE outcomes, and to inform clinical decision-making.Myocardial Infarction Forest PlotCoronary Revascularisation Forest Plot

Prognostic value of a novel artificial intelligence-based coronary computed tomography angiography-derived ischemia algorithm for patients with suspected coronary artery disease

Abstract Introduction Coronary computed tomography angiography (CCTA) has emerged as the first-line, non-invasive imaging tool to detect coronary artery disease (CAD) in patients with low to intermediate pre-test probability of CAD. However, CCTA cannot directly assess the presence of ischemia, which may lead to further downstream testing. A novel artificial-intelligence (AI)-based algorithm, comprising a machine-learned method that leverages atherosclerosis and vascular morphology features to determine vessel-level coronary ischemia from CCTA images, may be useful in this regard. Purpose We aimed to investigate the prognostic value of the AI-based ischemia algorithm for clinical events among symptomatic patients with suspected CAD referred for CCTA. Methods The AI-based ischemia algorithm was calculated by analysts blinded for patient characteristics and clinical outcomes using CCTA data from patients with suspected CAD who underwent clinically indicated CCTA at a large tertiary care center from February 2007 to December 2016. The primary endpoint was the composite of death, myocardial infarction (MI), and unstable angina pectoris (uAP) throughout a median follow-up of 8.1 years (IQR 6.0-9.6). Secondary endpoints were the association between the AI-based ischemia algorithm and the primary endpoint among patients with no/non-obstructive (i.e. ≤50%) CAD vs. obstructive (i.e. &amp;gt;50% stenosis) CAD in CCTA. Results 1574 patients were evaluated by the AI-based ischemia algorithm and 1540 were analyzable. Patients with positive AI-based ischemia findings (30.4%, n=468) had a significantly higher crude rate of the primary endpoint as compared to patients with negative AI-based ischemia findings (69.6%, n=1072) (HR 2.37, 95% CI 1.80-3.11, p&amp;lt;0.001), driven by higher rates of all endpoint composites (death: HR 1.48, 95% CI 1.13-2.22, p=0.007; MI: HR 5.42, 95% CI 3.10-9.49, p&amp;lt;0.001; uAP: HR 6.76, 95% CI 3.01-15.20, p&amp;lt;0.001). Results were consistent after adjusting for clinical confounders (age, sex, diabetes mellitus, smoking, hypertension, dyslipidemia, BMI&amp;gt;25 kg/m2, CAD family history) (primary endpoint: HR 1.66, 95% CI 1.24-2.22, p=0.001). Positive AI-based ischemia findings were associated with a significantly higher rate of the primary endpoint among patients with no/non-obstructive CAD in CCTA (n=1001/1487) (HR 2.56, 95% CI 1.53-4.27, p&amp;lt;0.001), but not among those with anatomically obstructive CAD in CCTA (n=486/1487) (HR 1.08, 95% CI 0.70-1.66, p=0.715). Conclusions A novel AI-based CCTA-derived ischemia algorithm was associated with a 1.7-fold increased adjusted rate of long-term death, MI, or uAP. This AI-based ischemia algorithm may be helpful to improve risk stratification, especially among patients with normal/non-obstructive CCTA.Kaplan Meier CCTA ≤50% and &amp;gt;50% stenosis

GDF-15 is associated with worse ischemic and bleeding outcomes in the acute phase and during follow-up in patients with acute coronary syndrome: insights from the TRACER trial

Abstract Introduction Growth differentiating factor-15 (GDF-15) is a stress responsive cytokine that increases with age. GDF-15 has been associated with mortality, myocardial infarction (MI), heart failure and bleeding in patients with acute coronary syndrome (ACS) and stable coronary artery disease. Purpose The aim of this study was to evaluate the levels of GDF-15 and their associations with risk of cardiovascular events and bleeding in patients with ACS in the acute setting and after one month. Methods Venous blood samples were obtained at the index event in 6800 patients and again after one month in 5313 patients with non-ST-segment elevation ACS (NSTE-ACS) randomized to vorapaxar vs placebo on top of dual antiplatelet treatment in the TRACER study. The GDF-15 level was centrally measured by the ROCHE ELISA assay in stored plasma aliquots. The main cardiovascular (CV) endpoint in this substudy was the composite of CV death, MI and ischemic stroke and main safety endpoint was non-procedural major or minor bleeding according to Thrombolysis in Myocardial Infarction (TIMI) classification. Cox-regression models were used to estimate unadjusted and adjusted associations between log-transformed GDF-15 and outcomes. Adjustments were made for study treatment and well-established clinical CV risk factors. All corresponding models but without the biomarker was fitted and a concordance index (c-index) calculated. A likelihood-ratio test was used to test for differences between the two c-indices. Results Median concentration of GDF-15 at baseline and after one month were 1226 ng/L and 1181 ng/L, respectively. The correlation between GDF-15 concentrations at baseline and after one month was r=0.80 (Figure 1). The levels of GDF-15 were independently associated with older age, presence of diabetes mellitus, renal dysfunction and smoking. GDF-15 levels both at baseline and after one month were independently associated with higher rate of CV death, MI and ischemic stroke and with non-procedural TIMI major or minor bleeding (Figure 2). At baseline the addition of GDF-15 levels to the multivariable model for subsequent CV death, MI or ischemic stroke increased the c-index from 0.656 to 0.668 (P&amp;lt;0.001), and for bleeding from 0.715 to 0.719 (P=0.037). At one month adding GDF-15 levels increased the c-index from 0.711 to 0.722 (P&amp;lt;0.001) for CV death, MI or ischemic stroke and from 0.735 to 0.783 (P&amp;lt;0.001) for bleeding. Conclusions In patients with NSTE-ACS levels of GDF-15 are independently associated with CV death, MI or ischemic stroke and non-procedural bleeding and contribute prognostic information both at the index event and after one month. Levels of GDF-15 remain stable over time and provide similar prognostic information in the acute and follow-up setting.Fig.1 Correlation GDF-15 baseline and 1mFig.2 Non-linear cox-regression

Prevalence and outcomes of acute coronary syndrome patients with and without standard modifiable risk factors undergoing percutaneous coronary intervention

Abstract Background Prevention strategies in acute coronary syndrome (ACS) have focused on patients with standard modifiable risk factors (SMuRFs; diabetes, hypercholesterolaemia, hypertension, and current smoking). There is increasing awareness that SMuRF-less patients may represent a unique subset of patients experiencing ACS. Purpose To investigate the prevalence, characteristics, and outcomes of SMuRF-less ACS patients compared to those with SMuRFs undergoing percutaneous coronary intervention (PCI) in a major city in Australia. Methods We analysed data from adult (≥18 years) ACS patients receiving PCI between 2005 and 2020 using a PCI Registry which contains data for all patients undergoing coronary intervention at one of six major hospitals. Patients with a known history of coronary artery disease were excluded. Overall clinical characteristics and outcomes for those with and without SMuRFs were examined. The primary outcome was 30-day all-cause mortality. Secondary outcomes included in-hospital outcomes, myocardial infarction (MI), revascularisation, and major adverse cardiovascular and cerebrovascular (MACCE) events at 30 days. Long-term mortality was investigated using Cox-proportional hazards regression. Results From 1 January 2005 to 31 December 2020, 2,727 (14.4%) of 18,988 patients were SMuRF-less. Mean (± standard deviation [SD]) age was similar between patients with and without SMuRFs (63±13 vs 63±12 years) and there were more females with SMuRFs (25% vs 20%, p&amp;lt;0.001). SMuRF-less patients were less likely to have a history of cerebrovascular disease (1.2% vs 4.2%, p&amp;lt;0.001), peripheral vascular disease (0.6% vs 3.0%, p&amp;lt;0.001), and chronic lung disease (8.6% vs 10.1%, p=0.014). They were more likely to present with out-of-hospital cardiac arrest (6.6% vs 3.9%, p&amp;lt;0.001) and ST-elevation MI (59% vs 51%, p&amp;lt;0.001). The left anterior descending artery was the target lesion in 46% of SMuRF-less patients compared to 39% of those with SMuRFs. During hospital stay, SMuRF-less patients were more likely to experience post-procedural cardiogenic shock (4.5% vs 3.6%, p=0.019) and arrhythmia (11.2% vs 9.9%, p=0.029). At 30 days, all-cause mortality did not differ between those with and without SMuRFs (3.2% vs 3.6%, p=0.290). Similarly, there were no differences in 30-day MI, revascularisation, and MACCE. During mean follow-up of approximately 7 years, being SMuRF-less was associated with a 12% decreased rate of mortality (adjusted Hazard Ratio 0.88 [95% confidence interval 0.78, 0.99], p=0.035). Conclusions Despite differences in characteristics (rates of cardiac arrest and ST-elevation MI), no difference in 30-day outcomes was observed among those with and without SMuRFs. However, SMuRF-less patients had lower hazard for long-term mortality. These findings suggest SMuRF-less patients may have novel risk factors and improved long-term outcome warranting further research.

Ticagrelor or Clopidogrel to reduce ischemic events after Percutaneous Coronary Intervention in chronic coronary syndrome in clopidogrel naive patient: the ALPHEUS Naive sub-study

Abstract Background The ALPHEUS trial showed a similar rate of type 4 myocardial infarction (MI) or major myocardial injury in elective PCI treated by clopidogrel or ticagrelor. Whether clopidogrel therapy at baseline might have affected these results is unknown. Purpose We evaluated the impact of ticagrelor versus clopidogrel loading dose in clopidogrel naïve patients as compared to patients already treated by clopidogrel in this pre-specified analysis. Methods We divided 1882 randomized patients with complete data on baseline clopidogrel into 2 groups according to presence of clopidogrel therapy &amp;gt; 7 days (long term clopidogrel = Clopi+) or its absence (clopidogrel naïve = Clopi-). The primary endpoint was the rate of PCI-related MI and myocardial injury as defined by the 3rd and 4th universal definition of MI evaluated within 48 h of PCI (or hospital discharge if earlier) and major and minor bleeding. Angiographic complications evaluated by the core laboratory (coronary slow flow, no flow, dissection, and thrombus) were also compared. Event rates were compared and the interaction of the allocated treatment in the randomized groups was evaluated. Results 1077 patients (57.2%) were Clopi- and 805 patients were Clopi+. Patients in the Clopi- group were less frequently male (78.0% vs 81.9%, p= 0.04) with less often dyslipidemia (57.8% vs 65.6%, p&amp;lt; 0.001) and peripheral artery disease (11.1% vs 14.4%, p= 0.03) and had less acute coronary syndrome in the last 12 months (3.4% vs 8.7% p= 0.002). The primary endpoint was less frequent in Clopi- as compared to tClopi+ (32.8% vs 40%, OR =0.73, CI [0.60-0.88], p=0.001). This difference was mainly driven by a lower rate of major myocardial injury 24.% vs 31.6% while the rate of type 4a MI and stent thrombosis were similar (8.4% vs 8.2%) and (0.4% vs 0.2%) respectively. Angiographic complication rate was similar in the Clopi- and the Clopi+ groups (14.6% vs 12.9%) OR=1.15 CI [0.88-1.5], p=0.31. Major bleedings were infrequent in the trial. (0.1% vs 0%), and minor bleeding did not differ significantly between Clopi- and Clopi+ patients (7.0% vs 4.8% OR=1.47, CI [0.99-2.19], p=0.06). At 30 days, no difference in any outcomes were reported between the two groups. Alike for the main trial results, in the Clopi- group, ticagrelor was not superior to clopidogrel in reducing periprocedural myocardial necrosis, p for interaction was 0.83. Conclusions Periprocedural MI and procedural angiographic complications were less frequent in clopidogrel naïve patients as compared to patients already on clopidogrel therapy, and not influenced by the potency of the P2Y12 inhibitor’s loading dose prior to PCI. These results globally suggest no benefit of a long term clopidogrel pretreatment in patients receiving a loading dose of P2Y12 in the 24 hours prior to PCI in chronic coronary syndrome undergoing elective PCI and support the use of clopidogrel as the standard of care.

Unrealized opportunities for cardiovascular risk reduction with optimized statin and ezetimibe in veterans with coronary artery disease

Abstract Background Many patients with coronary artery disease (CAD) do not achieve guideline-directed low-density lipoprotein cholesterol (LDL-C) goals (1,2). Purpose To quantify unrealized opportunities to improve clinical outcomes of Veterans with CAD through optimized oral lipid-lowering therapy (LLT) with statins and ezetimibe within the United States Veterans Affairs healthcare system. Methods Veterans with CAD by coronary angiography between 2015 and 2020 were identified, the observed LLT and LDL-C were described, and the observed rates of death, myocardial infarction, stroke, and coronary revascularization were determined. Potential reductions in these events with optimized statin alone or with ezetimibe were modelled based on expected further LDL-C reductions (3). Results The analysis cohort comprised 111,954 Veterans (59.7% statin-treated at baseline angiography) observed for median 3.4 (IQR 2.1-4.0) years. At 6 months, statin prescription increased to 68.7%, but high-intensity statin regimens were prescribed in only 52.9%, ezetimibe use was low (1.1%), and LDL-C remained ≥70 mg/dL in 52.1% of patients. At 4 years, observed incidences (95% CI) of death, myocardial infarction, stroke, and coronary revascularization were 21.6% (21.3-21.8), 5.0% (4.9-5.2), 2.2% (2.1-2.3), and 15.4% (15.2-15.7), respectively (Figure 1). With optimized statin, projected absolute reductions in these incidences were 1.3% (0.9-1.7), 0.8% (0.7-1.0), 0.2% (0.1-0.3), and 2.3% (2.0-2.7). With optimized statin and ezetimibe, projected absolute reductions were 1.8% (1.2-2.4), 1.1% (0.9-1.3), 0.3% (0.2-0.4) and 3.1% (2.6-3.6). Conclusions Suboptimal LLT was prevalent among Veterans with CAD. Meaningful improvements in their cardiovascular outcomes could be achieved with optimized statin alone. Despite lesser lipid-lowering efficacy of ezetimibe, its widespread use on a population level could contribute substantially to cardiovascular risk reduction from intensified oral LLT.Figure 1Figure 2