Rates Of Myocardial Infarction Research Articles

Effect of febuxostat on adverse events and mortality in gout in Taiwan: An interrupted time series analysis

To evaluate the influence of febuxostat on adverse events and mortality in gout. We retrospectively enrolled patients with newly diagnosed gout and prescribed urate-lowering therapy between 2006 and 2017 from the Taiwan National Health Insurance Database. These patients were divided into 2 groups: with and without comorbidities (n= 294 847 and 194 539). An interrupted time series analysis with adjustments for demographics, comorbidities, and comedication by propensity score-based stabilized weights was used to compare the trend of adverse events and mortality before vs after febuxostat was introduced in 2012. The proportion of febuxostat use gradually increased from 0% in 2012 to 30% in those with comorbidities and 10% in those without comorbidities in 2017. Allopurinol use decreased from 30% in 2012 to 10% in 2017. The slope of the 1-year incidence rate of Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) (per 10 000 patients) significantly reduced after 2012 in those with and without comorbidities (-0.375 per quarter, P= .015 and -.253 per quarter, P= .049). The slope of the 3-year incidence rate of acute myocardial infarction (AMI) (per 1000 patients), percutaneous coronary intervention (PCI) (per 1000 patients), and all-cause mortality (per 100 patients) significantly increased after 2012 in those with comorbidities (+0.207 per quarter, P= .013; +.389 per quarter, P= .002; +.103 per quarter, P= .001). Febuxostat may reduce SJS and TEN in all gout patients but increase AMI, PCI, and all-cause mortality in gout patients with comorbidities.

Rural and socioeconomic differences in the effectiveness of the HEART Pathway accelerated diagnostic protocol.

The HEART Pathway is a validated accelerated diagnostic protocol (ADP) for patients with possible acute coronary syndrome (ACS). This study aimed to compare the safety and effectiveness of the HEART Pathway based on patient rurality (rural vs. urban) or socioeconomic status (SES). We performed a preplanned subgroup analysis of the HEART Pathway Implementation Study. The primary outcomes were death or myocardial infarction (MI) and hospitalization at 30 days. Proportions were compared by SES and rurality with Fisher's exact tests. Logistic regression evaluated for interactions of ADP implementation with SES or rurality and changes in outcomes within subgroups. Among 7245 patients with rurality and SES data, 39.9% (2887/7245) were rural and 22.2% were low SES (1607/7245). The HEART Pathway identified patients as low risk in 32.2% (818/2540) of urban versus 28.1% (425/1512) of rural patients (p= 0.007) and 34.0% (311/915) of low SES versus 29.7% (932/3137) high SES patients (p= 0.02). Among low-risk patients, 30-day death or MI occurred in 0.6% (5/818) of urban versus 0.2% (1/425) rural (p= 0.67) and 0.6% (2/311) with low SES versus 0.4% (4/932) high SES (p= 0.64). Following implementation, 30-day hospitalization was reduced by 7.7% in urban patients (adjusted odds ratio [aOR] 0.76, 95% confidence interval [CI] 0.66-0.87), 10.6% in low SES patients (aOR 0.68, 95% CI 0.54-0.86), and 4.5% in high SES patients (aOR 0.83, 95% CI 0.73-0.94). However, rural patients had a nonsignificant 3.3% reduction in hospitalizations. HEART Pathway implementation decreased 30-day hospitalizations regardless of SES and for urban patients but not rural patients. The 30-day death or MI rate was similar among low-risk patients.

Association of Pretransplant Coronary Heart Disease Testing With Early Kidney Transplant Outcomes

Testing for coronary heart disease (CHD) in asymptomatic kidney transplant candidates before transplant is widespread and endorsed by various professional societies, but its association with perioperative outcomes is unclear. To estimate the association of pretransplant CHD testing with rates of death and myocardial infarction (MI). This retrospective cohort study included all adult, first-time kidney transplant recipients from January 2000 through December 2014 in the US Renal Data System with at least 1 year of Medicare enrollment before and after transplant. An instrumental variable (IV) analysis was used, with the program-level CHD testing rate in the year of the transplant as the IV. Analyses were stratified by study period, as the rate of CHD testing varied over time. A combination of US Renal Data System variables and Medicare claims was used to ascertain exposure, IV, covariates, and outcomes. Receipt of nonurgent invasive or noninvasive CHD testing during the 12 months preceding kidney transplant. The primary outcome was a composite of death or acute MI within 30 days of after kidney transplant. The cohort comprised 79 334 adult, first-time kidney transplant recipients (30 147 women [38%]; 25 387 [21%] Black and 48 394 [61%] White individuals; mean [SD] age of 56 [14] years during 2012 to 2014). The primary outcome occurred in 4604 patients (244 [5.3%]; 120 [2.6%] death, 134 [2.9%] acute MI). During the most recent study period (2012-2014), the CHD testing rate was 56% in patients in the most test-intensive transplant programs (fifth IV quintile) and 24% in patients at the least test-intensive transplant program (first IV quintile, P < .001); this pattern was similar across other study periods. In the main IV analysis, compared with no testing, CHD testing was not associated with a change in the rate of primary outcome (rate difference, 1.9%; 95% CI, 0%-3.5%). The results were similar across study periods, except for 2000 to 2003, during which CHD testing was associated with a higher event rate (rate difference, 6.8%; 95% CI, 1.8%-12.0%). The results of this cohort study suggest that pretransplant CHD testing was not associated with a reduction in early posttransplant death or acute MI. The study findings potentially challenge the ubiquity of CHD testing before kidney transplant and should be confirmed in interventional studies.

How did the COVID-19 pandemic affect the referral patterns for SPECT myocardial perfusion? A single center experience.

We evaluated the impact of the COVID-19 pandemic on the number of referrals for SPECT myocardial perfusion imaging (SPECT-MPI) as well as changes in the clinical and imaging characteristics. We respectively reviewed 1042 SPECT-MPI cases performed in a 4-month period during the COVID-19 pandemic (PAN; n=423) and compared their findings with those acquired in the same months before the pandemic (PRE; n=619). The number of stress SPECT-MPI studies performed during the PAN period significantly dropped compared to the number of studies carried out in the PRE period (p = 0.014). In the PRE period, the rates of patients presenting with non-anginal, atypical and typical chest pain were 31%, 25% and 19%, respectively. The figures significantly changed in the PAN period to 19%, 42%, and 11%, respectively (all p-values <0.001). Regarding the pretest probability of coronary artery disease (CAD), a significant decrease and increase were noticed in patients with high and intermediate pretest probability, respectively (PRE: 18% and 55%, PAN: 6% and 65%, p <0.001 and 0.008, respectively). Neither the rates of myocardial ischemia nor infarction differed significantly in the PRE vs. PAN study periods. The number of referrals dropped significantly in the PAN era. While the proportion of patients with intermediate risk for CAD being referred for SPECT-MPI increased, those with high pretest probability were less frequently referred. Image parameters were mostly comparable between the study groups in the PRE and PAN periods.

Anticoagulation for Atrial Fibrillation in Acute Coronary Syndrome Survivors Reduces Major Cardiovascular Events and Mortality.

The prevalence of atrial fibrillation (AF) in acute coronary syndrome (ACS) patients is increasing. Data on outcomes of anticoagulation in ACS patients with AF are lacking. The aim of our study was to investigate the prevalence of stroke, myocardial infarction, bleeding complications, and all-cause mortality in this population. PL-ACS and AMI-PL registries gather an all-comer population of ACS patients in Poland, exceeding half a million records. We have selected ACS survivors with concomitant AF on admission, divided them into subgroups with regard to the administered anticoagulation, and followed up with them for a 12-month period ( n = 13,973). Subsequently, groups were propensity score matched for age, sex, ejection fraction, diabetes, heart failure, renal impairment, and type of ACS. The study population was divided with regard to the administration of anticoagulation. Anticoagulation was prescribed in 2,466 patients (17.6%). The (D)OAC+ patients were younger; however, comorbidities were more prevalent in this group. The 12-month follow-up showed that the (D)OAC+ patients had significantly lower rates of all-cause mortality, myocardial infarction, and ischemic stroke, with no significant increase in bleeding events. After matching, the study groups consisted of 2,194 patients each and showed no differences in baseline characteristics. The outcomes of the 12-month observation were similar to the findings before matching. This all-comer national registry analysis shows that the use of guideline-recommended therapy and anticoagulation in ACS survivors with AF is associated with a lower rate of all-cause mortality, recurrent myocardial infarction, and ischemic stroke.

Same-Day Carotid Artery Stenting and Coronary Artery Bypass Surgery

The optimal treatment strategy for patients with severe carotid artery disease undergoing coronary artery bypass grafting is still problematic. The important question is whether it is necessary to treat significant carotid disease in patients who have undergone coronary artery bypass grafting. This study analyzed short- and midterm results after same-day carotid artery stenting and coronary artery bypass grafting. From 2013 to 2020, a total of 69 patients were enrolled in the study. Same-day carotid artery stenting and coronary artery bypass grafting were performed in all patients. The study's primary end points were the evaluation rate of stroke, myocardial infarction, and death within short- and midterm periods after the procedures. The 30-day mortality was 0%. The occurrences of perioperative adverse events, namely stroke, myocardial infarction, and transient ischemic attack, were 1 (1.4%), 1 (1.4%), and 4 (5.8%), respectively. Mean (IQR) follow-up time was 28 (IQR, 17-43) months. Six (8.8%) patients died during this period. Fatal stroke was registered in 2 cases, and 1 patient experienced a disabling stroke with a fatal outcome. The other 3 patients died because of chronic renal disease, a traffic accident, and for an unknown reason, respectively. Midterm survival in the group was 91.2%. The study showed that same-day carotid artery stenting and coronary artery bypass grafting for concomitant carotid and coronary disease treatment could be a promising and feasible therapeutic strategy.

Platelet Indices and Intracoronary Thrombus Grade as Predictors of In-Hospital Major Cardiovascular Events in Patients with ST Elevation Myocardial Infarction Post Primary Percutaneous Coronary Intervention

Background: The high mortality rate of ST Elevation Myocardial Infarction (STEMI) is caused by its complications, especially in-hospital major cardiovascular events (MACE). This study aims to determine the relationship between platelet indices and intracoronary thrombus grade as predictors of in-hospital MACE and the interaction of the combination of both predictors in patients with STEMI post-primary percutaneous coronary intervention (PCI). Methods: This prospective cohort study was conducted with STEMI patients who underwent primary PCI. Data was analyzed by SPSS 24.0.0.0 version. Results: There were 71 samples: 46 patients (64.8%) with a high platelet index and 48 patients (67.6%) with a high intracoronary thrombus grade. During in-hospital follow-up, there were found that 42 patients (59.2%) experienced MACE. The cut-off value used classifies high platelet index for PDW 11.25 fl (AUC 0.892; CI 95% 0.786-0.999; p&lt;0.001) and MPV 10.15 (AUC 0.901; CI 95% 0.812-0.990; p&lt;0.001). The Cox regression backward log-rank model showed both high platelet indices (adjusted HR 38.13; CI 95% 5.16-282.03; p&lt;0.001) and high Intracoronary Thrombus Grade (adjusted HR 31.67; CI 95% 4.28-234.54; p=0.001) played an independent role as predictors of MACE during hospitalization, regardless of the influence of coronary angiography results, Killip class, smoking and consumption of acetosal and clopidogrel. The combination of two predictors of high platelet indices and high Intracoronary Thrombus Grade based on SEM analysis showed that 95.2% experienced in-hospital MACE (Mantel-Haenzel Common Estimate 17.48; Breslow-Day Homogeneity p=0.772; Cochran’s and Mantel-Haenszel p=&lt;0.001), had better predictive ability as seen from the comparison of the respective AUC values, namely the combination, high platelet indices and high Intracoronary Thrombus Grade (0.942; 0.902; 0.873; p&lt;0.001). Conclusion: High platelet indices and high intracoronary thrombus grade can be used as additional information for risk stratification of in-hospital MACE of STEMI patients post-primary PCI, especially when both variables were combined.

Geographic Variations on the Safety and Efficacy of the Supreme Biodegradable Polymer DES: Results From PIONEER III

<h2>Abstract</h2><h3>Background</h3> The PIONEER III trial showed the 12-month safety and efficacy of the Supreme drug-eluting stent (DES) vs the durable polymer everolimus-eluting stent. We sought to assess whether the characteristics and clinical outcomes of the Supreme DES in PIONEER III were consistent among patients by enrollment location. <h3>Methods</h3> This subgroup analysis of the PIONEER III trial compared the characteristics and outcomes of patients recruited from North America, Europe, and Japan and the relative differences in patient outcomes according to the site recruitment volume. <h3>Results</h3> From October 2017 to July 2019, 1629 patients were recruited in North America (816, 50.1%), Europe (650, 39.9%), and Japan (163, 10%). Procedural success was achieved in 1556 of 1611 procedures (96.6%), with no difference by the geographic location. Target lesion failure at 12 months for combined groups was observed in 84 of 1629 patients (5.2%), with no significant geographic differences (4.7%, 6.5%, and 2.5%, respectively; <i>P</i> =.08), with similar results in the Supreme DES group alone (4.4%, 6.8%, and 3.7%, respectively, <i>P</i> =.20). Cardiac death at 12 months occurred in 0.4%, 0.2%, and 0.0% (<i>P</i> =.79), target vessel–related myocardial infarction occurred in 2.2%, 4.7%, and 3.7%, (<i>P</i> =.10), and clinically driven target lesion revascularization was required in 2.1%, 3.1%, and 0%, respectively (<i>P</i> =.15). Compared with those from high-recruiting sites, results from low-recruiting sites were similar for target lesion failure, major adverse cardiac events, stent thrombosis, and mortality, with a nonsignificant trend for higher rates of myocardial infarction. <h3>Conclusions</h3> Despite regional differences in patient characteristics, the clinical outcomes between Supreme DES and durable polymer everolimus-eluting stent in the PIONEER III trial were not different, supporting the generalizability and robustness of the findings from this multicenter controlled trial.

Warranty period of coronary computed tomography angiography and [15O]H2O positron emission tomography in symptomatic patients.

Data on the warranty period of coronary computed tomography angiography (CTA) and combined coronary CTA/positron emission tomography (PET) are scarce. The present study aimed to determine the event-free (warranty) period after coronary CTA and the potential additional value of PET. Patients with suspected but not previously diagnosed coronary artery disease (CAD) who underwent coronary CTA and/or [15O]H2O PET were categorized based upon coronary CTA as no CAD, non-obstructive CAD, or obstructive CAD. A hyperaemic myocardial blood flow (MBF) ≤ 2.3 mL/min/g was considered abnormal. The warranty period was defined as the time for which the cumulative event rate of death and non-fatal myocardial infarction (MI) was below 5%. Of 2575 included patients (mean age 61.4 ± 9.9 years, 41% male), 1319 (51.2%) underwent coronary CTA only and 1237 (48.0%) underwent combined coronary CTA/PET. During a median follow-up of 7.0 years 163 deaths and 68 MIs occurred. The warranty period for patients with no CAD on coronary CTA was ≥10 years, whereas patients with non-obstructive CAD had a 5-year warranty period. Patients with obstructive CAD and normal hyperaemic MBF had a 2-year longer warranty period compared to patients with obstructive CAD and abnormal MBF (3 years vs. 1 year). As standalone imaging, the warranty period for normal coronary CTA is ≥10 years, whereas patients with non-obstructive CAD have a warranty period of 5 years. Normal PET yielded a 2-year longer warranty period in patients with obstructive CAD.

Tissue Stents (Bio Stents): Search For Non- Metallic Stent And Can It Be A Game Changer In Cardiovascular Interventions?

Coronary and Vascular stenosis poses great challenge in terms of cardiovascular disease burden. Evolution of metallic stents has been key in treating Coronary Artery Disease both acute and chronic and has met challenges successfully. The last 2 decades have seen substantial reform in technology, bringing second and third generations of coronary and vascular stents mainly metallic drug-eluting stents (DES). Though stent related stenosis is big challenge, DES has met relatively much success especially during initial years. DES are found to be associated with good first-year outcomes but subsequent risk of stentrelated adverse events like thrombosis, myocardial infarction, restenosis usually appear after 1 year following implantation. The pathogenesis of these late events is related to the permanent presence of the metal stent frame or polymer within coronaries. Besides intimal hyperplasia, late stent thrombosis, and noncompliance with DAPT are still major issues leading to stent failure and often the need for reintervention. As an effective alternative to metallic stents, Bioresorbable scaffolds were developed to provide drug delivery and mechanical support functions similar to metallic drug-eluting stents (DES), followed by complete resorption with recovery of vascular structure and function, potentially improving very late clinical outcomes. A first-generation bioresorbable scaffold demonstrated to be no inferior to a contemporary metallic drug-eluting stents for overall 1-year patient-oriented and deviceoriented outcomes. However, increased rates of scaffold thrombosis and target vessel-related myocardial infarction were noted subsequently at 5 year follow up. Tissue/Bio Stents can present as a path breaking alternative approach to avoid intimal hyperplasia. They are characterised by presence of biodegradable struts with tissue mesh and complete absence of metal preventing ingrowth of the neointimal tissue into the lumen. Currently used stent materials include mainly metals and synthetic polymers. Their main limitation is lack of hemocompatibility, which can induce thrombosis and ultimately reocclusion, thus impairing the long-term performance of these devices. We are proposing use of biologically derived material to overcome this issue with the aim of enhancing the biocompatibility and the capability of this type of stents to support endothelialilzation. The aim of this article is to give a comprehensive overview of the manufacturing and applications of Tissue or Bio Stents as well as the different strategies followed for their development from the perspective of the material selection, fabrication approaches, and logical validation of the different concepts into animal and clinical trials.

Coronary microcirculation dysfunction evaluated by myocardial contrast echocardiography predicts poor prognosis in patients with ST-segment elevation myocardial infarction after percutaneous coronary intervention

BackgroundThe mortality rate of acute ST-segment elevation myocardial infarction (STEMI) remains substantial, despite advances in treatment strategies. Coronary microcirculation dysfunction (CMD) persists after percutaneous coronary intervention (PCI) in a substantial proportion of STEMI patients. The association between CMD assessed using myocardial contrast echocardiography (MCE) and prognosis requires further elucidation. This study aimed to evaluate the impact of CMD after successful PCI on the prognosis of patients with STEMI.MethodsWe enrolled 167 patients with STEMI after PCI who underwent MCE during hospitalization between January 2018 and March 2022. Patients were classified into the CMD and non-CMD groups according to the results of MCE. The clinical data and MCE results of both groups were analyzed. Follow-up was conducted for major adverse cardiac events.ResultsMCE detected CMD in 105 patients (62.9%). The CMD group contained fewer hypertensive patients (55.2% versus 74.2%, P = 0.015). Patients with CMD exhibited significantly higher levels of plasma troponin I (TnI) [73.2 (23.0–124.0) versus 28.9 (12.7–80.2) ng/mL, P = 0.004], higher levels of plasma B-type natriuretic peptide [255 (99–641) versus 193 (59–389) pg/mL, P = 0.004], poorer Killip classification (P = 0.038), and different culprit vessels (P < 0.001) compared to the non-CMD group. Patients with CMD exhibited lower left ventricular ejection fraction [50 (43–58) versus 61 (54–67) %, P < 0.001], poorer wall motion score index values (1.68 ± 0.4 versus 1.31 ± 0.26, P < 0.001) and poorer left ventricular global longitudinal strain [–11.2 (–8.7 to –14.1) versus –13.9 (–11.0 to –17.2) %, P < 0.001] compared to the non-CMD group. Patients underwent follow-up for 13 (7–20) months. After adjusting for hypertension, peak TnI level, culprit vessel, and Killip classification, CMD was an independent predictor of total major adverse cardiac events at 13 months’ follow-up [adjusted odds ratio (OR), 2.457; 95% confidence interval (CI), 1.042–5.790; P = 0.040], and patients with CMD had a higher risk of hospitalization for heart failure (adjusted OR, 5.184; 95% CI, 1.044–25.747; P = 0.044) and repeat myocardial infarction (adjusted OR, 2.896; 95% CI, 1.109–7.565; P = 0.030).ConclusionsMCE is a safe and effective method for detecting CMD in patients with STEMI. CMD detected by MCE after successful PCI in patients with STEMI is a common occurrence, which is associated with a significantly worse prognosis, especially hospitalization for heart failure and repeat myocardial infarction.

The influence of testosterone on the risk of cardiovascular events after percutaneous coronary intervention.

Between 2015 and 2018, 580 men undergoing PCI at a tertiary referral hospital were divided into low (<3.25 ng/mL) and normal (≥3.25 ng/mL) testosterone groups. Major adverse cardiovascular event (MACE) was defined as the composite outcome of CV death, myocardial infarction, and target lesion revascularization/target vessel revascularization (TLR/TVR) during up to 48 months follow-up after PCI. There were 111 and 469 patients in the low and normal testosterone groups, respectively, with the overall MACE rate of the former being higher than the latter (26.13% vs. 13.01%, p = 0.0006). Moreover, the overall TLR/TVR (20.72% vs. 11.73%, p = 0.0125) and myocardial infarction (3.6% vs. 0.85%, p = 0.0255) rates were significantly higher in those with low serum testosterone who also had a shorter average event-free survival analysis of MACE (25.22 ± 0.88 months) than those with normal testosterone levels (35.09 ± 0.47 months, log-rank p = 0.0004). Multiple logistic regression demonstrated an association between low serum testosterone (<3.25 ng/mL) and a higher MACE rate [odds ratio: 2.06, 95% confidence interval (CI) 1.21-3.51, p = 0.0081]. After adjusting for variables in a Cox regression model, hazard ratios (HRs) for MACE (HR: 1.88, 95% CI: 1.20-2.95, p = 0.0058) and TLR/TVR (HR: 1.73, 95% CI: 1.06-2.83, p = 0.0290) rates were higher in the low testosterone group than those in the normal testosterone group. Low serum testosterone concentrations were associated with a higher risk of MACE and TLR/TVR after PCI than those with normal testosterone levels.

Estimated versus observed 10-year atherosclerotic cardiovascular event rates in a rural population-based health initiative: The Heart of New Ulm Project

ObjectiveAssess discrepancy between estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk and observed 10-year event rates in a rural population participating in cardiovascular health initiative. MethodsThe study included a rural sample of individuals participating in the Heart of New Ulm (HONU), a population-based health initiative aimed at reducing ASCVD risk in a rural community. HONU conducted over 100 baseline screening events with 5221 individuals participating in 2009. For this analysis, we included participants who were aged 40–79 years, free of ASCVD at baseline, and had adequate data to calculate 10-year ASCVD risk. Electronic health record data and state death records were used to determine rates of non-fatal myocardial infarction and stroke, and ASCVD death from 2010–2019. ASCVD event rates were compared to estimated 10-year risks calculated using the Pooled Cohort Equations, stratified by sex and clinically relevant risk categories. ResultsThe sample (n = 2819, mean ± SD age 56.1 ± 9.9 years, 59.6% female) had a low prevalence of tobacco use (8.1% current smokers) and diabetes (6.5%) and a high prevalence of hypertension (44.4%) and hyperlipidemia (56.6%). The median estimated 10-year ASCVD risk for the entire sample was 5.7% (IQR 2.3–13.5%) with an observed 10-year ASCVD event rate of 3.4%. The largest gap between observed and estimated risk was in those at intermediate/high (≥7.5%) ASCVD risk (median 10-year risk 15.8% [IQR 10.4–29.0], observed ASCVD event rate 6.4%). ConclusioIn a sample of rural participants exposed to a multifaceted ASCVD prevention initiative, observed rates of ASCVD were substantially lower compared to estimated ASCVD risk. The potential for significantly lower than predicted ASCVD event rates in certain populations should be included in the clinician-patient risk discussion.

Physiologic risk factors increase risk of myocardial infarction with transcarotid artery revascularization in prospective trials

ObjectivePatients can be considered at high risk for carotid endarterectomy (CEA) because of either anatomic or physiologic factors and will often undergo transcarotid artery revascularization (TCAR). Patients with physiologic criteria will be considered to have a higher overall surgical risk because of more significant comorbidities. Our aim was to study the incidence of stroke, myocardial infarction (MI), death, and combined end points for patients who had undergone TCAR stratified by the risk factors (anatomic vs physiologic). MethodsAn analysis of prospectively collected data from the ROADSTER (pivotal; safety and efficacy study for reverse flow used during carotid artery stenting procedure), ROADSTER 2 (Food and Drug Administration indicated postmarket trial; postapproval study of transcarotid artery revascularization in patients with significant carotid artery disease), and ROADSTER extended access TCAR trials was performed. All 851 patients were considered to be at high risk for CEA and were included and stratified using high-risk anatomic criteria (ie, contralateral occlusion, tandem stenosis, high cervical artery stenosis, restenosis after previous endarterectomy, bilateral carotid stenting, hostile neck anatomy with previous neck irradiation, neck dissection, cervical spine immobility) or high-risk physiologic criteria (ie, age >75 years, multivessel coronary artery disease, history of angina, congestive heart failure New York Heart Association class III/IV, left ventricular ejection fraction <30%, recent MI, severe chronic obstructive pulmonary disease, permanent contralateral cranial nerve injury, chronic renal insufficiency). For trial inclusion, asymptomatic patients were required to have had ≥80% carotid stenosis and symptomatic patients to have had ≥50% stenosis. The primary outcome measures were stroke, death, and MI at 30 days. The data were statistically analyzed using the χ2 test, as appropriate. ResultsA total of 851 high surgical risk patients were categorized into two groups: those with anatomic-only risk factors (n = 372) or at least one physiologic risk factor present (n = 479). Of the 851 patients, 74.5% of those in the anatomic subset were asymptomatic, and 76.6% in the physiologic subset were asymptomatic. General anesthesia was used similarly in both groups (67.7% anatomic vs 68.1% physiologic). MI had occurred in eight patients in the physiologic group (1.7%), all of whom had been asymptomatic and in none of the anatomic patients (P = .01). The combined stroke, death, and MI rate was 2.1% in the anatomic cohort and 4.2% in the physiologic cohort (P = .10). Stratification of each group into asymptomatic and symptomatic patients did not yield any further differences. ConclusionsThe patients who had undergone TCAR in the present prospective, neurologically adjudicated trial because of high-risk physiologic factors had had a higher rate of MI compared with the patients who had qualified for TCAR using anatomic criteria only. These patients had experienced comparable rates of combined stroke, death, and MI rates. The anatomic patients represented a healthier and younger subset of patients, with notably low overall event rates.

CAN SOCIAL ENVIRONMENT OFFSET THE GENETIC RISK OF MYOCARDIAL INFARCTION AMONG OLDER ADULTS?

Abstract The interrelatedness between social determinants of health impedes researchers to identify important social factors for cardiovascular health. Additionally, it remains largely unknown whether a derivable social environment could offset the genetic risk for cardiovascular events. We developed a polysocial score approach to quantify the aggregate effect of social factors on myocardial infarction (MI). We also examined the association of polysocial score and polygenic risk scores (PGS), and their interaction, on MI. Data are from the Health and Retirement Study, a longitudinal cohort of a nationally representative sample of Black and White Americans with pre-calculated PGS for MI (N=6,036). We included 24 social factors from five categories (economic stability, neighborhood environment, education, community, and social context, and healthcare system) and used forward stepwise regression to screen for important ones. Polysocial score was created using 14 social factors and was classified as low (&amp;lt; 28), intermediate (29-39), and high (40+). The incidence of MI was 4.5, 8.5, 10.5 per 1000 person-years among Whites with a low, intermediate, and high PGS, respectively; no graded association was found among Blacks. Polysocial score stratified the rate of MI in each tertile of PGS among Whites. We found a significant additive interaction between PGS and polysocial score. The difference in MI rate was 10.3 per 1000 person-years among individuals with a high genetic risk, while the difference significantly reduced to 3.5 per 1000 person-years among those with a low genetic risk. Desirable social environment could possibly offset the increased risk of MI associated with genetics among Whites.

1031 IMPACT OF PRE-TREATMENT WITH A P2Y12 RECEPTOR INHIBITOR ON PERIPROCEDURAL MYOCARDIAL INFARCTION AND MYOCARDIAL INJURY IN NSTEMI

Abstract Background Dual antiplatelet therapy with aspirin and a P2Y12 receptor inhibitor is the standard of care in patients with acute coronary syndromes. The optimal timing of the administration of oral P2Y12 inhibitors has been largely debated, particularly among patients with non-ST-segment elevation myocardial infarction (NSTEMI). The latest European Society of Cardiology guidelines, based on recent scientific evidence, do not recommend routine pre-treatment with a P2Y12 inhibitor before coronary angiography. However, the impact of pre-treatment on the incidence of peri-procedural myocardial infarction (MI) and myocardial injury has never been explored. Purpose To evaluate the impact of pre-treatment with a P2Y12 receptor inhibitor on periprocedural myocardial infarction and injury in NSTEMI patients undergoing invasive treatment. Methods We evaluated all consecutive patients admitted to our coronary care unit from 2016 to 2021 affected by NSTEMI undergoing invasive management with percutaneous coronary intervention (PCI). We enrolled only patients with stable (≤ 20% variation) or falling pre-procedure baseline cardiac troponin (cTn) values. The entire population was divided into two groups: patients pre-treated with dual antiplatelet therapy (an oral P2Y12 inhibitor in adjunct to aspirin) before performing coronary angiography (upstream group) and patients who started an oral P2Y12 inhibitor only after PCI (downstream group). All patients received aspirin and anticoagulant therapy before coronary angiography. The primary endpoint was the incidence rate of periprocedural MI and myocardial injury according to the fourth universal definition of myocardial infarction. Finally, a safety endpoint of major and minor bleeding according to Thrombolysis in Myocardial Infarction (TIMI) criteria was evaluated for all bleeding episodes during hospitalization. Results A total of 878 patients with NSTEMI undergoing PCI and with pre-procedure stable cTn levels were analyzed: 615 (70%) constituted the upstream group. The mean age of the study population was 70.1±12.5 years and 71.3% were males. There were no significant differences regarding traditional cardiovascular risk factors, comorbidities, cTn and hemoglobin levels between the two groups. After PCI, the rate of periprocedural myocardial injury and MI did not significantly differ between the upstream and downstream groups (19.5% vs 24.7%, p=0.08 and 17.6% vs 19.4%, p=0.5, respectively). A trend of lower periprocedural myocardial injury and MI cumulative incidence was observed in the upstream group (37.1% vs 44.1%, p=0.051). Notably, major and minor bleedings during hospitalization occurred more frequently in the upstream group compared to the downstream one (5.2% vs 1.9%, p=0.02). Conclusions Among NSTEMI patients undergoing invasive management and with stable pre-procedure cTn levels, pretreatment with an oral P2Y12 inhibitor did not reduce the rate of periprocedural MI and myocardial injury but was associated with an increase in major and minor bleeding complications during hospitalization.

417 CLINICAL IMPACT OF HEALED CORONARY PLAQUES: AN OPTICAL COHERENCE TOMOGRAPHY STUDY

Abstract Introduction Pathological studies have shown that many atherosclerotic plaques destabilize without resulting in a clinical manifestation. Recent in vivo studies showed that healed plaques are more common in patients with chronic coronary syndrome (CCS) than in those with acute coronary syndrome (ACS), suggesting that they might be a marker of clinical stability. The aim of the present study was to evaluate the clinical impact of healed coronary plaques detected by optical coherence tomography (OCT) imaging. Methods A total of 208 patients with CCS or ACS who underwent OCT imaging of non-target/non-culprit vessels were enrolled. Only non-culprit segments were analyzed. Patients were divided into two groups according to the presence or absence of healed plaques detected by OCT. The incidence of major adverse cardiac events (MACE) at follow-up was assessed, defined as the composite of cardiac death, non-fatal myocardial infarction, and target vessel revascularization (TVR). Results Healed coronary plaques were observed in 39.7% of patients, and the prevalence was higher in those presenting with chronic coronary syndrome. Median follow-up time was 4 years, and was not different between the two groups. Patients with healed plaques had a significantly lower incidence of MACE at follow-up (13.6% vs 22%, p=0.019), mainly driven by a lower rate of non-fatal myocardial infarctions (4.9% vs 10.2%, p=0.05). The incidence of cardiac death and TVR was not significantly different between the two groups (1.2% vs. 3.1%, p=0.288; and 13.6% vs. 15.0%, p= 0.187, respectively). At multivariate Cox regression analysis, the presence of plaque disruption was an independent predictor of MACE (odds ratio [OR] 3.33, 95% confidence interval [CI] 1.39-7.98, p=0.007), while the presence of healed plaque was an independent protective factor (OR 0.44, 95% CI 0.22-0.89, p=0.022). Conclusions Healed coronary plaques detected by OCT imaging are associated with a favorable clinical outcome at long-term follow-up.

1129 IMAGING STRESS TEST OR CORONARY COMPUTED TOMOGRAPHY PRIOR TO NON-CARDIAC SURGERY? A SEVEN YEARS SINGLE CENTRE EXPERIENCE

Abstract Introduction Recent published ESC guidelines on non-cardiac surgery suggest the use of imaging stress test in patients with poor functional capacity and high likelihood of coronary artery disease or high clinical risk (class I, level B), while the use of coronary computed tomography has lower evidence (class IIa, level B). Witch test has the best performance in the clinical contest of pre-operative risk assessment is a matter of debate. Aim The aim of our single centre, retrospective study was to compare the prognostic role of the three main cardiac imaging modalities (CCT: Cardiac computed tomography, sCMR: stress cardiac magnetic resonance, SPECT MPI:single photon emission computed tomography myocardial perfusion imaging) in relation to 30 days post-surgery cardiac events (composite endpoint of myocardial infarction, unstable angina, cardiac death, cardiogenic shock, pulmonary oedema, life threatening cardiac arrythmias). Method Clinical data of patients from January 2015 to December 2021 were retrospectively collected from review of electronical medical records. Recorded data included demographic characteristics, clinical risk factors, results from laboratory tests, results from cardiac imaging tests, pharmacological therapy, type of intervention, cardiac complication within 30 days after surgery. Results Eight-hundred eighty-three patients were included (287 sCMR, 382 SPECT-MPI, 214 CCT). Rate of 30-days myocardial infarction was not significantly different between different modalities (CMR 1.1%, SPECT 1.3%; CT 0.5%; CMR vs SPECT p 0.998; sCMR vs CT p 0.639; SPECT vs CT 0.427); while planned invasive coronary angiography (ICA) was more common in CT group (CT 34%, CMR 16%, SPECT 10%, p&amp;lt;0,001). Absence of ischemia on stress test and absence of relevant coronary artery disease on CT are associate to lower cardiac events at follow-up (0.67%). Conclusions The use of imaging stress test and coronary CT are both associated to low incidence of cardiac events and should be recommended in risk assessment before non-cardiac surgery, in the appropriate clinical context.

Utility of the ACC/AHA Lesion Classification to Predict Outcomes After Contemporary DES Treatment: Individual Patient Data Pooled Analysis From 7 Randomized Trials.

Background Use of the modified American College of Cardiology (ACC)/American Heart Association (AHA) lesion classification as a prognostic tool to predict short- and long-term clinical outcomes after percutaneous coronary intervention in the modern drug-eluting stentera is uncertain. Methods and Results Patient-level data from 7 prospective, randomized trials were pooled. Clinical outcomes of patients undergoing single lesion percutaneous coronary intervention with second-generation drug-eluting stent were analyzed according to modified ACC/AHA lesion class. The primary end point was target lesion failure (TLF: composite of cardiac death, target vessel myocardial infarction, or ischemia-driven target lesion revascularization). Clinical outcomes to 5 years were compared between patients treated for noncomplex (class A/B1) versus complex (class B2/C) lesions. Eight thousand five hundred sixteen patients (age 63.1±10.8 years, 70.5% male) were analyzed. Lesions were classified as A, B1, B2, and C in 7.9%, 28.5%, 33.7%, and 30.0% of cases, respectively. Target lesion failure was higher in patients undergoing percutaneous coronary intervention of complex versus noncomplex lesions at 30 days (2.0% versus 1.1%, P=0.004), at 1 year (4.6% versus 3.0%, P=0.0005), and at 5 years (12.4% versus 9.2%, P=0.0001). By multivariable analysis, treatment of ACC/AHAclass B2/C lesions was significantly associated with higher rate of5-year target lesion failure (adjusted hazard ratio, 1.39 [95% CI, 1.17-1.64], P=0.0001) driven by significantly higher rates of target vessel myocardial infarction and ischemia-driven target lesion revascularization. Conclusions In this pooled large-scale analysis, treating complex compared with noncomplex lesions according to the modified ACC/AHA classification with second-generation drug-eluting stentwas associated with worse 5-year clinical outcomes. This historical classification system may be useful in the contemporary era for predicting early and late outcomes following percutaneous coronary intervention.

Radial and ulnar approach for carotid artery stenting with Roadsaver™ double layer micromesh stent:Early and long-term follow-up.

We aimed to evaluate the feasibility and safety of carotid artery stenting (CAS) with a newly designed double-layer micromesh stent using wrist approach in patients with significant carotid disease. Between January 2016 and December 2021, 105 patients undergoing CASwith Roadsaver™ stent were enrolled in a single center prospective study. Follow-up assessments included neurological exams, duplex ultrasound (DUS), and 12-lead ECG. The primary endpoint was the 30-day composite rate of stroke, death, and myocardial infarction. Secondary endpoints included procedure success, access site complications, device success, target lesion revascularization, and in-stent restenosis evaluated with DUS. Long-term outcomes up to 72 months of follow-up were assessed in all eligible patients. The study population was predominantly male (69.5%) with a median age of 68 ± 8 years. Patients were symptomatic in 80% of the cases, and 35% fulfilled the high-risk criteria for surgical endarterectomy. The right internal carotid artery was the target artery in 56 (53.4%), and the left in 49 (46.6%) of the cases. All procedures were successfully completed from the right wrist, with right radial access in 94 (89.5%) cases and ulnar artery access with previous radial artery occlusion in 11 (10.5%) cases. All patients were treated successfully with the study device. The primary endpoint was met with a 30-day major adverse eventrate of 0.9% (1/105). Up to 72 months of follow-up (median 30 ± 20 months) there were no strokes, neurological deaths, or target lesion revascularization of the treated lesion. Doppler ultrasound examination revealed nonsignificant in-stent restenosis in two asymptomatic patients. There was no hand ischemia detected in any patient. Results from this study demonstrate the radial and ulnar access for CASwith double layer micromesh Roadsaver™ stent is safe and feasible and associated with favorable early and long-term follow-up.