Risk Of Major Cardiac Events Research Articles

Abstract 4138477: Small Vessels, Big Challenges: Clinical and Demographic Correlates of Failure to Respond to Optimal Medical Therapy in Patients with Microvascular Angina

Background: Microvascular angina (MVA), resulting from coronary microvascular dysfunction, affects 40-50% of patients with exertional chest pain or dyspnea and a normal coronary angiogram. This condition significantly impairs quality of life and elevates the risk of major cardiac events, including myocardial infarction, stroke and death. MVA is classified as 'structural' (coronary flow reserve [CFR] <2.5&index of microcirculatory resistance [IMR] >25) or 'functional' (CFR <2.5&IMR <25). Current treatments are empirical, necessitating further investigation. Methods: This single-centre, retrospective study conducted in South Wales from 2019-24 examined MVA cases confirmed via national electronic health records. The Canadian Cardiovascular Society (CCS) angina grade was assessed at diagnosis and post optimal medical therapy (OMT) during clinic visits. Ordinal logistic regression was used to identify independent correlates of higher CCS grade, considering baseline LDL, age, diffuse epicardial disease, sex, hypertension, kidney function, smoking status and HbA1c levels as covariates. Results: Among 64 identified MVA cases (median age 69 yrs, IQR 61.3-77.8; 68.8% male), 81.3% had structural MVA, 6.3% functional MVA and 12.5% mixed disease. Coronary vessel testing was performed on 1, 2 or 3 vessels in 29.7% (n=19), 53.1% (n=34; 21 positive [+ve] in 2 vessels, 13 +ve in 1 vessel) and 17.2% (n=11; 5 +ve in 3 vessels, 5 +ve in 2 vessels, 1 +ve in 1 vessel) of cases, respectively. The LAD was most commonly affected vessel (82.8%). At diagnosis, 79.7% had CCS grade III or higher (Fig 1). Post OMT, 45.3% achieved CCS grade 0-I, 31.8% CCS grade II and 15.6% remained at CCS grade III (refractory angina). Medications included ranolazine (84.4%), beta-blockers (70.3%) and calcium channel blockers (28.1%). Ordinal logistic regression analysis (X 2 =0.27, p=0.033) identified baseline LDL (95% CI [0.16, 1.26]; p=0.011), age (95% CI [-0.12, -0.001]; p=0.045), diffuse epicardial disease (95% CI [0.016, 2.13]; p=0.047) and male sex (95% CI [0.066, 2.36]; p=0.038) as independent correlates of higher CCS grade, signifying poor response to OMT. Conclusion: MVA manifests regionally, underscoring the need for multi-territory testing. Although tailored OMT proved effective for many, 15.6% of patients continued to experience refractory symptoms (CCS grade III). This highlights the necessity for alternative therapeutic strategies to improve patient outcomes in this challenging condition.

Association between an Early Revascularization Strategy and Major Cardiac Events Based on Left Ventricular Dyssynchrony in Patients at Intermediate Risk of Major Cardiac Events Using the J-ACCESS Risk Model.

Objective This retrospective study aimed to investigate the association between therapeutic strategies and the development of major cardiac events (MCEs) in intermediate-risk patients by using the the Japanese Assessment of Cardiac Events and Survival Study by Quantitative Gated SPECT (JACCESS) risk model in combination with the stress phase bandwidth (SPBW), an index of left ventricular dyssynchrony. Methods Patients were followed-up for three years to confirm their prognosis. Based on the estimated propensity scores, the patients who underwent revascularization within the first 60 days after SPECT and those who did not were matched 1:1 (n=367 per group). The composite endpoint was the occurrence of MCEs, consisting of cardiac death, non-fatal myocardial infarction, and severe heart failure. SPBW was calculated by a phase analysis using the Heart Risk View-F software program, and the MCE rate was compared between the two groups by applying the normal value of SPBW (38°). Patients The study included 2,053 patients with either known or suspected coronary artery disease who underwent electrocardiogram-gated single-photon emission computed tomography myocardial perfusion imaging and were at intermediate risk of MCE according to the J-ACCESS risk model. Results During follow-up, 54 of the 734 patients (7.4%) experienced MCEs. The overall incidence of MCE in intermediate-risk patients was not significantly different between the two groups. However, the incidence of MCE in patients with an abnormal SPBW was significantly lower in those who underwent early revascularization (4.8% vs. 11.9%, p=0.0407). Conclusion The combination of the J-ACCESS risk model and the SPBW is thus considered to be an optimal treatment strategy for patients at intermediate risk of MCE, and early revascularization may lead to an improved prognosis in intermediate-risk patients with an abnormal SPBW.

Allostatic Load/Chronic Stress and Cardiovascular Outcomes in Patients Diagnosed With Breast, Lung, or Colorectal Cancer.

Cardiovascular disease and cancer share a common risk factor: chronic stress/allostatic load (AL). A 1-point increase in AL is linked to up to a 30% higher risk of major cardiac events (MACE) in patients with prostate cancer. However, AL's role in MACE in breast cancer, lung cancer, or colorectal cancer remains unknown. Patients ≥18 years of age diagnosed with the mentioned 3 cancers of interest (2010-2019) and followed up at a large, hybrid academic-community practice were included in this retrospective cohort study. AL was modeled as an ordinal measure (0-11). Adjusted Fine-Gray competing risks regressions estimated the impact of AL precancer diagnosis on 2-year MACE (a composite of heart failure, ischemic stroke, acute coronary syndrome, and atrial fibrillation). The effect of AL changes over time on MACE was calculated via piecewise Cox regression (before, and 2 months, 6 months, and 1 year after cancer diagnosis). Among 16 467 patients, 50.5% had breast cancer, 27.9% had lung cancer, and 21.4% had colorectal cancer. A 1-point elevation in AL before breast cancer diagnosis corresponded to a 10% heightened associated risk of MACE (adjusted hazard ratio, 1.10 [95% CI, 1.06-1.13]). Similar findings were noted in lung cancer (adjusted hazard ratio, 1.16 [95% CI, 1.12-1.20]) and colorectal cancer (adjusted hazard ratio, 1.13 [95% CI, 1.08-1.19]). When considering AL as a time-varying exposure, the peak associated MACE risk occurred with a 1-point AL rise between 6 and 12 months post- breast cancer, lung cancer, and colorectal cancer diagnosis. AL warrants investigation as a potential marker in these patients to identify those at elevated cardiovascular risk and intervene accordingly.

3D-printed, citrate-based bioresorbable vascular scaffolds for coronary artery angioplasty

Fully bioresorbable vascular scaffolds (BVSs) aim to overcome the limitations of metallic drug-eluting stents (DESs). However, polymer-based BVSs, such as Abbott's Absorb, the only US FDA-approved BVS, have had limited use due to increased strut thickness (157 μm for Absorb), exacerbated tissue inflammation, and increased risk of major cardiac events leading to inferior clinical performance when compared to metallic DESs. Herein we report the development of a drug-eluting BVS (DE-BVS) through the innovative use of a photopolymerizable, citrate-based biomaterial and a high-precision additive manufacturing process. BVS with a clinically relevant strut thickness of 62 μm can be produced in a high-throughput manner, i.e. one BVS per minute, and controlled release of the anti-restenosis drug everolimus can be achieved by engineering the structure of polymer coatings to fabricate drug-eluting BVS. We achieved the successful deployment of BVSs and DE-BVSs in swine coronary arteries using a custom-built balloon catheter and BVS delivery system and confirmed BVS safety and efficacy regarding maintenance of vessel patency for 28 days, observing an inflammation profile for BVS and DE-BVS that was comparable to the commercial XIENCE™ DES (Abbott Vascular).

Abstract 14540: Allostatic Load/Chronic Toxic Stress and Cardiovascular Outcomes in Breast, Lung and Colon Cancer Patients

Introduction: Cardiovascular disease (CVD) and cancer share a common risk factor: chronic toxic stress/allostatic load (AL). Our previous research found that a 1-point increase in AL is linked to a 25-30% higher risk of major cardiac events (MACE) in prostate cancer patients. Hypothesis: Higher AL is associated with increased MACE risk in patients with breast, lung, and colon cancer. Methods: Patients ≥18 years diagnosed for the first time with the mentioned 3 cancers of interest between 2010-2019 at a large, hybrid academic-community practice were included in this retrospective cohort study. AL was modeled as an ordinal measure (0-11; Table 1 ). Adjusted Fine-Gray Cox proportional hazard regressions estimated the impact of AL pre- and 60 days post- cancer diagnosis on 2-year MACE. Results: Demographic characteristics are summarized in Table 1. Two-year mace MACE occurred in 12.3%, 23.3%, and 9.7% of breast, lung, and colon cancer patients, respectively. Heart failure was the most common MACE, observed in 7.9%, 14.4%, and 4.8% of breast, lung, and colon cancer patients, respectively. Before cancer diagnosis, a 1-point increase in AL raised MACE risk by 11% (aHR=1.11, 95% CI 1.07-1.16) in breast cancer, 18% (aHR=1.18, 95% CI 1.11-1.25) in lung cancer, and 9% (aHR=1.09, 95% CI 1.01-1.18) in colon cancer. After cancer diagnosis, a 1-point increase in AL increased MACE risk by 10% (aHR=1.10, 95% CI 1.06-1.15) in breast cancer and 19% (aHR=1.19, 95% CI 1.12-1.25) in lung cancer, but was not statistically significant in colon cancer (aHR=1.07, 95% CI 0.99-1.16). Conclusion(s): Higher AL levels prior to breast, lung, and colon cancer diagnoses are associated with increased MACE risk. Thus, effective implementation of patient-centered communication considering stress levels, stressors, and coping mechanisms is necessary during cardiovascular screening for these cancer patients. Further prospective studies are needed.

Long-term clinical outcomes in patients with acute myocardial infarction complicated by cardiogenic shock according to the application and initiation time of extracorporeal membrane oxygenation in South Korea.

Limited data are available regarding the proper application time and long-term outcomes of extracorporeal membrane oxygenation (ECMO) in patients with cardiogenic shock. This cohort study appraised the clinical outcomes according to ECMO application without or before cardiopulmonary resuscitation (CPR) in patients with acute myocardial infarction (AMI) combined with cardiogenic shock. Between 2011 and 2015, a total of 13,104 patients with AMI were enrolled in a nationwide AMI registry. Eligible patients with cardiogenic shock, who underwent percutaneous coronary intervention, with a 3-year clinical follow-up, were analyzed. The 949 included patients were divided into two groups: no ECMO (n = 845) and ECMO application (n = 104). The ECMO group was further divided into ECMO without or before CPR (n = 11) and ECMO after CPR (n = 93). Significant differences were noted in major adverse cardiac events (MACEs) between the no ECMO and ECMO application groups during the 3-year follow-up (41.5% vs. 80.8%; p < 0.001). However, the ECMO without or before CPR group showed similar outcomes to the no ECMO group in 3-year MACEs (63.6% vs. 41.5%; p = 0.055). MACEs during 3 years of follow-up were significantly lower in the ECMO without or before CPR group than in the ECMO after CPR group (63.6% vs. 82.8%; p = 0.005). A significantly lower risk of major cardiac events in ECMO without or before CPR suggests that early application of ECMO can be a reasonable strategy to improve outcomes in patients with AMI complicated by cardiogenic shock.

The Impact of Cardiac Sparing Techniques on Major Cardiac Events for Patients Undergoing Breast Radiotherapy

In radiotherapy, studies with historical estimates have shown a linear relationship between cardiac dose and risk of major cardiac events with no safe dose threshold. This study investigates the relationship between cardiac dose and event rates for patients undergoing breast radiotherapy with modern heart-sparing techniques, where substantially lower cardiac doses are achieved. From 2008 to 2018, all patients undergoing curative whole breast or chest wall radiotherapy at a tertiary care center were included. In this study, the deep-inspiration breath hold (DIBH) technique was implemented in 2013 as the standard of care for left-sided patients. Cardiacdosimetricdata from the clinical treatment plan was extracted and matched to patients from the ongoing, prospectively collected Alberta Provincial Project for Outcome Assessment in Coronary Heart disease (APPROACH) database that experienced a major adverse cardiac event (MACE). MACE was defined as myocardial infarction, hospitalization for unstable angina, hospitalization for heart failure,or clinically indicated coronary revascularization.For all the left- and right-sided patients, the population event rates, the median time to event, and the average (± standard deviation) of the mean heart physical dose is reported. The proportion of left- and right-sided patients experiencing a major cardiac event were tested for independence using a two-sample z-test for proportions. A student's t-test was used to measure significance for mean heart dose. An alpha of 0.05 was used to indicate significance for both tests. A total of 4893 patients received breast radiotherapy with 2429 left-sided, 2429 right-sided, and 35 synchronous bilateral. For all patients, Table 1 describes laterality, treatment characteristics, and prescription. The median (range) age at the time of first radiotherapy treatment was 59 (23-94). Of these patients with contours available, 96 left-sided (3.9%) and 69 right-sided (2.8%) patients experienced a MACE (p = 0.03) with a mean heart dose of 1.4 (±0.7)Gyand 0.5 (±0.2)Gy, in the event cohorts respectively (p < 0.001). The mean time to event was 4.7 (±3.2) years and 4.8 (±3.0) years for left- and right-sided patients, respectively (p = 0.83). For the left-sided cohort treated with DIBH, the mean heart dose is 1.0 (±0.8)Gy. In the era of modern radiotherapy and cardiac-sparing techniques, mean heart dose and corresponding event rates are stillsignificantlyhigher for left-sided patients than right-sided patients. Future work will aim to test whether there is a safe threshold for cardiac dose in the context of these results.

The Association between Influenza Vaccine and Risk of Chronic Kidney Disease/Dialysis in Patients with Hypertension.

Influenza vaccination could decrease the risk of major cardiac events in patients with hypertension. However, the vaccine's effects on decreasing the risk of chronic kidney disease (CKD) development in such patients remain unclear. We retrospectively analysed the data of 37,117 patients with hypertension (≥55 years old) from the National Health Insurance Research Database during 1 January 2001 to 31 December 2012. After a 1:1 propensity score matching by the year of diagnosis, we divided the patients into vaccinated (n = 15,961) and unvaccinated groups (n = 21,156). In vaccinated group, significantly higher prevalence of comorbidities such as diabetes, cerebrovascular disease, dyslipidemia, heart and liver disease were observed compared with unvaccinated group. After adjusting age, sex, comorbidities, medications (anti-hypertensive agents, metformin, aspirin and statin), level of urbanization and monthly incomes, significantly lower risk of CKD occurrence was observed among vaccinated patients in influenza season, non-influenza season and all season (Adjusted hazard ratio [aHR]: 0.39, 95% confidence level [C.I.]: 0.33-0.46; 0.38, 95% C.I.: 0.31-0.45; 0.38, 95% C.I.: 0.34-0.44, respectively). The risk of hemodialysis significantly decreased after vaccination (aHR: 0.40, 95% C.I.: 0.30-0.53; 0.42, 95% C.I.: 0.31-0.57; 0.41, 95% C.I.: 0.33-0.51, during influenza season, non-influenza season and all season). In sensitivity analysis, patients with different sex, elder and non-elder age, with or without comorbidities and with or without medications had significant decreased risk of CKD occurrence and underwent hemodialysis after vaccination. Moreover, the potential protective effect appeared to be dose-dependent. Influenza vaccination decreases the risk of CKD among patients with hypertension and also decrease the risk of receiving renal replacement therapy. Its potential protective effects are dose-dependent and persist during both influenza and noninfluenza seasons.

Allostatic load and cardiovascular outcomes in males with prostate cancer.

Cardiovascular disease (CVD) is the leading cause of death in men with prostate cancer (PC). Accumulated stress plays an important role in CVD development. The cumulative burden of chronic stress and life events can be measured using allostatic load (AL). The initial cohort included males aged 18 years and older diagnosed with PC (2005-2019). AL was modeled as an ordinal variable (0-11). Fine-Gray competing risk regressions measured the impact of precancer diagnosis AL and postdiagnosis AL in 2-year major cardiac events (MACE). The effect of AL changes over time on MACE development was calculated via piecewise Cox regression (before, and 2 months, 6 months, and 1 year after PC diagnosis). We included 5261 PC patients of which 6.6% had a 2-year MACE. For every 1-point increase in AL before and within 60 days after PC diagnosis, the risk of MACE increased 25% (adjusted hazard ratio [aHR] =1.25, 95% confidence interval [CI] = 1.18 to 1.33) and 27% (aHR = 1.27, 95% CI = 1.20 to 1.35), respectively. Using AL as a time-varying exposure, the risk of MACE increased 19% (aHR = 1.19, 95% CI = 1.11 to 1.27), 22% (aHR = 1.22, 95% CI = 1.14 to 1.33), 28% (aHR = 1.28, 95% CI = 1.23 to 1.33), and 31% (aHR = 1.31, 95% CI = 1.27 to 1.35) for every 1-point increase in AL before, 2 months after, 6 months after, and 1 year after PC diagnosis, respectively. AL and its changes over time are associated with MACE in PC patients, suggesting a role of a biological measure of stress as a marker of CVD risk among men with PC.

T-MACS score vs HEART score identification of major adverse cardiac events in the emergency department

BackgroundIschemic heart disease is the leading cause of mortality worldwide, and its prevalence is rising. ObjectiveThe goal of this study was to evaluate the HEART and T-MACS scores for predicting major cardiac events (MACE) in patients presenting to the emergency department with chest pain. MethodThis study was single center and prospectively conducted. The demographic information, T-MACS and HEART scores of the participants were recorded and calculated. Acute myocardial infarction (AMI), mortality, and the need for coronary revascularization were considered as major adverse cardiac events (MACEs). The statistical analysis was carried out using SPSS (IBM Statistics, New York) version 24, and significance was determined at the p < 0.05 level. ResultsThe 514 patients included in our study had a mean age of 52.01 ± 19.10 years, with 55.3% were female and 44.7% was male. A total of 78(%15.1) cases were diagnosed with AMI. Fifty patients (%9.7) underwent percutaneous coronary intervention, 12 (%2.3) patients underwent coronary artery by-pass graft, and 8 (%1.5) patients died within a one-month period. The sensitivity and negative predictive values of the T-MACS score for the very low risk classification were 93.90% (86.3%–98.0%) and 97.7% (94.7%–99.0%), respectively, and the sensitivity and negative predictive values of the HEART score for the low risk classification were 89.59% (77.3%–93.1%) and 96.6% (94.2%–98.0%), respectively. The specificity and positive predictive values for the high risk classification were 99.77% (98.7%–100%) and 97.2% (82.9%–99.6%), respectively for the T-MACS score and 95.14% (92.7%–97%) and 63.2% (51.4%–73.5%), respectively for the HEART score. ConclusionThe T-MACS score was shown to be more accurate than the HEART score in predicting low risk (very low risk for the T-MACS score), high risk, and anticipated one-month risk for MACE in patients coming to the emergency department with chest pain.

Abstract 10355: Allostatic Load and Cardiovascular Outcomes in Males With Prostate Cancer

Introduction: Prostate cancer (PC) is the leading type of newly diagnosed cancer in males. Cardiovascular disease (CVD) is the leading cause of death in men with PC. Accumulated stress, which is triggered by multiple environmental factors and life events, plays an important role in CVD development. The cumulative burden of chronic stress and life events can be measured using allostatic load (AL). Hypothesis: We hypothesize that AL is associated with the development of major cardiac events (MACE) after the diagnosis of PC. Methods: Data were obtained from a Cleveland area integrated health care systems informatics platform. The initial cohort included males ≥18 years diagnosed with PC between 2005 and 2019. AL was modeled as an ordinal variable from 0 to 11. Fine and Gray competing risk regression model accounting for the competing risk of all-cause mortality were used to calculate the impact of pre-cancer diagnosis AL and post-diagnosis AL in 2-year major cardiac events (MACEs). The effect of AL variation over time on MACEs development was calculated via the piecewise Cox Regression model where the time periods considered were before PC diagnosis, 2 months after, 6 months after and 1-year after PC diagnosis. Results: We analyzed 5,261 (19,840 person-years) PC adenocarcinoma patients, of which 6.6% (N=347) had a 2-year MACE. For every 1 point increase in AL before PC diagnosis and within 60 days after PC diagnosis the risk of MACE increased 25% (adjusted Hazards Ratio [aHR] =1.25, 95% Confidence Interval [CI] = 1.18-1.33), and 27% (aHR=1.27; 95% CI = 1.20-1.35), respectively. Using AL as a time varying exposure, the risk of MACE increased 19% (aHR=1.19, 95% CI 1.11-1.27), 22% (aHR=1.22, 95% CI 1.14-1.33), 28% (aHR=1.28, 95% CI 1.23-1.33), and 31% (aHR=1.31, 95% CI 1.27-1.35) for every 1 point increase in AL before PC diagnosis, 2 months after, 6 months after and 1-year after PC diagnosis, respectively. Conclusion: AL and its variation over time are associated with MACE in PC patients, suggesting a role of a biological measure of stress as a marker of CVD risk among men with PC. Preventive measures to minimize AL may require collaboration between cancer control and cardio-oncology.

Predictive Value of TIMI Risk Index for Angiographic No-reflow after Primary Percutaneous Coronary Intervention

Objective: In patients with acute coronary artery disease, the TIMI risk index (TRI), the thrombolysis in myocardial infarction (TIMI) risk score, and the global registry of acute coronary events (GRACE) risk score (GRS) have all been documented. The aim of this study was to determine the relationship between no-reflow (NRF) and admission TRI, major cardiac events (MACE), and in-hospital mortality in patients undergoing primary percutaneous coronary intervention (P-PCI).&#x0D; Methods: Between March and December 2019, 100 consecutive patients diagnosed with STEMI and treated with PPCI at Tanta Main University Hospital in Tanta, Egypt, were included in the research population. Each patient consented following a thorough history taking, evaluation of coronary risk factors, clinical examination, and electrocardiogram analysis. Additionally, all instances were classified using the Killip method. The GRS, TRS, and TRI values were examined.&#x0D; Results: The GRS, TRS, and TRI scores were significantly associated with increased NRF, MACE, and hospital mortality in STEMI patients treated with P-PCI, suggesting that TRI is a straightforward indicator with fewer parameters that accurately reflects P-PCI success.&#x0D; Conclusion: TRI has been demonstrated to enhance the risk of in-hospital mortality and MACE. TRI uses straightforward and cost-effective ways to test patients who have experienced a STEMI. Additionally, a high TRI may assist in identifying high-risk individuals and developing suitable treatment solutions.

Prognostic risk stratification based on left ventricular mechanical dyssynchrony in patients at low or intermediate risk of major cardiac events using the J-ACCESS risk model.

There have been no reports on prognostic prediction and risk stratification based on stress phase bandwidth (SPBW), or a left ventricular (LV) mechanical dyssynchrony index, in patients with known or suspected stable coronary artery disease (CAD) at low or intermediate risk of major cardiac events (MCEs) using the J-ACCESS risk model. We retrospectively investigated 4,996 consecutive patients with known or suspected CAD who underwent rest 201Tl and stress 99mTc-tetrofosmin electrocardiogram (ECG)-gated single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) and followed up for 3 years to confirm their prognosis. MCE risk over 3 years was estimated using an equation based on that used in the J-ACCESS study. The composite endpoint was the onset of MCEs consisting of cardiac death, non-fatal myocardial infarction (MI), and severe heart failure requiring hospitalization. SPBW was calculated by phase analysis with the Heart Risk View-F software and its normal upper limit was set to 38°. Based on the estimated 3-year incidence of MCEs obtained from the J-ACCESS risk model, 4,123 of the 4,996 consecutive patients were classified as low (n = 2,653) or intermediate risk (n = 1,470) and they were analyzed for follow-up. During the follow-up, 153 patients experienced MCEs: cardiac death (n = 38), non-fatal MI (n = 45), and severe heart failure (n = 70). The results of the multivariate analysis showed age, estimated glomerular filtration rate (eGFR), stress LV ejection fraction, and stress SPBW to be independent predictors of MCEs. The actual 3-year MCE rate in patients at intermediate risk was significantly higher than in those at low risk (6.7% vs. 2.1%, P < 0.0001). However, the actual 3-year MCE rate in patients with abnormal SPBW (> 38°) was 4.0% and 9.2% in low- and intermediate-risk patients, respectively, which corresponded to intermediate and high risk. Kaplan-Meier analysis also showed significant risk stratification by normal SPBW values for both low- and intermediate-risk patients. LV mechanical dyssynchrony assessed with ECG-gated SPECT MPI is useful for risk stratification of known or suspected stable CAD patients at low or intermediate risk of MCEs and may help identify higher risk patients who could not be identified as being at risk based on J-ACCESS risk assessment.

Endovascular Treatment of an Elderly Diabetic Patient with a Circular Myocardial Infarction in Cardiogenic Shock Complicated by Stent Thrombosis

The most common cause of cardiogenic shock (CS) is acute myocardial infarction (AMI), which is diagnosed in approximately 5–8% of patients hospitalized for AMI and is more common in patients with acute ST-segment elevation myocardial infarction (STEMI). CS is caused by severe myocardial dysfunction, which leads to a decrease in cardiac output, hypoperfusion of the end organs, and hypoxia. Mortality in diabetic patients with AMI is high. Besides the fact that type 2 diabetes mellitus (DM2) contributes to the progression of coronary atherosclerosis, coronary pathology in this category of patients occurs against the background of a specific diabetic myocardial lesion – diabetic cardiomyopathy. Against the background of cardiomyopathy, acute heart failure is more often developed with a decrease in global myocardial contractility up to CS, which increases hospital-acquired mortality in MI by more than 15 times. The increased risk of death observed in patients with DM2 in the acute period of myocardial infarction (MI) persists for several years, and therefore, at present, in patients with the acute coronary syndrome (ACS) and diabetes, an early invasive strategy is preferable to a conservative strategy. The SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) trial demonstrated that in patients with CS complicating AMI, emergency revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) improved long-term survival when compared with initial intensive medical therapy. However, in the CULPRIT-SHOCK (Culprit Lesion Only PCI Versus Multivessel PCI in Cardiogenic Shock) study, stenting of non-infarct-dependent coronary arteries in CS increases the risks of major cardiac events, as well as the number of repeated revascularizations within 30 days and 1 year. Patients with multivessel lesions, in most cases, are elderly patients (75–90 years old) who have age restrictions on taking the loading dose at the prehospital stage. Such a loading dose of clopidogrel may not be sufficient to saturate the patient in fact, despite optimal epicardial recanalization, a large proportion of patients still experience impaired reperfusion and in-stent thrombosis. A large body of evidence has been accumulated on the benefits of glycoprotein (GP) IIb-IIIa inhibitors in terms of prevention of stent thrombosis, and benefits in mortality, especially among high-risk patients, and as an upstream strategy.

Impact of pectoralis muscle loss on cardiac outcome and survival in Cancer patients who received anthracycline based chemotherapy: retrospective study

IntroductionThe impact of pectoralis muscle mass index (PMI) on cardiac events is not well studied in cancer patients, especially in those who have received chemotherapy with high potential cardiac toxicity such as anthracyclines.MethodsIndividuals aged ≥18 years with a diagnosis of breast cancer, sarcoma, or lymphoma who received anthracycline-based chemotherapy at the University of Minnesota MHealth Fairview between 2009 and 2014. Eligible patients had to have two CT scans: a baseline CT scan within 6 months prior to chemotherapy and a follow-up CT scan within 2 years after treatment. The PMI was calculated as the right pectoralis muscle area indexed to height squared. Multivariable linear regression was used to analyze factors associated with PMI at follow-up, overall mortality, and major cardiac events (MACE).ResultsA total of 474 patients (breast cancer 192; lymphoma 184; sarcoma 98) participated with a median age of 61 years at the time of baseline CT scan; 161 (34%) were male. Almost all patients received anthracyclines except 12% who received trastuzumab only. The median baseline PMI was 5.8 cm2/m2 (4.9, 7.7) which decreased 10.5% after chemotherapy, to 5.2 cm2/m2 (4.4, 6.4). Baseline PMI was not significantly associated with OS, but we detected lower risks of MACE with larger PMI at baseline. Greater baseline PMI was associated with greater follow-up PMI, but also with greater relative PMI loss. Female gender, older age, and history of smoking were also associated with greater PMI losses.ConclusionGreater pre-treatment pectoralis muscle index in patients treated with anthracyclines have a lower risk of MACE. Early identification of sarcopenia using PMI could trigger proactive engagement for intervention and risk-stratified therapies.

Disparities in the Use of Cardiac Rehabilitation in African Americans

Purpose of reviewCardiac rehabilitation (CR) is a comprehensive outpatient program that reduces the risk of mortality and recurrent events and improves functional status and quality of life for patients recovering from acute cardiovascular disease (CVD) events. Among individuals with established CVD, African Americans have a higher risk of major cardiac events, which underscores the importance of CR use among African Americans. However, despite their high likelihood of adverse outcomes, CR is poorly utilized in African Americans with CVD. We review data on CR utilization among African Americans, barriers to participation, and the implications for policy and practice.Recent findingsAlthough established as a highly effective secondary prevention strategy, CR is underutilized in general, but especially by African Americans. Notwithstanding efforts to increase CR participation among all groups, participation rates remain low for African Americans and other minorities compared to Non-Hispanic Whites. The low CR participation rates by African Americans can be attributed to an array of factors including differential referral patterns, access to care, and socioeconomic factors. There are several promising strategies to improve CR participation which include promoting evidence-based guidelines, reducing barriers to access, novel CR delivery modalities, including more African Americans in CR clinical research, and increasing diversity in the CR workforce.SummaryAfrican Americans with CVD events are less likely to be referred to, enroll in, and complete CR than Non-Hispanic Whites. There are many factors that impact CR participation by African Americans. Initiatives at the health policy, health system, individual, and community level will be needed to reduce these disparities in CR use.

Prognostic Significance of Feature-Tracking Right Ventricular Global Longitudinal Strain in Non-ischemic Dilated Cardiomyopathy.

Aims: Left ventricular global longitudinal strain (GLS) by cardiac magnetic resonance feature tracking (CMR-FT) analysis has shown an incremental prognostic value compared to classical parameters in non-ischemic dilated cardiomyopathy (NICM). However, less is known about the role of right ventricular (RV) GLS. Our objective was to evaluate the prognostic impact of RV-GLS by CMR-FT analysis in a population of NICM patients.Methods: In this multicenter study, we examined NICM patients evaluated with a comprehensive CMR-FT study. Major cardiac events (MACEs) were considered as the study primary outcome measure and were defined as a composite of (a) cardiovascular death, (b) cardiac transplant or destination therapy ventricular assist device, (c) hospitalization for life-threatening ventricular arrhythmias or implantable cardiac defibrillator appropriate intervention. Heart failure (HF) related events, including hospitalizations and life-threatening arrhythmia-related events were considered as secondary end-points. Receiver operating time-dependent analysis were used to calculate the possible additional effect of RV-GLS to standard evaluation.Results: We consecutively enrolled 273 patients. During a median follow-up of 39 months, 41 patients (15%) experienced MACEs. RV-GLS and LV late gadolinium emerged as the strongest prognostic CMR-FT variables: their association provided an estimated 3-year MACEs rate of 29%. The addition of RV-GLS significantly improved the prognostic accuracy in predicting MACEs with respect to the standard evaluation including LGE (areas under the curve from 0.71 [0.66–0.82] to 0.76 [0.66–0.86], p = 0.03). On competing risk analysis, RV-GLS showed a significant ability to reclassify overall both HF-related and life-threatening arrhythmia-related events, regardless of LV and RV ejection fraction.Conclusions: In NICM patients, RV-GLS showed a significant prognostic role in reclassifying the risk of MACEs, incremental with respect to standard evaluation with standard prognostic parameters.

Influenza Vaccination and the Risk of Ventricular Arrhythmias in Patients With Chronic Obstructive Pulmonary Disease: A Population-Based Longitudinal Study

Backgrounds: Influenza vaccination could decrease the risk of major cardiac events in patients with chronic obstructive pulmonary disease (COPD). However, the effects of the vaccine on decreasing the risk of ventricular arrhythmia (VA) development in such patients remain unclear.Methods: We retrospectively analyzed the data of 18,658 patients with COPD (≥55 years old) from the National Health Insurance Research Database from January 1, 2001, to December 31, 2012. After a 1:1 propensity score matching by the year of diagnosis, we divided the patients into vaccinated and unvaccinated groups. Time-varying Cox proportional hazards regression was applied to assess the time to event hazards of influenza vaccination exposure.Results: The risk of VA occurrence was significantly lower in the vaccinated group during influenza season and all seasons [adjusted hazard ratio (aHR): 0.62, 95% CI: 0.41–0.95; aHR: 0.69, 95% CI: 0.44–1.08; and aHR: 0.65, 95% CI: 0.48–0.89, in the influenza season, non-influenza season, and all seasons, respectively]. Among patients with CHA2DS2-VASc scores (conditions and characteristics included congestive heart failure, hypertension, diabetes, stroke, vascular disease, age, and sex) of 2–3, receiving one time and two to three times of influenza vaccination were associated with lower risk of VA occurrence in all seasons (aHR: 0.28, 95% CI: 0.10–0.80; aHR: 0.27, 95% CI: 0.10–0.68, respectively). Among patients without stroke, peripheral vascular disease, and diabetes, a lower risk of VA occurrence after receiving one and two to three times vaccination was observed in all seasons. Among patients with a history of asthma and patients without a history of heart failure, ischemic heart disease, angina hypertension, or renal failure, a significantly lower risk of VA occurrence was observed after the first time of vaccination in all seasons.Conclusions: Influenza vaccination may be associated with lower risks of VA among patients with COPD aged 55–74. Further investigation is still needed to resolve this clinical question.

A novel flow and pressure catheter for complete interventional cardiology physiology management

Abstract Ischemia with No Obstructive Coronary Artery (INOCA) in angina patients increases the risk of major cardiac events, with a 1.5x increased mortality rate. There is a link between COVID-19 infection and impairment in the myocardial micro-vasculation which may cause an increase of INOCA patients. Fractional Flow Reserve (FFR), is the standard of care in cardiology but its diagnostic function is only related to Obstructive Coronary Artery disease (or epicardial) and it is ineffective with INOCA. The lack of effective and accurate tools for timely evaluation of coronary impairments creates a clinical unmet need. The PhysioCath catheter was developed within the Eurostars project “FP-Catheter, E!113577” aims to resolve this need a provide an effective tool to interventional cardiologists. The main project outcome is a catheter prototype equipped with a blood flow velocity sensor based on a thermo-convection principle, and a fiber optic pressure sensor (based on Fabry-Perot principle). While the use of Fabry-Perot type of sensor is already standard in the industry, the use of a thermo-convection sensor represents a progress with respect the state of the art. The sensor creates an overheat of 7°C above the physiological blood's temperature (considered as being within the safety limits), and it exchanges thermal power with the blood stream. The power is then measured and converted to velocity by means of a calibration curve. The project encompassed interviews with 14 clinical experts, the summary of the interviews indicated that the preferred form of the device is an over the wire microcatheter, with rapid exchange. Within the project then, it was developed a 3Fr microcatheter, with a rapid exchange section of 24cm. Both pressure sensor and flow velocity sensor were integrated in this embodiment. Finally, the PhysioCath prototype was evaluated in a bench test study. The test setup was composed by an anatomical silicone phantom of the aortic root and the coronaries (Elastrat, Geneva, Switzerland), perfused with a peristaltic pump (Harvard Apparatus, Holliston MA, US). The measurements performed by the flow velocity sensor were compared against and external doppler flow velocity sensor. While the pressure measurement was assessed for stability and presence of drift. The data processing revealed and extreme accuracy in the measurement of flow based indexes like CFR (±6% variability), accuracy of the blood flow velocity measurement (±10%), and extreme stability in the measurement of both pressure and flow velocity. In the second part of the project (that is currently ongoing), it will be studied the performance of the device within an animal setting. In conclusion, the PhysioCath device is a microcatheter integrating bot pressure measurement and blood flow velocity measurement. Its performance is of very high accuracy and stability, that represent a main step ahead with respect the current state of the art, based mainly on thermodilution. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Eureka-Eurostars Test benchMicrocatheter prototype

The interaction between pre-admission β-blocker therapy, the Revised Cardiac Risk Index, and mortality in geriatric hip fracture patients.

BACKGROUNDAn association between β-blocker (BB) therapy and a reduced risk of major cardiac events and mortality in patients undergoing surgery for hip fractures has previously been demonstrated. Furthermore, a relationship between an increased Revised Cardiac Risk Index (RCRI) score and a higher risk of postoperative mortality has also been detected. The purpose of the current study was to investigate the interaction between BB therapy and RCRI in relation to 30-day postoperative mortality in geriatric patients after hip fracture surgery.METHODSAll patients older than 65 years who underwent primary emergency hip fracture surgery in Sweden between January 1, 2008, and December 31, 2017, except for pathological fractures, were included in this retrospective cohort study. Patients were divided into cohorts based on their RCRI score (RCRI 1, 2, 3, and ≥4) and whether they had ongoing BB therapy at the time of admission. A Poisson regression model with robust standard errors of variance was used, while adjusting for confounders, to evaluate the association between BB therapy, RCRI, and 30-day mortality.RESULTSA total of 126,934 cases met the study inclusion criteria. β-Blocker therapy was associated with a 65% decrease in the risk of 30-day postoperative mortality in the whole study population (adjusted incidence rate ratio [95% confidence interval], 0.35 [0.32–0.38]; p < 0.001). The use of BB also resulted in a significant reduction in 30-day postoperative mortality within all RCRI cohorts. However, the most pronounced effect of BB therapy was seen in patients with an RCRI score greater than 0.CONCLUSIONβ-Blocker therapy is associated with a reduction in 30-day postoperative mortality, irrespective of RCRI score. Furthermore, patients with an elevated cardiac risk appear to have a greater benefit of BB therapy.LEVEL OF EVIDENCETherapeutic/care management, level II