Risk Of Myocardial Infarction Research Articles

The incidence of cardiovascular conditions in patients admitted to hospital with and without COVID-19 in the South-East of Scotland

Abstract Background Multiple studies have reported an increased risk of acute myocardial infarction, cardiac arrhythmia, heart failure, myocarditis, and venous thromboembolism in patients admitted to hospital with COVID-19 infection. Whether the incidence of these cardiovascular conditions differ in patients hospitalised with COVID-19 compared to those who have COVID-19 excluded is not clear. Methods In a prospective, multi-centre, cohort study in secondary and tertiary care hospitals in Scotland, consecutive adults with symptoms of suspected COVID-19 were identified by the attending clinician using an electronic form integrated into the care pathway. Using linked electronic health record data, we evaluated the incidence of acute myocardial infarction, atrial fibrillation, heart failure hospitalisation, myocarditis, and venous thromboembolism during the index admission and the first 90 days following the index admission. In multivariable regression models the frequency of cardiovascular conditions at 90 days were compared in patients with confirmed COVID-19 infection defined by RT-PCR test with those in whom COVID-19 was excluded. Results Between April 2020 and May 2022, 53,644 (median age 68 [interquartile range, IQR 49-90] years, 54% women) consecutive patients were hospitalised and underwent RT-PCR for suspected COVID-19 infection. In total, 4,365 (8%) had COVID-19 confirmed and 49,279 (92%) had COVID-19 excluded. At 90 daythe myocardial infarction was less common (2% versus 5%) and venous thromboembolism was more common (6% versus 4%) in patients with COVID-19 compared to those without, but the proportion with atrial fibrillation (15% versus 14%), heart failure hospitalisation (10% versus 9%), and myocarditis (<0.1% versus <0.1%) were similar. Overall, the proportion with a cardiovascular condition at 90 days did not differ in patients with or without COVID-19 (Figure). Age (over 65 years, adjusted hazard ratio [aHR] 2.75, 95% confidence interval [CI] 2,61 to 2.89), male sex (aHR 1.35, 1.30 to 1.40), and risk factors (diabetes [aHR 1.13, 1.08 to 1.19], hyperlipidaemia [aHR 1.09, 1.01 to 1.18], hypertension [aHR 1.45, 1.39 to 1.52]) were independent predictors of cardiovascular complications, whilst COVID-19 status was not associated with increased risk (aHR 0.94, 0.88 to 1.01). Conclusion Cardiovascular conditions are common in patients hospitalised with suspected COVID-19, however the incidence at 90 days does not differ in those with or without COVID-19 and COVID-19 infection does not confer an increase in risk.

Influence of urban noise exposure on early-onset myocardial infarction risk prediction

Abstract Results from the DECIBEL-MI (Determination of Environmental CIty-noise's Burden, Exposure, and Link to Myocardial Infarction) Study Background Urban noise has not been incorporated into existing risk scores for cardiovascular events. The present study endeavors to explore the impact of noise exposure on the individual risk of early-onset myocardial infarction (MI). Methods All consecutive patients aged ≤ 50 years with acute MI who were admitted to a heart center between 2015 and 2023 and were residing in our city were included. The LIFE-CVD model was used to predict the 10-year cardiovascular risk of the patients based on traditional risk factors at the time of MI. The Geoportal Bremen was used to calculate both the daytime (Lden) and nighttime (Lnight) residential noise exposure levels. Results Among the 430 patients aged 50 years or younger diagnosed with MI, an elevated incidence of noise exposure compared to the general population in the same region was observed. This result was observed in both Lden (65% vs. 53%, p < 0.01) and Lnight (55% vs. 41%, p < 0.01). Patients with MI and a low LIFE-CVD score (≤2.5%) exhibited significantly higher noise exposure in comparison to those with a high LIFE-CVD score (2.32 vs. 1.36, p < 0.01 for Lden, and 1.72 vs. 1.00, p < 0.01 for Lnight). The average noise exposure increased with decreasing traditional risk factors exposure (see Figure 1). This inverse relationship persisted significantly in a linear regression analysis, even after adjusting for potential confounding factors such as socioeconomic status, PM10 and renal function (p < 0.01). Consequently, the incorporation of urban noise exposure contributes to optimizing the stratification of risk groups within LIFE-CVD risk categories. Conclusion Young patients with myocardial infarction (MI) who had fewer traditional risk factors were exposed to higher noise levels. Through comprehensive multivariate analysis, we identified a consistent inverse association between residential noise and the estimated cardiovascular risk based on traditional risk factors. Incorporating noise exposure into clinical care considerations has the potential to enhance the accuracy of MI prediction. Figure 1: Comparison of Lden in patients with MI ≤ 50 years with different 10-year LIFE-CVD risk categories (based on traditional risk factors)

Correlation analysis of self-rated health and net adverse clinical events in patients with acute myocardial infarction

Abstract Backgrounds Self-rated health (SRH） is a recognized standard risk factor for myocardial infarction, but its impact on prognosis remains uncertain. Purpose This study aims to investigate the impact of self-rated health on the long-term clinical outcomes of myocardial infarction patients. Methods The data for this study were derived from a retrospective cohort of patients admitted to and discharged from 72 secondary and tertiary hospitals from 2010 to 2023, Patients were divided into satisfied and unsatisfied groups based on their responses to an SRH questionnaire. Propensity score matching (PSM) was utilized to balance covariates between the two groups and analyze the relationship between SRH and clinical outcomes. The primary endpoint was net adverse clinical events (NACE), comprising cardiac death, recurrent myocardial infarction, revascularization, ischemic stroke, and bleeding events (BARC ≥3). The secondary endpoint comprised the individual components of the primary endpoint. Results The study included a total of 55,054 AMI patients, with 54,049 rating their health as satisfactory and 1,005 patients as unsatisfactory. In the satisfactory group, patients tended to be younger, had fewer females, better Killip classification, a higher proportion of STEMI cases, a higher rate of undergoing PCI, and a lower prevalence of concomitant disease such as diabetes, hypertension, chronic kidney disease, cerebrovascular disease, peripheral vascular disease, thyroid disease, and chronic lung disease. Additionally, patients in the satisfactory group had a higher proportion of antiplatelet therapy use (aspirin, ticagrelor). 1,005 pairs were well matched after PSM. After a median follow-up of 1626 days, the proportion of all-cause death, cardiac death, and recurrent myocardial infarction in the satisfied group was significantly lower than that in the unsatisfied group. Multivariable Cox regression analysis revealed that satisfactory SRH was associated with a reduced risk of NACE (aHR 0.809, 95%CI 0.704-0.930, P=0.002), cardiac death (aHR 0.790, 95%CI 0.665-0.939, P=0.007), and recurrent myocardial infarction (aHR 0.734, 95%CI 0.563-0.955, P=0.021). Conclusions Good SRH can decrease the risk of NACE in myocardial infarction patients, underscoring the importance of considering SRH in clinical assessment.

The clinical characteristics and prognosis of patients with acute non-ST-segment elevation myocardial infarction complicated with impaired activity daily living

Abstract Background Impaired activities of daily living (ADL) have been identified as an independent risk factor for cardiovascular diseases. This study aims to describe the clinical characteristics, treatment modalities, and prognosis of acute non-ST-segment elevation myocardial infarction (NSTEMI) patients with impaired ADL. Methods The data for this study were derived from a Health and Medical Big Data Superplatform, comprising a retrospective cohort of patients admitted to and discharged from 72 secondary and tertiary hospitals from 2010 to 2023. The inclusion criteria encompassed patients with a discharge diagnosis of NSTEMI.ADL prior to NSTEMI was evaluated using the Barthel index(BI),a widely used assessment tool for evaluating ADL.The patients' BI were obtained from patients’ resident health records, and patients were categorized into two groups: ADL normal and ADL impaired group. A comparative analysis was conducted between the two groups regarding clinical characteristics, treatment regimens, and prognosis. Results The study included 28,227 NSTEMI patients with normal ADL and 1,576 NSTEMI patients with impaired ADL. Baseline data revealed that the ADL impaired group had a higher proportion of females (49.4% vs. 43.2%, p < 0.001), older age (77.0 [69.0, 83.0] vs. 71.0 [66.0, 78.0], p < 0.001), and a higher proportion of patients with KILLIP III and above (25.86% vs. 17.44%, p < 0.001). Additionally, the ADL impaired group had a greater number of pre-existing comorbidities. Regarding treatment, the proportion of patients undergoing percutaneous coronary intervention (PCI) was significantly lower in the ADL impaired group (16.5% vs. 65.3%, p < 0.001). Moreover, the ADL impaired group showed lower utilization rates of antiplatelet agents, ACEI/ARBs, beta-blockers, ARNI, statins, and nitrates, while the utilization rates of diuretics and cardiac glycosides were higher. In terms of prognosis, the ADL impaired group exhibited a higher in-hospital mortality rate (6.03% vs. 3.35%, p < 0.001). During a median follow-up period of 876 days, the ADL impaired group had significantly higher rates of all-cause mortality (61.2% vs. 35.9%, p < 0.001) and cardiovascular mortality (41.8% vs. 24.8%, p < 0.001), while the rate of revascularization (6.69% vs. 9.20%, p = 0.008) was lower. There were no significant differences in the risks of recurrent non-fatal myocardial infarction (10.7% vs. 10.8%, p = 0.935), recurrent stroke (10.90% vs. 9.48%, p = 0.08), and hemorrhagic stroke (0.82% vs. 0.74%, p = 0.806). Following adjustment for age, gender, KILLIP classification, medical history, and treatment strategies in a multivariable Cox regression analysis, impaired ADL remained an independent risk factor for increased all-cause mortality (aHR 1.167, 95%CI: 1.091-1.249, p < 0.001). Conclusions The decline in ADL is significantly associated with adverse clinical outcomes among NSTEMI patients.Baseline characteristics of patientsMedications of patients

Impact of different P2Y12 inhibitors in acute coronary syndrome patients with severe chronic kidney disease: insights from the CORALYS registry

Abstract Background The impact of the most potent P2Y12i ticagrelor and prasugrel after acute coronary syndrome in patients with chronic kidney disease (CKD) remains unclear. Most evidence on dual antiplatelet therapy (DAPT) comes from real-world study but is limited to glomerular filtration rate (GFR) under 60 ml/min whereas no data are available regarding patients with severe CKD (stages IV-V) Methods Consecutive patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI) and severe CKD defined as GFR under 30 ml/min not on dialysis from the CORALYS (Incidence and Predictors of Heart Failure After Acute Coronary Syndrome) registry were included. Incidence of Net Adverse Clinical Events (NACE) defined as major adverse cardiac events (MACE, a composite of cardiovascular death, myocardial infarction and unplanned revascularizations) in addition to major bleedings (classified as BARC scale 3 to 5) was our primary endpoint. Overall MACE and their single components, all bleedings, major bleedings and hospitalizations for heart failure were the secondary ones. Results Of 14699 patients in the CORALYS registry, 257 presented with severe CKD not on dialysis and had available data on antiplatelet regimen at discharge. Patients were divided into two groups according to the type of P2Y12i prescribed at discharge: 193 (75.1%) were given clopidogrel while 64 (24.9%) with ticagrelor or prasugrel. Our populaiton was predominantly male (153, 59.5%) with an average age 75.8 ± 10.9 years old. Average GFR was 21.8 ± 6.3 ml/min. Over a median follow-up of 459 days, Ticagrelor and Prasugrel were associated to lower rates of NACE compared to Clopidogrel (39.9% vs 25.0%, p=0.036). This was mainly driven by an excess of both CV mortality (31.1% vs 6.3%) and myocardial infarction (20.7% vs 9.4%) reported in the clopidogrel group. No difference was reported regarding overall bleeding events (5.7% vs 4.6% with clopidogrel and new P2Y12i respectively, p=0.81) and major bleedings (1.7% vs 4.6% with clopidogrel and new P2Y12i respectively, p=0.15). At multivariate Cox regression analysis DAPT with Ticagrelor/Prasugrel resulted independently associated with a lower risk of NACE (Adj Hr 0.41, 95%CI 0.23-0.74, p=0.003) whereas left main involvement or multivessel coronary disease led to higher risk of NACE (Adj HR 1.96 95%CI 1.21-3.18, p=0.006) Conclusions In ACS patients treated with PCI with severe CKD ticagrelor and prasugrel were associated to lower risk of NACE, MACE, CV death and myocardial infarction compared to clopidogrel. No significative difference was reported in overall and major bleedings despite a relative increase of major bleedings in the group treated with Ticagrelor or Prasugrel.

Usefulness of mean attenuation of pericoronary adipose tissue as a predictor of coronary microvascular dysfunction

Abstract Background/Introduction Coronary microvascular dysfunction (CMD) is a condition in which the distal microvasculature is compromised, resulting in inadequate blood flow to the subsequent arteries and myocardial ischemia. Index of microvascular resistance (IMR), which can quantify CMD, is becoming the standard for the diagnosis of CMD. Patients with CMD have a 4 to 5 times greater risk of cardiovascular death and myocardial infarction than patients without heart disease and similar cardiovascular risk. Early diagnosis of CMD may reduce cardiovascular risk and improve quality of life with therapeutic intervention. Pericoronary adipose tissue mean attenuation (PCATMA) is an indirect measure of adipocyte size and lipid content around coronary artery, reflecting inflammation status. Previous studies have shown that both PCATMA and CMD are associated with the functional severity of coronary artery disease, but no study has yet examined the relationship between PCATMA and CMD. Purpose We conducted a study comparing PCATMA in patients with and without CMD. Methods Between September 2022 and October 2023, 25 patients without significant stenosis (<50% stenosis) who underwent IMR measurement on invasive coronary angiography and coronary CT angiography (CCTA) were included. CMD was diagnosed when the IMR exceeded 25 as measured by a pressure wire inserted into the left anterior descending artery after invasive coronary angiography had excluded significant stenosis. PCATMA was measured on CCTA using the average of the values of right coronary artery, left anterior descending artery, and left circumflex artery. Multivariable logistic regression analysis with stepwise forward selection was used to assess predictors for patients with abnormal IMR. The following variables were included for adjustment: PCATMA, age, sex, diabetes, dyslipidemia, hypertension. Results The mean age of 25 patients in this study was 63 years, 48.0% were female, 29.2% had diabetes, 62.5% had dyslipidemia and 66.7% had hypertension. PCATMA was significantly higher in patients with abnormal IMR (IMR>25) (-79.6 [IQR: -82.1, -74.6] HU vs -86.3 [IQR: -89.8, -78.9] HU, p = 0.043). Multivariate logistic regression analysis demonstrated that PCATMA remained an independent predictor of patients with abnormal IMR (OR 1.27 [95% CI: 1.05–1.65], p = 0.039). Optimal cut-off value of PCATMA for predicting patients with abnormal IMR by Youden index was -82.1 HU (AUC = 0.75 [95% CI: 0.55-0.95]). Conclusions In patients without significant coronary artery stenosis, PCATMA on CCTA may be used to predict the patients with CMD, noninvasively.

Assessing one-year risk of heart failure following first time myocardial infarction and subsequent five-year mortality risk: a nationwide study of 34,401 patients

Abstract Introduction A comprehensive understanding of the post-myocardial infarction (MI) trajectory leading to heart failure (HF) and its profound impact on long-term mortality is imperative for effective secondary prevention and risk assessment. Methods We conducted a registry-based nationwide cohort study of all Danish patients with a first MI during 2014 to 2020. Excluding patients with prior HF, individuals were followed for one year post-MI, assessing HF incidence through hospital admissions and visits to elective HF ambulatory clinics. Among those who survived one year, long-term mortality 1-6 years post-index MI was assessed using landmark analysis and Cox proportional hazards models adjusting for age, gender and comorbidities and hazard. Patients were categorized into three groups: not HF, referred for elective HF outpatient follow-up, and acute admission for HF. Results Among 34,301 individuals with a first MI and surviving the first year (median age 67.5, and 66.9 % male), 3.3 % were admitted acute for HF while 11.2 % had an elective HF outpatient follow-up within one year of the MI event (see Figure 1a). We observed a significant association between acute HF admissions post-MI and increased five-year mortality risk (hazard ratio [HR] 1.63, 95% confidence interval [CI] 1.40-1.90, p-value <0.001, see Figure 1b) (absolute 5-year risk: 18.4 %). In contrast, the five-year mortality risk for patients with elective outpatient HF follow-up was comparable to that of individuals without HF (HR 1.06 [0.94-1.19], p-value 0.34) (absolute 5-year risk: 9.6 vs 8.5 %). Conclusion Our findings suggest that acute admission for HF after a first time MI occur in 3.3 % of the patients with a subsequent significantly increased mortality risk compared to patients that do not develop clinical HF. Admission for HF in patients with a first time MI should be considered as a relatively rare but fatal complication.

Machine learning for prediction of all-cause mortality in acute coronary syndrome

Abstract Background Acute coronary syndrome (ACS) remains one of the leading causes of death globally. Accurate and reliable mortality risk prediction of ACS patients is essential for developing targeted treatment strategies and improve prognostication. Traditional models for risk stratification such as the Global Registry of Acute Coronary Events (GRACE) and the Thrombolysis In Myocardial Infarction (TIMI) risk scores offer moderate discriminative value, and do not incorporate contemporary predictors of ACS prognosis. Machine learning (ML) models have emerged as an alternate method that may offer improved risk assessment. This study aims to compare machine learning models with traditional risk scores for predicting all-cause mortality in patients with ACS. Methods PubMed, EMBASE, Web of Science and Cochrane databases were searched until 1st November 2023 for studies comparing ML models with traditional statistical methods for event prediction of ACS patients. The primary outcome was comparative discrimination measured by C-statistics with 95% confidence intervals between ML models and traditional methods in estimating the risk of all-cause mortality. Results Ten studies were included (239627 patients). The summary C-statistic of all ML models across all endpoints was 0.89 (95% CI, 0.86-0.92), compared to traditional methods 0.82 (95% CI, 0.79-0.85). The difference in C-statistic between all ML models and traditional methods was 0.07 (p<0.05). Three models undertook external validation, and calibration was inconsistently reported. Conclusion ML models demonstrated superior discrimination of all-cause mortality for ACS patients compared to traditional risk scores. Despite outperforming well-established prognostic tools such as the GRACE and TIMI scores, current clinical applications of ML approaches remain uncertain, particularly in view of the methodological limitations of existing models and the need for greater validation.

Prevalence of coronary microvascular disease in myocardial infarction with non-obstructive coronary artery disease

Abstract Background Six percent of patients presenting with acute myocardial infarction (MI) have MI with non-obstructed coronary artery disease (MINOCA). Coronary microvascular disease (CMD) is common in angina with non-obstructive coronary artery disease (ANOCA), but its prevalence and severity in MINOCA is undefined. Purpose Patients with CMD may have elevated risk of myocardial infarction despite no significant stenosis. We tested the hypothesis that patients with MINOCA have more significant burden of CMD than patients with ANOCA. Methods A retrospective case-control study was performed on patients who underwent invasive testing for signs of coronary ischemia and found to have non-obstructive disease (stenoses< 50%). Cases of MI were classified as MINOCA (n=87) and compared to patients with ANOCA (n=552). Patients with spontaneous coronary artery dissection, myocarditis, Takotsubo cardiomyopathy or prior atherothrombotic MI were excluded. Coronary catheterization was performed followed by invasive provocation testing with adenosine and acetylcholine using a Doppler flow wire. CMD was subdivided into endothelium-independent, defined as coronary flow reserve (CFR) < 2.5 with intra-coronary adenosine, and endothelium dependent, defined as < 50% increase in coronary blood flow with acetylcholine. Epicardial vasoconstriction > 90% with typical anginal symptoms was classified as epicardial vasospasm. Results There was no difference in age, sex or traditional coronary risk factors between the MINOCA and ANOCA groups (Table 1). Fifty (57%) of patients with MINOCA had type 2 MI secondary to supply-demand mismatch. Both MINOCA and suspected ANOCA patients had a high prevalence of CMD (71% vs 67%) and endothelium-independent CMD is more prevalent in MINOCA (64.5% vs 50.4%). Although odds of endothelium-dependent CMD were similar, the CFR within this group and CMD overall was worse in MINOCA patients (Figure 1). There was no difference in epicardial spasm. Conclusion Coronary microvascular disease and vasomotor dysfunction are common in patients with MINOCA, with a higher prevalence of endothelium-independent CMD and more severe CMD overall compared to patients with ANOCA. Treatment of CMD in patients with MINOCA may help reduce recurrence and warrants further investigation.

Spinal cord injury and risk of overall and type specific cardiovascular diseases: A meta-analysis.

Cardiovascular disease (CVD) is a growing concern among people with spinal cord injury (SCI). This meta-analysis aims to explore the risk of overall CVD and specific types of cardiovascular events among SCI patients. This meta-analysis is registered on PROSPERO (CRD CRD42024537888). The data sources comprised PubMed, Embase, the Cochrane Library, and reference lists of the included studies. The literature collection span is from database establishment until April 17, 2024. This meta-analysis encompassed observational studies investigating the association between SCI and the risk of overall types of CVD or specific CVD types. Risk of bias was evaluated utilizing the Newcastle-Ottawa Quality Assessment Scale (NOS) and the Agency for Healthcare Research and Quality (AHRQ) Scale. Odds ratios (ORs) with 95% confidence intervals (CIs) were aggregated using a random-effects model. Our initial search generated 5357 relevant records form these international databases. This meta-analysis encompassed 9 observational studies involving 2,282,691 individuals, comprising 193,045 patients with SCI and 2,209,646 controls. We observed a 1.56-fold [OR = 1.56, 95% CI (1.43, 1.70), I2 = 91.3%, P < 0.001] rise in the risk of overall types of CVD among SCI patients, with a 1.82-fold increase in males and a 1.76-fold increase in females. SCI patients without comorbidities exhibited a 2.10-fold elevated risk of overall CVD types, while those with comorbidities had a 1.48-fold increased risk. Concerning specific CVD types, SCI patients showed a 1.58-fold [OR = 1.57, 95% CI (1.22, 2.03), I2 = 92.4%] higher risk of myocardial infarction, a 1.52-fold [OR = 1.52, 95% CI (1.07, 2.16), I2 = 88.7%] increase in atrial fibrillation, a 1.64-fold [OR = 1.64, 95% CI (1.22, 2.20), I2 = 95.5%] elevation in heart failure risk, and 2.38-fold [OR = 2.38, 95% CI (1.29, 4.40), I2 = 92.5%] increments in stroke risk. But there was no statistically significant difference in the risk of hypertension [OR = 1.54, 95% CI (0.98, 2.42), I2 = 96.6%]. The risk of overall CVD in SCI patients surpassed that of the non-SCI control group, with elevated risks of specific cardiovascular events like myocardial infarction, atrial fibrillation, heart failure, and stroke. Clinicians should prioritize awareness of CVD risks in SCI patients.

Efficacy of lipid lowering therapy beyond statins to prevent cardiovascular events

Abstract Background Lipid lowering therapy is a key cornerstone in secondary prevention of patients with coronary artery disease. However, only a minority of patients with statin therapy reach LDL thresholds as suggested by the ESC. Ezetimibe, bempedoic acic, and proprotein convertase subtilisin/kexin type 9 (PCSK-9) (synthase-) inhibitors allow for the reduction in LDL-cholesterol in addition to statin therapy. Purpose We aimed to perform a meta-analysis of existing trials, evaluating how lipid lowering therapy beyond statins impacts cardiovascular outcome. In specific, we evaluated the potential influence of duration of follow-up on the association with mortality endpoints. Methods We performed a systematic search using the Pubmed, Cochrane, SCOPUS, and Web of Science databases for studies, evaluating the impact of an intensified lipid lowering therapy via ezetimibe, bempedoic acid, Bococizumab, Alirocumab, Evolocumab, Inclisiran in addition to statin therapy compared to statin therapy alone. Manuscript and congress presentations, published until 1st of August 2023, were included. We made our search specific and sensitive using Medical Subject Headings terms and free text and considered studies published in English language. Search terms used were : "Bempedoic Acid" or "Bococizumab" or "Alirocumab" or "Evolocumab" or "Ezetimibe" or "Inclisiran" and "statin" and "cardiovascular events". Results A total of 123,785 patients from 15 randomized controlled trials (IMPROVE-IT, FOURIER, ODYSSEY Outcomes, ODYSSEY LONG TERM, EWTOPIA 75, PACMAN-AMI, RACING, SIPRE I, SPIRE II, OSLER-1 and OSLER-2, CLEAR HARMONY, CLEAR OUTCOMES, CLEAR SERENITY, CLEAR WISDOM) were included. Treatment with ezetimibe or a PCSK-9 inhibitor was associated with a 19% risk reduction in cardiovascular events (OR [95%CI]: 0.81 [0.75; 0.86]). Effect sizes were similar for myocardial infarction (0.81 [0.74; 0.89]) and even more pronounced for ischemic stroke (0.77 [0.70; 0.84]). In contrast, all-cause mortality was not improved by the intensified lipid lowering therapy (0.99 [0.93; 1.04]). Stratifying by follow-up duration of &amp;lt; vs. ≥ 3 years, no improvement in all-cause mortality was observed in both groups (&amp;lt;3 years: 1.04 [0.93; 1.17]; ≥3 years: 0.97 (0.88; 1.06). No relevant heterogeneity and inconsistency between groups was present in all analyses (detailed data not shown). Conclusion Intensified LDL-lowering therapy with ezetimibe, bempedoic acic or PCSK-9 inhibitors, in addition to statins, reduces the risk of myocardial infarction and stroke, however, does not impact overall mortality. A potential survival benefit was also not observed in studies with follow-up duration of ≥ 3 years.

Stroke-Heart syndrome: a population-based cohort study and cluster analysis

Abstract Background The onset of acute cardiovascular complications following a stroke, also known as "Stroke-Heart Syndrome", can occur in up to 20% of patients following a stroke. The syndrome remains under-investigated and limited data exists related to the occurrence and impact of the Stroke-Heart Syndrome in an Asian population. Objectives We aimed to investigate the potential impact of the Stroke-Heart Syndrome and its associations in a retrospective population based-cohort study. Methods The analysis included patients with new-onset ischaemic stroke (IS) June 2006 and May 2022 with 5 years’ follow-up. Patients who developed acute cardiovascular complications within 28 days of their index stroke were compared to patients who did not. The association between acute cardiovascular complications and longer term outcomes were evaluated using multivariate Fine-Grey analyses to adjust for competing risk of mortality, and a Cox regression model for all-cause mortality. Inverse probability of treatment weighting was applied prior to analysis. Furthermore, a hierarchical cluster analysis was performed in the cohort of stroke patients with "Stroke-Heart Syndrome", to further evaluate associations between the identified clusters and (i) longer term outcomes, as well as (ii) the development of acute cardiovascular complications. Results A total of 141,118 patients (median age 72.4 (IQR 62.6 to80.8) years; 45.4% female) were included in the analysis, 6,457 of who developed acute cardiovascular complications, and 134,661 of whom did not. At 5 years follow-up, acute cardiovascular complications were associated with a higher risk of developing recurrent ischaemic stroke (Sub-distribution Hazard Ratio [SHR]: 1.20, 95% Confidence Interval [CI]: 0. 1.12-1.28, p= &amp;lt;0.001), haemorrhagic stroke (SHR: 1.15, 95%CI: 1.03-1.28, p=0.014), myocardial infarction (SHR: 1.53, 95%CI: 1.39-1.69, p=&amp;lt;0.001), and cardiovascular death (SHR: 1.57, 95%CI: 1.45-1.71, p=&amp;lt;0.001) as well as all-cause mortality (HR: 1.07, 95%CI: 1.07-1.07, p=&amp;lt;0.001). A total of 4 clusters were identified in the cluster analysis. Compared to Cluster 3, the other Clusters were associated with increased 5-year risk of myocardial infarction, cardiovascular death and all-cause mortality (p=&amp;lt;0.001). In this cohort, compared to Cluster 2, the other clusters had an increased risk of developing acute cardiovascular complications, in particular acute ischaemic heart disease and acute heart failure (p=&amp;lt;0.001). Cluster 3 tended to be younger with fewer comorbidities and prescribed medications. Over 90% of the patients in Cluster 2 were aged over 75 (with 43% aged 85 years or over). Conclusion Stroke-Heart Syndrome was associated with long-term adverse cardiovascular events in this Asian cohort of ischaemic stroke patients.

Safety of COVID-19 vaccines regarding cardiovascular events: a systematic review and meta-analysis

Abstract Background Since the outbreak of COVID-19, extensive vaccination strategies have almost excelled in reducing the mortality and severity of COVID-19 infection; however, although there are several authorized vaccines thus far, vaccine hesitancy has risen among various populations. Cardiovascular adverse events have been among the highly reported adverse events of the vaccines. Herein, we aimed to systematically assess the studies that reported the safety of COVID-19 outcomes regarding cardiovascular outcomes. Methods Three online databases were comprehensively searched, including PubMed, Scopus, and Embase. Relevant observational/interventional studies and case reports/series were included. Study characteristics, demographic features of the populations, vaccine type and dosage, and outcomes of interest were extracted. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated to compare the groups vaccinated and those that have not. Results From the 2960 initial searched records, 21 observational/interventional studies, and 110 case reports/series were included. Meta-analysis revealed that there is no difference between vaccinated and non-vaccinated regarding all new-onset cardiac disorders (RR 1.14, 95% CI 0.71 to 1.85, p-value=0.59). On the other hand, vaccinated patients had a higher risk of myopericarditis, compared to the general population by 74% (RR 1.74, 95% CI 1.56 to 1.94, p-value &amp;lt;0.01). There was no difference between the groups in terms of risk of myocardial infarction. Among 219 individuals reported in case reports and series, 193 were diagnosed with myocarditis and pericarditis. Notably, 95.34% of these patients were vaccinated with mRNA-based vaccines. Conclusion This systematic review and meta-analysis implied that there is no increase in overall new-onset cardiac adverse events, while there might be an increased risk of myopericarditis based on some studies’ findings. This highlights that since there is no added cardiovascular risk associated with COVID-19 vaccination, all individuals are encouraged to get vaccinated.Forest plots for meta-analyses

Pericardial adipose tissue (PAT) as a cell model to assess patient responsiveness to docosahexaenoic acid (DHA) and eicopentaenoic acid (EPA)

Abstract Background The abundance of epicardial (EAT) and pericardial adipose tissue (PAT) is associated with several cardiac risk factors and a higher carotid intima-media thickness, with a potential contributory role to the development of atherosclerosis and coronary artery disease (CAD). Under conditions promoting obesity, both epicardial and pericardial adipose tissue undergo a metabolic shift, acquiring an inflammatory and pro-atherogenic phenotype. Addressing dysmetabolism and inflammation associated with EAT and PAT are a promising and innovative therapeutic approach for preventing coronary atherosclerosis. Recent data have highlighted a noteworthy association between the abundance of adipose tissue n-3 polyunsaturated fatty acids (PUFA) eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), as well as their ratio to the omega-6 FA arachidonic acid (AA), with a lower risk of myocardial infarction. Purpose To develop an efficient method for isolation of adipocytes from human PAT and evaluation of adipocyte response to DHA and EPA. Methods PAT samples were collected from 9 CAD patients, undergoing coronary artery bypass graft surgery and immediately processed before to assess more than 50 experimental conditions. Isolated adipocytes were morphologically and molecularly characterized. Cell responsiveness was evaluated by cell exposure to inflammatory stimuli, with or without variable amounts of DHA, EPA, or AA assessing a spectrum of gene expressions and pro-inflammatory functional activities. Results Pure cultures of pericardial adipocytes exhibited prolonged viability (beyond 72 hours). and retained responsiveness to pro-inflammatory and lipolytic stimuli, while also showing the capacity to activate the insulin signalling pathway. Cell exposure to DHA or EPA resulted in a downregulation of messenger (m)RNA expression for monocyte chemoattractant protein (MCP)-1, interleukin (IL)-6 and metalloproteinase (MMP)-9 (p&amp;lt;0.05) and in upregulation of uncoupling protein-(UCP)-1, UCP-2 and peroxisome proliferator-activated receptor (PPAR)γ (p&amp;lt; 0.05) (Figure 1). In line with mRNA expression, a significant reduction in both cytokines and MMP-9 protein release was observed (p&amp;lt;0.05) (Figure 2). These effects paralleled a significant incorporation of DHA and EPA into total cell lipids (p&amp;lt;0.05). Functionally, the cell supernatant from DHA- or EPA-conditioned cells displayed diminished ability to attract monocytes in chemotaxis assays. AA exhibited no such activities. Conclusion(s) In a novel cellular model of isolated and cultured adipocytes from PAT, DHA and EPA attenuated the inflammatory and dysmetabolic characteristics of this cardiac adipose tissue.

Sex differences in coronary atherosclerotic plaque activity using 18F-sodium fluoride positron emission tomography

Abstract Background There are sex differences in the extent, severity, and outcomes of coronary artery disease. Purpose To assess the influence of sex on coronary atherosclerotic plaque activity measured using coronary 18F-sodium fluoride (18F-NaF) positron emission tomography (PET), and to determine whether 18F-NaF PET has prognostic value in both women and men. Methods In a post-hoc analysis of observational cohort studies of patients with coronary atherosclerosis who had undergone 18F-NaF PET CT angiography, we compared the coronary microcalcification activity (CMA) in women and men. Results Baseline 18F-NaF PET CT angiography was available in 999 participants (151 (15%) women) with 4282 patient-years of follow-up. Compared to men, women had lower coronary calcium scores (116 [interquartile range, 27-434] versus 205 [51-571] Agatston units; p=0.002) and CMA values (0.0 [0.0-1.12] versus 0.53 [0.0-2.54], p=0.01). Following matching for plaque burden by coronary calcium scores and clinical comorbidities, there was no sex-related difference in CMA values (0.0 [0.0-1.12] versus 0.0 [0.0-1.23], p=0.21) and similar proportions of women and men had no 18F-NaF uptake (53.0% (n=80) and 48.3% (n=73); p=0.42), or CMA values &amp;gt;1.56 (21.8% (n=33) and 21.8% (n=33); p=1.00). Over a median follow-up of 4.5 [4.0-6.0] years, myocardial infarction occurred in 6.6% of women (n=10) and 7.8% of men (n=66). Coronary microcalcification activity greater than 0 was associated with a similarly increased risk of myocardial infarction in both women (HR: 3.83; 95% CI:1.10-18.49; p=0.04) and men (HR: 5.29; 95% CI:2.28-12.28; p&amp;lt;0.001). Conclusions Although men present with more coronary atherosclerotic plaque than women, increased plaque activity is a strong predictor of future myocardial infarction regardless of sex.Sex differences in CAD activityCase examples

Relationship between lipoprotein(a) and endogenous fibrinolytic status in patients with STEMI

Abstract Background The risk of myocardial infarction is at least doubled in individuals with lipoprotein(a) (Lp[a]) levels &amp;gt;90th percentile.[1] Lp(a) may exert pro-thrombotic effects by impairing fibrinolysis. Lp(a) has a high degree of homology to plasminogen and can competitively inhibit tissue plasminogen activator (tPA)-mediated plasminogen activation and tPA-mediated clot lysis.[2] Furthermore, Lp(a) stimulates the activity of plasminogen activator inhibitor-1, the major inhibitor of the fibrinolytic system. In patients with ST-segment elevation myocardial infarction (STEMI), impaired endogenous fibrinolysis is a strong, independent risk factor for recurrent cardiovascular events,[3] but the drivers of this are not fully understood. Whether impaired endogenous fibrinolysis is related to increased Lp(a) levels in patients with STEMI, is not known. Purpose We aimed to assess the relationship between Lp(a) and endogenous fibrinolysis in patients with STEMI. Methods In a prospective, observational study, venous blood samples were drawn from patients presenting with STEMI immediately before revascularisation, after dual antiplatelet therapy but before heparin administration. Endogenous fibrinolysis was measured immediately in non-anticoagulated whole blood using the point-of-care Global Thrombosis Test, which measures the time for occlusive thrombus formation under high shear (occlusion time) and the time for spontaneous lysis of the thrombus (lysis time).[3] Assessment of Lp(a) levels, measured by particle enhanced immunoturbidimetric assay, was performed with paired plasma samples, standardized against the International Federation of Clinical Chemistry reference material SRM2B for nmol/L. Lp(a) &amp;gt;32 nmol/L is associated with increased risk of ischaemic heart disease. Results A total of 80 patients were included (age 64±14y, 25% females and 86% Caucasian). There was a positive correlation between Lp(a) level and lysis time (r = 0.330, P = 0.003) (Figure 1). Lysis time was significantly longer in patients with Lp(a) &amp;gt;32 nmol/L (2782 [1626-3683] vs. 1725 [1259-2955] s, P = 0.044). Using a cut-point of lysis time ≥2500 s previously associated with a significantly increased cardiovascular risk in patients with STEMI, we showed that Lp(a) was significantly higher in patients with lysis time ≥2500 s (40 (22-111) vs. 18 (7-73) nmol/L, P = 0.045). Table 1 shows the relationship between clinical characteristics and Lp(a) and lysis time. Lp(a) level was higher in non-Caucasian patients. There was no correlation between Lp(a) and occlusion time (r = 0.156, P = 0.168). Conclusion In patients with STEMI, longer endogenous fibrinolysis time is related to higher Lp(a) level. Raised Lp(a) levels may, in part, contribute to impaired endogenous fibrinolysis. Future studies are required to assess whether reduction in Lp(a) with novel therapies currently in phase 3 trials can favourably modulate fibrinolysis and improve clinical outcomes.Figure 1

Prognostic impact of intravascular imaging in percutaneous coronary intervention according to atherothrombotic risk

Abstract Background Recent randomized controlled trials support intravascular imaging-guided PCI to improve patient prognosis, however, future risk of clinical events in patient with coronary artery disease is not solely determined by lesion characteristics or how these lesions are treated. Objectives Current study investigated whether the effects of intravascular imaging in complex percutaneous coronary invention (PCI) would differ according to atherothrombotic risks. Methods This study was post-hoc analysis of the RENOVATE-COMPLEX-PCI trial that compared intravascular imaging-guided PCI with angiography-guided PCI in patients with complex coronary artery lesions. Study population was stratified according to atherothrombotic risk assessed by Thrombolysis In Myocardial Infarction Risk Score for Secondary Prevention (TRS-2P) (a sum of age≥75 years, diabetes mellitus, hypertension, smoking, peripheral arterial disease, stroke, coronary artery bypass grafting, heart failure, and renal dysfunction) into low-risk (TRS-2P&amp;lt;3) or high-risk (TRS-2P≥3) groups. The primary endpoint was target vessel failure (TVF), a composite of cardiac death, target vessel related myocardial infarction, or clinically driven target vessel revascularization. Results Among the total patients, 1,247 were low-risk and 392 were high-risk. The risk of TVF was significantly higher in the high-risk group than the low-risk group (15.5% vs. 7.2%; hazard ratio [HR], 2.13; 95% confidence interval [CI], 1.51–3.00; P&amp;lt;0.001). The benefits of intravascular imaging-guided PCI over angiography-guided PCI did not differ between the low-risk group (5.6% vs. 10.4%; HR, 0.56; 95% CI, 0.36–0.86) and the high-risk group (14.1% vs. 18.5%; HR, 0.71; 95% CI, 0.41–1.24) without significant interaction (interaction P=0.496). Conclusions Although patients with high atherothrombotic risk had significantly worse clinical outcome than those with low atherothrombotic risk, the prognostic impact of intravascular imaging-guided PCI compared with angiography-guided PCI was similarly observed in both low and high future atherothrombotic risk groups.Structured Graphical Abstract

Older women with non-ST-elevation acute coronary syndrome undergoing invasive or conservative management: an individual patient data meta-analysis

Abstract Aims Women and older patients are underrepresented in randomised controlled trials (RCTs) investigating treatment strategies following acute coronary syndrome. To evaluate the benefit of invasive versus conservative strategy of older women with non-ST-elevation acute coronary syndrome (NSTEACS). Methods This analysis from an individual patient data meta-analysis included six RCTs comparing an invasive management with a conservative management in older NSTEACS patients. The primary endpoint was the composite of all-cause mortality or myocardial infarction (MI). Secondary endpoints included all-cause mortality, cardiovascular death, MI, urgent revascularisation and stroke. Follow-up time was censored at 1 year. Results In total, 717 women (median age 84.0 [interquartile range 81.0-87.0] years) were included. The primary endpoint occurred in 21.0% in the invasive strategy versus 27.8% in the conservative strategy (hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.52-1.13, P=0.160 using random effect) at 1-year follow-up. The invasive management was associated with reduced risk of MI (HR 0.49, 95% CI 0.32-0.73, P&amp;lt;0.001) and urgent revascularisation (HR 0.44, 95% CI 0.20-0.98, P=0.045). No significant differences were identified in the risk of all-cause mortality, cardiovascular death and stroke. Among males, there was no significant association between the treatment strategy and primary or secondary endpoints. Conclusions An invasive strategy compared to a conservative strategy did not reduce the composite outcome of all-cause mortality or MI in older NSTEACS women at 1-year follow-up. An invasive strategy reduced the individual risk of MI and urgent revascularisation. Our results support the beneficial role of the invasive strategy in older NSTEACS women. Registration This meta-analysis is registered with PROSPERO (CRD42023379819).

ACE Inhibitors and Angiotensin Receptor Blockers for the Primary and Secondary Prevention of Cardiovascular Outcomes: Recommendations from the 2024 Egyptian Cardiology Expert Consensus in Collaboration with the CVREP Foundation.

The renin-angiotensin-aldosterone system (RAAS) plays a pivotal role in regulating blood pressure (BP), with dysregulation of RAAS resulting in hypertension and potentially heart failure (HF), myocardial infarction (MI), cardio-renal syndrome, and stroke. RAAS inhibitors, such as angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs), have advantages beyond BP control. However, differences between these two drug classes need to be considered when choosing a therapy for preventing cardiovascular events. A panel of 36 Egyptian cardiologists developed consensus statements on RAAS inhibitors for primary and secondary prevention of cardiovascular outcomes and stroke, using a modified three-step Delphi process. The consensus statements highlight the importance of effective BP control and the role of RAAS blockade for prevention and management of various cardiovascular diseases. ACEis and ARBs differ in their mode of action and, thus, clinical effects. On the basis of available evidence, the consensus group recommended the following: ACEis should be considered as first choice (in preference to ARBs) to reduce the risk of MI, for primary prevention of HF, and for secondary prevention of stroke. ACEis and ARBs show equivalent efficacy for the primary prevention of stroke. Evidence also favors the preferential use of ACEis in patients with type 2 diabetes, for BP control, for the primary prevention of diabetic kidney disease, and to reduce the risk of major cardiovascular and renal outcomes. Treatment with an ACEi should be started within 24 h of ST segment elevation MI (and continued long term) in patients with HF, left ventricular systolic dysfunction, and/or diabetes. Angiotensin receptor/neprilysin inhibitors (ARNIs) are the first choice for patients with HF and reduced ejection fraction, with ACEis being the second choice in this group. ARBs are indicated as alternatives in patients who cannot tolerate ACEis. ACEis may be associated with cough development, but the incidence tends to be overestimated, and the risk can be reduced by use of a lipophilic ACEi or combining the ACEi with a calcium channel blocker. RAAS blockade is an essential component of hypertension therapy; however, the protective effects provided by ACEis are superior to those of ARBs. Therefore, an ACEi is indicated in almost all cases, unless not tolerated.

Clinical risk prediction, coronary computed tomography angiography, and cardiovascular events in new-onset chest pain: the PROMISE and SCOT-HEART trials.

Whether index testing using coronary computed tomography angiography (CTA) improves outcomes in stable chest pain is debated. The risk factor weighted clinical likelihood (RF-CL) model provides likelihood estimation of obstructive coronary artery disease. This study investigated the prognostic effect of coronary CTA vs. usual care by RF-CL estimates. Large-scale studies randomized patients (N = 13 748) with stable chest pain to coronary CTA as part of the initial work-up in addition to or instead of usual care including functional testing. Patients were stratified according to RF-CL estimates [RF-CL: very-low (≤5%), low (>5%-15%), and moderate/high (>15%)]. The primary endpoint was myocardial infarction or death at 3 years. The primary endpoint occurred in 313 (2.3%) patients. Event rates were similar in patients allocated to coronary CTA vs. usual care [risk difference (RD) 0.3%, hazard ratio (HR) 0.84 (95% CI 0.67-1.05)]. Overall, 33%, 44%, and 23% patients had very-low, low, and moderate/high RF-CL. Risk was similar in patients with very low and moderate/high RF-CL allocated to coronary CTA vs. usual care [very low: RD 0.3%, HR 1.27 (0.74-2.16); moderate/high: RD 0.5%, HR 0.88 (0.63-1.23)]. Conversely, patients with low RF-CL undergoing coronary CTA had lower event rates [RD 0.7%, HR 0.67 (95% CI 0.47-0.97)]. The number needed to test using coronary CTA to prevent one event within 3 years was 143. Despite an overall good prognosis, low RF-CL patients have reduced risk of myocardial infarction or death when allocated to coronary CTA vs. usual care. Risk is similar in patients with very-low and moderate/high likelihood.