Three-vessel Coronary Artery Disease Research Articles

A systematic screening and heart team approach contributes to unravel novel risk factors in revascularisation candidates of complex coronary artery disease: a machine learning approach.

The baseline characteristics affecting mortality following percutaneous or surgical revascularisation in patients with left main (LM) and/or three-vessel (3V) coronary artery disease (CAD) differ between real-world practice and those established in randomized control trials (RCT) due to the constraints of inclusion/exclusion criteria. This study aimed to assess whether systematic screening identifies novel and registry-specific baseline characteristics influencing long-term mortality. LASSO (Least Absolute Shrinkage and Selection Operator) regression was used to screen 42 baseline characteristics shared by the SYNTAX trial and a single-center Polish registry of 1035 consecutive patients with complex CAD, receiving revascularization and followed up for 5 years. After screening, classical Cox regression analysis was performed to examine the suitability of a Linear model for predicting 5-year mortality, which was then compared to the mortality predicted in the same cohort using the SYNTAX score 2020 (SS2020). Five-year mortality in the registry was 12.3%, with the strongest predictors of pulmonary hypertension, chronic obstructive pulmonary disease and insulin-dependent diabetes. In an internal validation, the linear model constructed after LASSO screening and combined with a classical Cox regression analysis improved the prediction of 5-year mortality compared to the SS2020 (c-index 0.92 and 0.75, respectively). Machine learning improved the detection of registry-specific risk factors in all comers patients amenable to surgical or percutaneous revascularization who were discussed in a heart team. The risk factors identified from RCT are not necessarily the same as those detected in real clinical practice when systematic screening is applied.

Fractional Flow Reserve–Guided Percutaneous Coronary Intervention (PCI) as Compared with Coronary Bypass Surgery in Patients with Three-Vessel Coronary Artery Disease

Fractional Flow Reserve–Guided Percutaneous Coronary Intervention (PCI) as Compared with Coronary Bypass Surgery in Patients with Three-Vessel Coronary Artery Disease

Nearly catastrophe coronary perforation: Is it second drug-eluting stent effective?

Coronary artery perforation (CAP) is an uncommon yet serious complication. Although severe perforations (Ellis III) have become more frequent, the overall mortality rate associated with perforations (7.5%) has decreased in recent years. Unfortunately, our medical facility cannot always access a cover stent. The aim of this case report was to demonstrate the effectiveness of using a second drug-eluting stent as an alternative and successful treatment approach in a CAP patient. This is the case of a 67-year-old female with stable angina pectoris Canadian Cardiovascular Society classification III (CCS III), three-vessel coronary artery disease (CAD), who declined CABG (Syntax score of 44) and had type II diabetes mellitus. The patient underwent elective percutaneous coronary intervention (PCI), and we identified diffuse stenosis in the proximal to distal portions of the left anterior descending artery (LAD) with extensive calcification. Furthermore, there was a chronic total occlusion (CTO) in obtuse marginal (OM) 2, as well as critical stenosis in OM3, 80% stenosis in the proximal part of right coronary artery (RCA), 90% stenosis in the middle of the RCA, 90–95% in the distal RCA, and diffuse stenosis ranging from 70–80% in the distal posterolateral. During the procedure to alleviate the stenosis in the left circumflex artery (LCx), we encountered a coronary perforation classified as Ellis type III while using a 2.5/20 mm NC balloon inflated to 12 atm for 12 seconds. In response, we performed stent placement from the proximal LCx to OM2 using the Xience Xpedition drug-eluting stent (DES) measuring 2.5/28 mm. Subsequently, we conducted extended balloon inflation (intermittent) for five minutes. Despite these efforts, the coronary perforation, still classified as Ellis type III, persisted. We decided to employ intrastent stenting (a second DES strategy) with the Coroflex Isar DES measuring 2.5/28 mm, followed by prolonged balloon inflation. The outcome revealed no remaining perforation, Thrombolysis in Myocardial Infarction (TIMI) III flow, and no complications such as pericardial effusion after 48 hours of monitoring. The implantation of a second DES proved to be a practical approach for managing a significant CAP.

Endarterectomy may be an effective additional treatment for three diffuse coronary artery disease complicated with diabetes.

In order to evaluate the clinical efficacy of coronary endarterectomy (CE) and coronary artery bypass grafting (CABG) in patients with diabetes complicated with three diffuse coronary artery stenosis. A retrospective analysis was conducted on 460 patients with diabetes mellitus and diffuse three-vessel coronary artery disease who underwent CABG in our department from September 2015 to December 2021. The patients were divided into two groups according to whether they underwent CE: the simple CABG group (group A, n = 254) and the CABG combined CE group (group B, n = 206). The perioperative outcomes, recurrent angina pectoris during 1-year follow-up, and the patency rate of the grafted vessel in coronary CT angiography were compared between the two groups. There was no significant difference in the 30days mortality rate between the two groups (2.3% vs 2.4%, p < 0.05). Group A had a shorter operation time [(3.55 ± 0.59) h versus (4.35 ± 0.65) h], less bypass grafts [(2.72 ± 0.83) versus (3.65 ± 0.72) vessels/case], a lower incidence of perioperative myocardial infarction (7.1% vs 12.6%), and a lower number of patent graft vessels at 1-year follow-up [(2.15 ± 0.42) versus (2.88 ± 0.68) vessels/case] compared with group B (all p < 0.05). Group A had a higher incidence of recurrent angina during follow-up (14.49% vs 6.47%) (p < 0.05). Although there was no significant difference in the incidence of MACCE events between the two groups, the probability of revascularization was higher in group A. Compared with single CABG, combined CE in patients with diabetes mellitus and diffuse three-vessel coronary artery disease can achieve more complete revascularization, reduce the recurrence of angina pectoris and the needing of postoperative revascularization, but the incidence of perioperative myocardial infarction is higher.

Current spectrum and outcomes of infarct-related cardiogenic shock: insights from the CULPRIT-SHOCK registry and randomized controlled trial.

We analysed consecutive patients with acute myocardial infarction complicated by cardiogenic shock (CS) who were enrolled into the CULPRIT-SHOCK randomized controlled trial (RCT) and those with exclusion criteria who were included into the accompanying registry. In total, 1075 patients with infarct-related CS were screened for CULPRIT-SHOCK in 83 specialized centres in Europe; 369 of them had exclusion criteria for the RCT and were enrolled into the registry. Patients were followed over 1 year. The mean age was 68 years and 260 (25%) were women. 13.5%, 30.9%, and 55.6% had one-vessel, two-vessel, and three-vessel coronary artery disease (CAD), respectively. Significant left main (LM) coronary artery stenosis was present in 8.0%. 54.2% of the patients had cardiac arrest before admission. Thrombolysis in myocardial infarction (TIMI) 3 patency of the infarct vessel after percutaneous coronary intervention was achieved in 83.6% of all patients. Mechanical circulatory support was applied in one-third of patients. Total mortality after 30 days and 1 year was 47.6% and 52.9%. Mortality after 1 year was highest in patients with LM coronary artery stenosis (63.5%), followed by three-vessel (56.6%), two-vessel (49.8%), and one-vessel CAD (38.6%), respectively. Mechanical complications were rare (21/1008; 2.1%) but associated with a high mortality of 66.7% after 1 year. In specialized centres in Europe, short- and long-term mortality of patients with infarct-related CS treated with an invasive strategy is still high and mainly depends on the extent of CAD. Therefore, there is still a need for improvement of care to improve the prognosis of infarct-related CS.

Characteristics of Patients With Acute Coronary Syndrome and Normal Electrocardiogram.

Patients with acute coronary syndrome (ACS) and normal electrocardiogram (ECG) may have an increased risk of late diagnosis and complications of the disease. To study the demographic, angiographic and echocardiographic characteristics of patients hospitalized for ACS in whom the ECG was normal on admission to the hospital. This retrospective study included patients who were hospitalized for ACS without ST-elevation between 2015 and 2023 and who had coronary artery disease (CAD) confirmed by coronary angiography. By further inspection of the electronic databases, patients with ACS who had a normal ECG on admission were filtered out and analyzed separately. Of the total 3137 patients with suspected ACS without ST-elevation, 129 patients (4.1%) were diagnosed as having ACS with a normal ECG. In three patients a non-atherosclerotic cause for the ACS was found. A significantly higher proportion of patients had single-vessel (54.3%) compared to two-vessel (29.5%) and three-vessel (14%) CAD. In addition to a normal ECG, 5.7% of patients with single-vessel CAD and 3.5% of patients with multi-vessel CAD had normal troponin levels and normal regional LV systolic function on echocardiography. Less than 5% of hospitalized patients with ACS without ST-elevation had a normal ECG on admission. The majority of these patients have single-vessel CAD. In about 5% of patients with single-vessel CAD, neither elevated troponin levels nor LV asynergy are detected.

Effects of peripheral artery disease on long-term outcomes after percutaneous coronary intervention versus coronary artery bypass grafting in patients with severe coronary artery disease

BackgroundThere is a scarcity of data evaluating the effect of peripheral artery disease (PAD) on long-term mortality after percutaneous coronary intervention (PCI) relative to coronary artery bypass grafting (CABG) in patients with severe coronary artery disease in real-world practice. MethodsAmong 14,867 consecutive patients who underwent their first coronary revascularization with PCI or isolated CABG between 2011 and 2013 in the CREDO-Kyoto PCI/CABG registry Cohort-3, the current study population consisted of 3380 patients with three-vessel coronary artery disease or left main coronary artery disease. Long-term clinical outcomes were compared between PCI and CABG stratified by the presence or absence of PAD. Median clinical follow-up was 5.9 (IQR: 5.1–6.8) years. ResultsThere were 461 patients with PAD (PCI: N = 307, CABG: N = 154), and 2919 patients without PAD (PCI: N = 1823, CABG: N = 1096). The cumulative 5-year mortality after coronary revascularization was 31.2 % in patients with PAD and 16.2 % in those without PAD (p < 0.0001). There was a higher risk of PCI relative to CABG for all-cause death in patients with and without PAD (adjusted HR, 1.59; 95%CI, 0.99–2.53; p = 0.054, and HR, 1.25; 95%CI, 1.01–1.56; p = 0.04) without interaction (p interaction p = 0.48); Nevertheless, there was no excess risk of PCI relative to CABG for cardiovascular death regardless of PAD. ConclusionsThe long-term mortality after coronary revascularization was significantly higher in severe CAD patients with PAD than those without PAD. There was a higher mortality risk of PCI relative to CABG in patients with and without PAD without interaction, which was mainly driven by excess non-cardiovascular deaths.

Off-pump vs. on-pump bypass surgery grafting in diabetic patients with three-vessel disease: a propensity score matching study

BackgroundControversy exists regarding the advantages and risks of off-pump vs. on-pump coronary artery bypass grafting (CABG) for patients with diabetes. We therefore compare the early clinical outcomes of off-pump vs. on-pump procedures for diabetic patients with three-vessel disease.Materials and methodsWe conducted a retrospective analysis of clinical data obtained from 548 diabetic patients with three-vessel coronary artery disease who underwent isolated CABG between January 2016 and June 2020. To adjust the differences of baseline characteristics between the off-pump CABG (OPCAB) and on-pump CABG (ONCAB) groups, propensity score matching (PSM) was used. Following 1:1 matching, we selected 187 pairs of patients for further comparison of outcomes within the first 30 days after surgery.ResultsThe preoperative characteristics of the patients between the two groups were clinically comparable after PSM. The OPCAB group exhibited a significantly higher incidence of incomplete revascularization (27.3% vs. 14.4%; P = 0.002) compared with the ONCAB group. No differences were seen in mortality within 30 days between the matched groups (1.1% vs. 3.7%; P = 0.174). Notably, the OPCAB group had a lower risk of respiratory failure or infection (2.1% vs. 7.0%; P = 0.025), less postoperative stroke (1.1% vs. 4.8%; P = 0.032), and reduced postoperative ventilator assistance time (35.8 ± 33.7 vs. 50.9 ± 64.8; P = 0.005).ConclusionOPCAB in diabetic patients with three-vessel disease is a safe procedure with reduced early stroke and respiratory complications and similar mortality rate, myocardial infarction, and renal failure requiring dialysis to conventional on-pump revascularization.

Radical mediastinal lipectomy for tamponade-like cardiac physiology

BackgroundRe-opening the chest is an unwanted and potentially morbid complication after open heart surgery, most commonly required for refractory bleeding or tamponade. In this report, we present a unique case of a postoperative coronary artery bypass patient, demonstrating clinical features of cardiac tamponade of the right atrium and ventricle with inconclusive findings on imaging.Case presentationA 62 year-old male presented to hospital with exertional angina and a coronary angiogram found severe three-vessel coronary artery disease with preserved left ventricular function. He underwent an uncomplicated triple coronary artery bypass surgery. Over the following hours in the cardiac intensive care unit, the patient had a climbing serum lactate level and increasing vasopressor requirements. On investigations, there was evidence of compression of the right heart. The patient was taken back to the operating room where very little clot or bleeding was identified, rather there was significant amounts of mediastinal fat surrounding the heart which was subsequently resected with wide margins. The patient had complete resolution of their symptoms and an uncomplicated postoperative course thereafter.ConclusionsTo our knowledge, this case is the first reported occurrence of cardiac constriction from excessive mediastinal fat after open heart surgery. Identifying patients at high-risk for excessive pericardial fat, as well as considering alternative modalities of imaging appear to be the main stay in diagnosis at this point. Current treatment is a mediastinal lipectomy with wide margins, avoiding injury to surrounding structures such as the phrenic nerve and innominate vein. Future study might consider the value of prophylactic mediastinal lipectomy at time of surgery, and methods to improve detection with current and future imaging modalities.

The effect of LDL-C/HDL-C ratio on severity of coronary artery disease and 2-year long-term prognosis in patients with premature coronary heart disease---a multicenter, observational results

Abstract Background Low density lipoprotein cholesterol (LDL-C) level is a strong predictor of premature coronary heart disease（CHD）and a risk factor for poor prognosis. While high density lipoprotein cholesterol (HDL-C) is a protective factors for atherosclerosis. However, the relationship between the LDL/HDL ratio and the severity of coronary artery disease and the prognosis of patients with premature CHD is still unclear. Purpose To explore the effect of LDL-C/HDL-C ratio on the severity of coronary artery disease and 2-yeat long-term prognosis in patients with premature CHD. Methods This prospective, multicenter, observational cohort study is from the PROMISE study. 18701 patients with CHD were selected from January 2015 to May 2019. 3861 patients with premature CHD were enrolled in the current study. According to the median of LDL-C/HDL-C ratio (2.4), Patients were divided into two groups: low LDL-C/HDL-C group (LDL-C/HDL-C≤2.4, n=1867) and high LDL-C/HDL-C group (LDL-C/HDL-C&amp;gt;2.4, n=1994). Results Compared with the low LDL-C/HDL-C ratio group, the high LDL-C/HDL-C ratio group was younger. The levels of total cholesterol, triglyceride and LDL-C in the high LDL-C/HDL-C group were significantly higher than those in the low LDL-C/HDL-C group (3.67 ± 0.85 vs 4.91 ± 1.15; 1.66 ± 1.49 vs 2.22 ± 1.45; 2.0 ± 0.57 vs 3.22 ± 0.95, respectively, all p&amp;lt;0.001), and the HDL-C level was lower (1.17 ± 0.29 vs 0.96 ± 0.21, p&amp;lt;0.001). The number of target lesions, the number of coronary artery lesions, the preoperative SNYTAX score and the proportion of three-vessel coronary artery disease in the high LDL-C/HDL-C group were significantly higher than those in the low LDL-C/HDL-C group (0.97 ± 0.80 vs 1.04 ± 0.74, p=0.002; 1.85 ± 0.84 vs 2.04 ± 0.84, p&amp;lt;0.001; 11.70 ± 8.05 vs 13.81 ± 8.87, p&amp;lt;0.001; 27.4% vs 36.2%, respectively, p&amp;lt;0.001). Correlation analysis showed a significant positive correlation between LDL-C/HDL-C ratio and preoperative SYNTAX score, the number of coronary artery lesions, the number of target lesions and whether it was a three-vessel coronary artery disease (all p&amp;lt;0.05). The 2-year follow-up results showed that the incidence of MACCE in the high LDL-C/HDL-C group was significantly higher than low LDL-C/HDL-C group (6.9% vs 9.1%, p=0.011). COX multivariate regression analysis showed LDL-C/HDL-C ratio has no relationship with 2-year adverse events with patients with premature CHD. Conclusion (1) The patients with LDL-C/HDL-C ratio higher than 2.4 may suffer from atherosclerotic cardiovascular disease earlier; (2) High LDL-C/HDL-C ratio has significantly positive correlation with the severity of coronary artery disease in patients with premature CHD. The incidence of MACCE of patients with high LDL-C/HDL-C ratio was significantly higher in 2 years follow-up; (3) LDL-C/HDL-C ratio may be a better indicator for evaluating the severity of coronary artery disease and long-term prognosis in patients with premature CHD.Comparison of coronary artery disease2-year outcomes

Can machine learning improve risk prediction and individualise decision making between percutaneous and surgical revascularisation?

Abstract Background/Introduction In patients with three-vessel coronary artery disease (CAD) and/or left main (LM) CAD, individual risk prediction plays a key role in deciding between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). Purpose The aim of this study was to assess whether these individualised revascularization decisions can be improved by applying machine learning (ML) algorithms and integrating clinical, biological, and anatomical factors. Methods The present study consisted of patients enrolled in the SYNTAX study, which is a randomized trial comparing PCI and CABG in patients with complex coronary artery disease. ML algorithms were used to develop a prognostic index for 5-year death, which was combined, in the second stage, with assigned treatment (PCI or CABG), and pre-specified effect-modifiers: disease type (3-vessel or LMCAD) and anatomical SYNTAX score. The model’s discriminative ability to predict the risk of 5-year death and treatment benefit between PCI and CABG was cross-validated in the SYNTAX trial (n=1800 patients) and externally validated in the CREDO-KYOTO registry (n=7362), and then compared to the original SYNTAX score II 2020 (SS2020). Results The gradient boosting ML model identified the top 10 prognostic factors at the time of decision making as: age, creatinine clearance, left ventricular ejection fraction, peripheral vascular disease, C-reactive protein, hemoglobin, HbA1c, glucose, systolic and diastolic pressure. The ML model performed best for predicting 5-year all-cause death with C-indexes of 0.78 (95% CI 0.75-0.81) in cross-validation and 0.77 (95% CI 0.76-0.79) in external validation. The ML model discriminated 5-year mortality better than the SS2020 in the external validation cohort (vs C-index 0.72 for SS2020, p &amp;lt;0.001) and identified heterogeneity in the treatment benefit of CABG versus PCI (Figure). Conclusions An ML-based approach for identifying individuals who benefit from CABG or PCI is feasible and effective. Implementation of this model in health care systems—trained to collect large numbers of parameters—may harmonize decision making.Figure

Impact of repeat revascularization within 5 years on 10-year mortality after percutaneous or surgical revascularization

Abstract Background The SYNTAX trial demonstrated negative impact of repeat revascularization (RR) on 5-year outcomes following percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in patients with three-vessel (3VD) and/or left main coronary artery disease (LMCAD). We aimed to investigate the impact of RR within 5 years, on 10-year mortality in patients with 3VD and/or LMCAD after PCI or CABG. Methods The SYNTAXES study evaluated the vital status out to 10 years of patients with 3VD and/or LMCAD. Patients were stratified by RR within 5 years and randomized treatment. The association between RR within 5 years and 10-year mortality was assessed. Results A total of 330 (220 RR after initial PCI and 110 RR after initial CABG) out of 1800 patients (18.3%) underwent RR within 5 years from initial revascularization. RR occurred more frequently after initial PCI than after initial CABG (25.9% vs 13.7%, p&amp;lt;0.001). Overall, 10-year mortality was comparable between patients undergoing RR and those not (28.2% vs 26.1%, adjusted HR: 1.17, 95% CI: 0.93-1.48, p=0.187). Among patients requiring RR, those who underwent PCI as initial revascularization had a higher risk of 10-year mortality compared to initial CABG (33.5% vs 17.6%, adjusted HR: 2.09, 95% CI: 1.21-3.61, p=0.008). Conclusions In the SYNTAXES study, RR within 5 years had no impact on 10-year all-cause death in the population overall. Among patients requiring any repeat procedures, 10-year mortality was higher after initial treatment with PCI than after CABG. These exploratory findings should be investigated with larger populations in future studies.Graphic Abstract

Conventional cardiovascular risk factors in young individuals with three-vessel coronary artery disease experiencing sudden cardiac death

Abstract Background Coronary artery disease (CAD) is a major cause of sudden cardiac death (SCD) in young victims under 50 years of age. Despite the young age, highly advanced CAD is a common finding at autopsies. Purpose We aimed to determine the prevalence of conventional cardiovascular risk factors in ischemic SCD victims under the age of 50 years with a three-vessel CAD detected at autopsy. Methods The study population was derived from the Fingesture study, consisting of consecutive victims of SCD in Northern Finland between years 1998-2017 (n=5,869). All victims underwent medico-legal autopsy with histological examinations, and toxicology investigations was performed if necessary. Pre-mortem clinical history was obtained from available medical records and medication, questionnaires to closest family members and police reports about the conditions of the death. Results In the Fingesture study, a total of 266 SCDs caused by CAD were observed in victims under 50 years of age. Three-vessel disease was detected in 118 victims (44%). The victims with three-vessel disease had more commonly a history of diabetes (26% vs. 14%, p=0.017) compared with victims with fewer major coronary arteries affected. No statistically significant difference was detected in the prevalence of known dyslipidemia (16% vs. 9%, p=0.134), hypertension (29% vs. 19%, p=0.103), male gender (88% vs. 91%, p=0.552), family history of SCD (33% vs. 36%, p=0.841), smoking (81% vs. 72%, p=0.371), or mean age (45 years vs. 44 years, p=0.120). Conclusions The history of diabetes was the only conventional risk factor associated with three-vessel disease in young individuals who experienced SCD determined to be caused by CAD. Along with previous studies, these results highlight the role of diabetes in the development of CAD and adverse outcomes in young people.

Interim prediction of two-year all-cause mortality in patients with de novo multivessel coronary artery disease undergoing intended multivessel PCI

Abstract Background/Introduction coronary revascularization in patients with de novo three-vessel coronary artery disease (3VD) without Left Main disease can be performed by either PCI or CABG after objective Heart Team consensus. In the ongoing Multivessel TALENT trial (NCT04390672)1, the intended multivessel PCI is performed using DES with ultrathin struts and biodegradable polymers under the guidance of quantitative flow ratio (QFR) and intracoronary imaging with IVUS or OCT. Purpose The Logistic Clinical SYNTAX score (logSYNTAX) to predict 2-year all-cause mortality after PCI was developed in 15,883 patients treated in the GLOBAL LEADERS trial and externally validated in 10,100 patients. This study aims to predict 2-year all-cause mortality after intended multivessel PCI in the currently enrolled trial population to identify patients who should be considered high risk. Methods and results We performed an interim analysis in the first consecutive 781 patients of the ongoing Multivessel TALENT Trial aimed to enrol 1550 patients. Thirteen clinical predictors are used in the logSYNTAX score: SYNTAX I-score, presence of 3VD and/or LM disease, age, creatinine clearance in mL/min, LVEF, BMI, serum hemoglobin level(g/dL), the White Blood Cell Count (WBC, in 109 cells/L) and the presence of COPD, PVD, diabetes mellitus, current smoking and/or a history of stroke. LVEF and BMI have additional squared terms to adjust for non-linear associations with all-cause mortality. The predicted mortality was estimated using the survival function developed in the GLOBAL LEADERS trial. We considered patients high-risk if the estimated risk was above the 3rd quartile. In 563 patients, all thirteen predictors necessary for 2-year mortality prediction were available. Median 2-year all-cause mortality of 1.9% (1.09-3.82; IQR2.73). 142 patients (25%) with an increased estimated 2-year mortality risk (&amp;gt;3.8%) due to higher prevalence of the aforementioned predictors; higher median age [75 (9.0) vs. 67 (12.0), p &amp;lt;0.001], a lower median LVEF [55% (20) vs. 94% (35.5), p &amp;lt;0.001] and a higher median SYNTAX score [26.0 (13.5) vs. 20.0(11.0), p &amp;lt;0.001]. A complete overview of predictors can be found in table 1. High age, an impaired LVEF, and an increased anatomical SYNTAX-I score were the main contributors to high mortality in this study cohort (see figure 1). Conclusion(s) In 563 patients, the median predicted 2-year all-cause mortality was 1.9%. Nevertheless, a non-neglectable amount of patients were estimated to be at increased risk for all-cause 2-year mortality. Accurate prediction by knowledge of aforementioned predictors is pivotal for appropriate mortality risk prediction to segregate high-risk patients with 3VD for individual decision-making on coronary revascularization, even if surgical revascularization is no option, and guide optimal treatment with use of intravascular imaging to achieve an optimal PCI result.Table 1Figure 1

Abstract 14555: Early Predictors That Identify Patients With Significant Left Main and Three-Vessel Coronary Artery Disease in Non-ST Elevation Acute Coronary Syndrome: Validating the MADISON Score

Introduction: In patients with non-ST elevation acute coronary syndrome (NSTE-ACS), identifying those with a high probability of having high-risk disease such as left main (LM) or three-vessel disease (3VD) could influence decisions to preload with P2Y12 inhibitors and timing of coronary angiography. The MADISON score was developed to predict LM/3VD on coronary angiography in patients with NSTE-ACS. In this study, we validated the MADISON score using data from an external cohort. Methods: The MADISON score was first developed using a retrospective cohort of 1700 patients presenting with NSTE-ACS at the University of Wisconsin-Madison (UW) (2011-2018). Those with prior CABG, cardiac arrest/shock, and bleeding on initial presentation were excluded from the analysis. Multivariable estimates were employed and model performance was assessed using receiver operating characteristic curve analysis. The score was then validated using a retrospective Houston Methodist Hospital (HMH) cohort of 622 patients (2019-2022). Results: The MADISON score variables and their adjusted odds ratios (95% CI) are presented in Figure 1A. Risk categories and corresponding LM/3VD probabilities are presented in Figure 1B. In the UW cohort, the area under the curve (AUC) was 0.68 (0.65-0.71) (Figure 2A). Interestingly, the AUC was also 0.68 (0.64-0.72) in the HMH validation cohort (Figure 2B). Conclusions: The MADISON score performed well and similarly between 2 large, independent cohorts in predicting patients most likely to have LM/3VD. The MADISON score is a simple and practical tool to guide decisions. Prospective validation of the score is planned to evaluate its impact on clinical outcomes.

Abstract 16155: Achieving Coronary Artery Disease Regression: A Triumph of Lifestyle Modification and Optimal Medical Therapy

Background: Coronary artery disease (CAD) is the leading cause of death worldwide. Early recognition of risk factors and targeting them using lifestyle modifications and pharmacological measures is vital for secondary prevention. This case demonstrates the effectiveness of comprehensive management in achieving marked regression of CAD. Case presentation: A 45-year-old female with a history of type II diabetes mellitus, hypertension, and hyperlipidemia with markedly elevated lipoprotein (A) of 233 nmol/L presented with chronic coronary syndrome (CCS). She had a strong family history of CAD and denied smoking, alcohol use, and recreational drug use. Transthoracic echocardiography revealed preserved left ventricular systolic function with an ejection fraction of 50%, regional wall motion abnormalities in the form of inferior wall hypokinesia, and mild mitral regurgitation. She underwent coronary angiography (CA) which revealed significant three-vessel CAD. Figure 1 Decision making: She underwent successful percutaneous coronary intervention (PCI) to the RCA and PDA with two overlapping drug-eluted stents and plain balloon angioplasty to the PL branch. The patient adhered to strict lifestyle modification and was prescribed optimal anti-ischemic and anti-diabetic medications. She lost 22 lbs over two years, her LDL went down from 178 to 14 mg/dl and A1c from 12.2 to 6.8. During follow up, she started to complain of dyspnea on exertion for two weeks. Despite the marked laboratory improvement and despite she was found to be anemic at that time which can explain her symptoms, decision was to proceed to CA given her high pretest probability. A repeat CA showed marked regression in her CAD. Figure 2 Conclusion: Regression of coronary artery disease is a reality giving hope for not just stopping disease progression but achieving reduction in plaque size with optimal medical therapy, where pharmacological measures and lifestyle modifications work synergistically.

Abstract 17670: Double Trouble: Exploring the Rare Coexistence of Right and Left Atrial Thrombus After Left Atrial Appendage Ligation and Maze Procedure

Introduction: Left atrial appendage (LAA) harbors around 90% of thrombus in patients with Atrial Fibrillation(AF) related strokes. Incomplete surgical ligation and LAA stump are independent risk factors for stroke and thromboembolism in AF patients. To our knowledge, we report the first case of biatrial thrombus occurring within 1 week of surgery. Case Presentation: A 76-year-old man with Paroxysmal AF and three-vessel coronary artery disease presented with 3-week exertional and resting shortness of breath and chest pain. Troponins were negative, and EKG revealed AF. Cardiothoracic surgery planned coronary bypass, MAZE procedure, and LAA clipping. Intra-operative transoesophageal echocardiogram(TEE) showed ejection fraction of 35% without LAA clot. Post-operatively, despite anticoagulation(AC) and beta blocker therapy, AF recurred within a week. Subsequent TEE prior to anticipated cardioversion(CV) revealed thrombus on the superior vena cava border of right atrium, anterolateral wall of left atrium and near the mitral valve annulus. CV was deferred, and he was sent to rehab with AC. We hypothesize that the thrombus may be attributed to a stunned atrium caused by ischemic myocardial injury. Our case underscores the need for heightened suspicion of thrombus in individual cases. Discussion: Left atrial appendage occlusion (LAAO) was implemented as stroke prophylaxis strategy in AF during surgical interventions like maze and coronary bypass. while the European Society of Cardiology advises continuing AC after LAAO, studies suggest discontinuing AC in high-risk bleeding patients after successful surgical AF ablation and LAAO if sinus rhythm is maintained for ≥3 months. LAAOS III study shows economic benefit of concomitant surgical LAAO during cardiac surgery in AF patients with CHA2DS2-VASc score ≥2 for stroke prevention. When used alongside AC, it offers incremental benefits. Safety of discontinuing AC after LAAO requires further investigation.

Clinical utility of polygenic scores for cardiometabolic disease in Arabs

Arabs account for 5% of the world population and have a high burden of cardiometabolic disease, yet clinical utility of polygenic risk prediction in Arabs remains understudied. Among 5399 Arab patients, we optimize polygenic scores for 10 cardiometabolic traits, achieving a performance that is better than published scores and on par with performance in European-ancestry individuals. Odds ratio per standard deviation (OR per SD) for a type 2 diabetes score was 1.83 (95% CI 1.74–1.92), and each SD of body mass index (BMI) score was associated with 1.18 kg/m2 difference in BMI. Polygenic scores associated with disease independent of conventional risk factors, and also associated with disease severity—OR per SD for coronary artery disease (CAD) was 1.78 (95% CI 1.66–1.90) for three-vessel CAD and 1.41 (95% CI 1.29–1.53) for one-vessel CAD. We propose a pragmatic framework leveraging public data as one way to advance equitable clinical implementation of polygenic scores in non-European populations.

BPIFB4 and its longevity-associated haplotype protect from cardiac ischemia in humans and mice

Long-living individuals (LLIs) escape age-related cardiovascular complications until the very last stage of life. Previous studies have shown that a Longevity-Associated Variant (LAV) of the BPI Fold Containing Family B Member 4 (BPIFB4) gene correlates with an extraordinarily prolonged life span. Moreover, delivery of the LAV-BPIFB4 gene exerted therapeutic action in murine models of atherosclerosis, limb ischemia, diabetic cardiomyopathy, and aging. We hypothesize that downregulation of BPIFB4 expression marks the severity of coronary artery disease (CAD) in human subjects, and supplementation of the LAV-BPIFB4 protects the heart from ischemia. In an elderly cohort with acute myocardial infarction (MI), patients with three-vessel CAD were characterized by lower levels of the natural logarithm (Ln) of peripheral blood BPIFB4 (p = 0.0077). The inverse association between Ln BPIFB4 and three-vessel CAD was confirmed by logistic regression adjusting for confounders (Odds Ratio = 0.81, p = 0.0054). Moreover, in infarcted mice, a single administration of LAV-BPIFB4 rescued cardiac function and vascularization. In vitro studies showed that LAV-BPIFB4 protein supplementation exerted chronotropic and inotropic actions on induced pluripotent stem cell (iPSC)-derived cardiomyocytes. In addition, LAV-BPIFB4 inhibited the pro-fibrotic phenotype in human cardiac fibroblasts. These findings provide a strong rationale and proof of concept evidence for treating CAD with the longevity BPIFB4 gene/protein.

Acute coronary syndromes in chronic hemodialysis patients: a series of 34 cases (case series).

This single-centered retrospective descriptive study included 34 hemodialysis patients hospitalized in the cardiovascular ICU. The mean age of patients in our study was 64.4±11.3 years. The main cardiovascular risk factor found in our study was age, with a prevalence of 76.50%, followed by hypertension, with a prevalence of 67.60%. Diabetes was present in 55.90% of patients. The authors also found that 17.90% of patients were obese, and 29.40% had abdominal obesity. The main cause of renal disease in our study was diabetic nephropathy (52.90% of cases), followed by hypertensive nephropathy (23.50% of cases). ST segment elevation myocardial infarction was found in 14.70% of cases, and non-ST-segment elevation myocardial infarction in 85.30% of cases. Coronary angiography was performed in 76.40% of patients. Single-vessel coronary artery disease (CAD) was found in 20%, two-vessel CAD in 50%, and three-vessel CAD in 30% of the cases. Coronary artery calcifications were observed in 21.42% of cases. 38.23% had an angioplasty, and 20.58% were referred for a coronary artery bypass graft. Despite the high mortality rate after acute coronary syndrome, hemodialysis patients are less likely to undergo diagnostic angiography or coronary revascularization. Patients on hemodialysis tend to have multiple, diffuse, calcified CAD.