Cerebrovascular Events Research Articles

Stroke is Not an Accident: An Integrative Review on the Use of the Term 'Cerebrovascular Accident'.

Cerebrovascular accident (CVA) is an outdated term for describing stroke as it implies stroke is an accident. We conducted an integrative review to determine use of CVA in terms of 1) frequency in major medical journals over time; 2) associated publication characteristics (e.g., number of authors, senior author country, topic); and 3) frequency in medical records. We searched Google Scholar for publications in leading neurology and vascular journals (Quartile 1) across two 5-year periods (1998-2002 and 2018-2022) using the terms "cerebrovascular accident" or "CVA." Two reviewers independently reviewed full-text publications and recorded the frequency of CVA use. Rates of use (per 1,000 articles/year) were calculated for each journal and time period. Associations of publication characteristics with CVA use were determined using multivariable logistic regression models. In addition, admission and discharge forms in the Auckland Regional Community Stroke Study (ARCOS V) were audited for frequency of use of the term CVA. Of the 1,643 publications retrieved, 1,539 were reviewed in full. Of these, CVA was used ≥1 time in 676 publications, and ≥2 times in 276 publications (129 in 1998-2002; 147 in 2018-2022). The terms CVA and stroke both appeared in 57% of publications where CVA was used ≥2 times in 1998-2002, compared to 65% in 2018-2022. Majority of publications were on the topic of stroke (22% in 1998-2002; 20% in 2018-2022). There were no associations between publication characteristics and the use of CVA. The highest rate of CVA use in 2018-2022 was in Circulation, and increased over time from 1.3 uses per 1,000 publications in 1998-2002 to 1.8 uses per 1,000 publications in 2018-2022. The largest reduction the use of CVA was in Neuroepidemiology (2.0 uses per 1,000 publications in 1998-2002 to 0 uses in 2018-2022). The term CVA was identified in 0.2% of stroke admission and discharge forms audited (17/7808). We found evidence of changes in the use of CVA in the scientific literature over the past two decades. Editors, authors and clinicians should avoid the use of the term CVA as it perpetuates the use of a non-specific, non-diagnostic, and non-scientific term.

Impact of COVID-19 on cardiology and neurology services in a peripheral hospital in Northern Israel

Abstract Background The indirect impact of COVID-19 pandemic on clinical services remains incompletely described in secondary care hospitals outside major urban centers. We compared clinical outcomes before and during the pandemic in a disrupted service (Neurology) and a non-disrupted one (Cardiology) in a peripheral hospital in Israel, using Cerebral Vascular Accident (CVA) and ST-elevation myocardial infarction (STEMI) as clinical indicators, respectively. Methods We compared demographics, treatment and outcomes from CVA and STEMI patients who attended Ziv Medical Center, Israel, during the pandemic (15/3/2020-15/4/2022) and before (1/1/2018-14/3/2020), Using chi-square, t-test and Wilcoxon-Mann-Whitney tests. Results 1029 CVA and 497 STEMI patients were included. Those who arrived during the pandemic were demographically comparable to those arriving before. Compared to pre-pandemic, intra-pandemic median time for CVA patients from arrival to imaging was longer (23 vs. 19 minutes, p = 0.001). However, timing from arrival to tissue Plasminogen Activator administration was similar (49 vs. 45 min, p = 0.61). The likelihood of transfer to another hospital was higher (20.3% vs. 14.4% p = 0.01) and median length of stay (LOS) was shorter (3 vs. 4 days, p < 0.05). Among STEMI patients, median time from arrival to percutaneous coronary intervention during the pandemic was shorter than before (45 vs. 50 minutes p = 0.02) and median ejection fraction at discharge was higher (50% vs. 45% p = 0.02). Mean LOS was shorter (3.86 vs. 4.48 p = 0.01), and unplanned re-admission to the ED was less frequent (7.8% vs. 14.6% p = 0.01). No significant changes in mortality were observed. Conclusions Our data shows no major negative impact of the COVID-19 pandemic on CVA and STEMI outcomes, and possibly improved care in the less disrupted department. Follow-up qualitative studies with neurology and cardiology staff already in action to comprehend how quality of care was maintained during the crises. Key messages • In peripheral setting, COVID-19 hadn’t negatively impact Neurology or Cardiology acute clinical outcomes. • The consequences of maintaining clinical performance when working under adverse conditions requires further research.

Association of cardiac amyloidosis with periprocedural complications in patients with severe aortic stenosis undergoing transcatheter aortic valve replacement: a systematic review and meta-analysis

Abstract Introduction Cardiac amyloidosis (CA) has been frequently observed in patients with aortic stenosis (AS). While transcatheter aortic valve replacement (TAVR) may be an option, the association of CA with risk of periprocedural complications has not been well evaluated. Purpose This study aimed to evaluate the association of CA with periprocedural complications after TAVR in patients with severe AS. Methods A literature search was performed for studies evaluating patients with severe AS undergoing AVR, comparing periprocedural safety endpoints for patients with and without CA. The primary endpoints were vascular complications and bradyarrhythmias post-TAVR requiring permanent pacemaker (PPM) implantation. Secondary endpoints included periprocedural acute kidney injury (AKI), cerebrovascular accidents (CVA), and major bleeding events. Endpoints were defined using the Valve Academic Research Consortium-2 criteria. The search was not restricted to time or publication status. Results 6 studies with 1,138 patients with severe AS (150 with CA, 988 without CA) met inclusion criteria. Mean age was 82 years, 52.4% were men, all except 1 study assessed only patients with ATTR CA. Echocardiographic mean aortic valve parameters included valve area of 0.718 cm2, mean gradient of 40.8, and peak velocity of 4.13 m/s. The mean left ventricular ejection fraction was 55.2%. The presence of CA was not associated with an increased risk of periprocedural vascular complications (OR 0.69, 95% CI 0.25-1.88; p=0.47). While a trend toward higher risk of periprocedural PPM implantation was observed in patients with CA, this finding did not reach statistical significance (OR 1.51; 95% CI 0.77-2.94; p=0.23). The presence of CA was not associated with increased risk of periprocedural AKI, CVA, or major bleeding (OR 1.3, 95% CI 0.32-5.3; p=0.72, OR 0.65, 95% CI 0.17-2.41; p=0.52; OR 0.55, 95% CI 0.16-1.87; p=0.34). Conclusion In the context of patients with severe AS undergoing TAVR, the presence of cardiac amyloidosis did not increase the risk of periprocedural complications, including vascular complications, AKI, CVA, or major bleeding. Although a trend toward a higher risk of bradyarrhythmias requiring PPM implantation was noted in patients with CA, further studies are warranted to confirm this observation. Overall, these findings contribute valuable insight into the safety profile of TAVR in the patients with CA.Figure 1Figure 2

The added value of deep learning to submaximal exercise electrocardiogram for the 10-year prediction of major adverse cardiovascular and cerebrovascular events

Abstract Background The added value of exercise ECG data to traditional risk factors in predicting cardiovascular events remains unclear. Deep learning of ECG signals has demonstrated state-of-the-art performance in detecting subtle abnormalities indicative of cardiovascular disease. We investigated whether deep learning analysis of exercise ECGs could improve the prediction of major cardiovascular and cerebrovascular events (MACCE) with respect to established risk models in a large population-based cohort. Purpose To assess the added value of submaximal exercise ECG measurements to established cardiovascular risk prediction models. Methods We obtained ECG recordings from 41,076 UK Biobank participants without cardiovascular disease (CVD) who underwent a submaximal exercise ECG test. We obtained ECG recordings from 41,076 UK Biobank participants without cardiovascular disease (CVD) who underwent a submaximal exercise ECG test. We created two deep neural network ECG risk scores: one derived from conventional ECG parameters, measured at rest, peak exercise and late-stage recovery, and another based on the complete ECG (Q-ECG). We assessed the added value of conventional ECG parameters and Q-ECG risk scores to the UK's current prediction algorithm (QRISK3). We estimate the association between ECG parameters and MACCE, using Cox Proportional hazard models, following adjustment for traditional risk factors. All models were internally validated via 5-fold cross-validation and 1000 bootstrap iterations. Predictive performance was evaluated using Harrel's C-index, Net Reclassification Index (NRI) and net benefit. Findings: Incident MACCE was reported in 4,082 (9.9%) individuals in the study population and 3,463(9.7%) individuals with valid ECG parameters over a median follow-up period of 12.5 years. We found combined conventional ECG and Q-ECG scores were independently associated with MACCE, following adjustment for multiple testing: adjusted hazard ratio [HZ] = 1.76 (95% CI:1.63-1.91); HZ = 1.14 (95% CI:1.10-1.18), respectively, per standard deviation increase. Both conventional ECG parameters and Q-ECG were predictive of MACCE, independent of clinical risk factors, C-index = 0.64 (95%CI 0.63-0.65); net benefit = 0.09(95% CI 0.07 - 0.11) and C-index = 0.56 (95% CI 0.55-0.57); net benefit = 0.07(95% CI 0.05 - 0.09). ECG measurement's modestly improved model discrimination over the bassline QRISK3 risk score when combined with QRISK3 risk factors for conventional markers and Q-ECG score, respectively; ΔC-index 0.03 (95% CI: 0.02 – 0.04) and ΔC-index 0.03 (95% CI: 0.02 – 0.03); However, we observed no significant improvements in classification at the current recommended threshold of 10%. Conclusion In individuals without a history of prior cardiovascular disease, ECG measures independently predict the risk of MACCE. When combined with QRISK3, neural-network-derived ECG risk scores marginally improve cardiovascular risk prediction over QRISK3.

Predicting atrial fibrillation within 7 years follow-up using machine learning models

Abstract Background The prevalence of atrial fibrillation (AF), the most common type of cardiac arrhythmia, has increased globally. AF is also the leading cardiac factor for several cardiovascular and cerebrovascular events. Early prediction and treatment of AF prevents major cardiovascular and cerebrovascular events. Purpose Our objective is to predict AF risk within 7-years follow-up using only twelve basic factors and applying machine learning (ML) models. Methods Data from the German epidemiological trial on ankle brachial index (getABI) were utilized in this work. GetABI includes 6,457 patients with mean age of 72.53 years. 3,985 individuals were assessed for AF of which 393 patients suffered from AF at 7-years follow-up. The feature selection was initially done manually, ending up in 45 features. The 10 best features were extracted from this dataset according to the SHAP (SHapley Additive exPlanations) values. The final features were body mass index, sensitive CRP, cholesterol, LDL-cholesterol, troponin I, NT-pro-BNP, glomerular filtration rate, ratio of triglycerides and HDL-cholesterol, gamma-GT, heart rate, including age and sex as major factors. The handling of missing values was achieved by SimpleImputer, estimating the mean values. XGBoost and Random Forest predicted AF. Logistic Regression was also used as a baseline model. The data were split into training and test set and ML models were applied for 100 iterative runs, extracting results with mean values. Results XGBoost was the most accurate model, predicting the AF with 71.19 % mean accuracy, 66.37 % mean sensitivity and 75.61 % mean specificity. Figure 1 depicts the performance of all models. Additionally, Receiver Operating Characteristic Curve (ROC) and Area Under Curve (AUC) for each model are presented in Figure 2. XGBoost also outperformed all the others models, achieving the highest mean AUC value, equal to 70.99 %. Contrariwise, logistic regression had the lowest overall performance. Conclusion ML models, specifically XGBoost, achieved accurate AF prediction in 3,985 individuals utilizing only twelve clinical-routine data.Evaluation results of each used model.ROC curve and AUC value of each model.

Recreational drugs use as prognostic factor of major adverse cardiovascular and cerebrovascular events in patients hospitalised for acute cardiovascular events

Abstract Background Among patients admitted to the intensive cardiac care unit (ICCU), systematic screening for recreational drugs evidenced a significant prevalence of recent use and was associated with a higher rate in-hospital outcomes. However, long-term cardiovascular consequences of recreational drug use remain uncertain. Purpose We aimed to evaluate the prognostic impact of recreational drugs use at 1-year follow-up to predict major adverse cardiovascular and cerebrovascular events (MACCE) in consecutive patients admitted to ICCUs for acute cardiovascular events from the Addiction in Intensive Cardiac Care Units (ADDICT-ICCU) study. Methods In this prospective multicentric study, all consecutive patients admitted to ICCUs over two weeks in April 2021 at 39 centres across France were included. Screening for recreational drugs use was performed by systematic urinary testing. One-year follow-up consisted of a clinical visit or direct contact with the patient and the referring cardiologist. The primary composite outcome was the occurrence of one of the combined MACCE defined as cardiovascular death, nonfatal myocardial infarction (MI) or stroke. Subgroup analysis was performed in patients hospitalised at baseline for acute coronary syndrome. Results Of the 1499 consecutive patients screened, 1392 (93%) patients (63±15 years, 70% males) had a complete 1-year follow-up. Among them, 157 (11%) had an initial positive test for recreational drug use (cannabis, opioids, cocaine, amphetamines, 3,4-methylenedioxymethamphetamine [MDMA]). After 1-year of follow, 94 (7%) patients experimented MACCE. Patients with positive testing exhibited a higher rate of MACCE than non-users (13% vs 6%, respectively, p=0.002). After adjustment for traditional prognosticators, recreational drug use was independently associated with the occurrence of MACCE (HR=2.99; 95% CI: 1.73-5.16, p<0.001). In the subgroup analysis of 713 patients hospitalised at baseline for acute coronary syndrome, 96 (14%) had a positive recreational drug test and 50 (7%) experienced MACCE. Using a multivariable Cox analysis in this population, recreational drug use was still independently associated with MACCE after adjustment for traditional prognosticators (HR=2.98; 95% CI: 1.43-6.21, p=0.004). Conclusions In a large cohort of consecutive patients admitted to ICCUs for acute cardiovascular events, the prevalence of recreational drug use was 11%. Recreational drug use was strongly associated with the occurrence of 1-year MACCE even after adjustment for traditional prognosticators.Central illustrationPrognostic impact of drug use

Exploring the effects of reduced alcohol consumption on major adverse cardiovascular and cerebrovascular events in chronic heavy drinkers: a nationwide population-based cohort study

Abstract Background/Introduction Chronic heavy alcohol consumption is a well-established risk factor for cardiovascular disease (CVD), and the potential cardiovascular benefits of mild to moderate alcohol consumption need validation, particularly in the context of behavioral change from heavy drinking. Currently, there is a lack of research examining the potential benefits of reduced alcohol consumption in chronic heavy drinkers, specifically in relation to different subtypes of CVD. We hypothesized that habitual changes in alcohol consumption among chronic heavy drinkers would have a long-term prognostic effect on future CVD outcomes. Purpose We investigated the association between reduced alcohol consumption and the risk of major adverse cardiovascular and cerebrovascular events (MACCE) in chronic heavy drinkers. Methods From the Korean National Health Insurance Service-Health Screening database, we included a cohort of chronic heavy drinkers who underwent serial health examinations over two consecutive time-periods (first period: 2005–2008; second period: 2009–2012). Heavy drinking was defined according to the National Institute on Alcohol Abuse and Alcoholism criteria as >56 g/day or >196 g/week for men, and >42 g/day or >98 g/week for women. Overall, 13,854 heavy drinkers at baseline (mean age 55.84 ± 5.98 years; 91.6 % men) were categorized into two groups based on the alcohol consumption changes in the second period: sustained heavy drinking (n=9,403; 67.9%) or reduced drinking (n=4,451; 32.5%). The primary outcome was MACCE, a composite of nonfatal myocardial infarction or angina undergoing revascularization, any stroke accompanied by hospitalization, and all-cause death during follow-up. Results In this nationwide population-based cohort study, during a total follow-up of 107,102 person-years, the sustained heavy drinking group experienced a significantly higher incidence of MACCE than the reduced drinking group (incidence rate, 825 vs. 655 per 100,000 person-years; log-rank p=0.004). Reduced alcohol consumption was associated with a 28% lower risk of MACCE compared to sustained heavy drinking (adjusted-hazard ratio [HR]: 0.780, 95% confidence interval [CI] 0.656–0.928). These benefits were mostly driven by a significant reduction in the incidence of angina (adjusted-HR: 0.631, 95% CI 0.425–0.926) and ischemic stroke (adjusted-HR: 0.657, 95% CI 0.472–0.914). The preventive effects of reduced alcohol intake were consistently observed across various subgroups of heavy drinkers, except for smoking status (p-interaction=0.015) and even after including abstainers in the sensitivity analysis. Conclusion Reduced alcohol consumption in heavy drinkers could lower the future risk of CVD, with the most pronounced benefits expected for stable/unstable angina and ischemic stroke. Further research is warranted to explore the optimal strategies for promoting sustained reductions in alcohol intake.Cumulative MACCE incidence curves

Octogenarians, nonagenarians and centenarians with myocardial infarction over time in Sweden

Abstract Background The aim of this study was to evaluate temporal changes in baseline characteristics, in-hospital management and medication at discharge in very elderly with myocardial infarction (MI). Methods Between 2003 and 2016, we included all consecutive patients 80 years or-older, with a MI, included in the nationwide SWEDEHEART registry. The study period was divided into seven equal admission periods. Outcomes included major adverse cardiac and cerebrovascular events (MACCE, including death, MI or stroke) and net adverse cardiac and cerebrovascular events (NACCE, including MACCE and bleeding). All patients had complete 1-year follow up. To evaluate any potential associations between in-hospital management/medications at discharge and clinical outcomes, we adjusted for baseline characteristics and clinical presentation using multivariable Cox regression models. Results We included 85,054 patients. Over time, the proportion of patients with comorbidities such as hypertension, diabetes mellitus, prior percutaneous coronary intervention and a previous bleeding significantly increased but patients were less likely to have a prior MI and previous heart failure (HF). On arrival, the proportion of patients with acute HF declined. Invasive management significantly increased over time as well as prescription of evidence-based medication at discharge. At 1 year, the cumulative rate of MACCE and NACCE significantly decreased. We found a significantly lower risk for death, MI and stroke and a higher risk for bleeding. The observed differences remained significant after adjustment. We found no significant interaction between infarct type and outcomes. Conclusion During the study period, the prognosis in very elderly patients with MI substantially improved. In a population that has been excluded from randomised control trials, implementation of evidence-based management for patients with a MI, seemed to be associated with the lower risk for MACCE and NACCE over time.Cumulative rate of MACCE

Comparison of cardiovascular outcomes in patients with diabetes treated with tirzepatide versus semaglutide: a multi-institutional analysis

Abstract Introduction Glucagon-like-peptide-1 (GLP-1) receptor agonists have been demonstrated to have cardiovascular benefits in patients with diabetes. Two of the most prescribed medications in this class are tirzepatide and semaglutide. Tirzepatide is a dual glucose-dependent insulinotropic polypeptide and GLP-1 receptor agonist, while semaglutide is a selective GLP-1 receptor agonist. Tirzepatide and semaglutide have previously been directly compared to assess efficacy in glycemic control as the primary endpoint. However, there is limited data directly comparing cardiovascular outcomes between the two medications in patients with diabetes. This retrospective cohort study compares the incidence of major adverse cardiovascular events (MACE) in patients with diabetes treated with tirzepatide or semaglutide. Purpose The purpose of this study is to identify differences in cardiovascular outcomes between patients with diabetes treated with tirzepatide as compared to semaglutide. Materials and Methods The TriNetX research network was used for this study. Two patient cohorts were generated using International Classification of Disease 10 (ICD-10) codes and medication codes in the TriNetX system. Both cohorts of patients had a history of diabetes (E08-E13) and no prior history of cerebral vascular accident (I63) or myocardial infarction (I21). One cohort received semaglutide and the other tirzepatide. Each cohort was prohibited from receiving the other agent. The cohorts were balanced for age, race, gender, and ethnicity by propensity score matching and the greedy nearest neighbor algorithm resulting in 36,212 patients in each arm. They were then evaluated for the 3-year outcomes of major adverse cardiovascular events (myocardial infarction, cerebral vascular accident, and death). Results Tirzepatide was associated with statistically significantly fewer MACE outcomes compared to semaglutide for each of the individual endpoints as well as the overall composite endpoint over the 3 year follow up period. Table 1. MACE events for semaglutide and tirzepatide. Table 2. Relative risks for semaglutide MACE endpoints compared to tirzepatide. Conclusions In this retrospective cohort study, tirzepatide was associated with a lower incidence of major adverse cardiovascular events compared to semaglutide in patients with diabetes. These findings suggest that tirzepatide offers superior cardiovascular protection for primary prevention compared to semaglutide and warrant further investigation in future studies and clinical trials.Table 1Table 2

Sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide 1 receptor agonists and cancer mortality. A real-world registry

Abstract Background Sodium-glucose cotransporter 2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1ra) reduce cardiovascular events through different mechanisms, nevertheless, their association with cancer remains unclear. Purpose We aim to compare the combined treatment (SGLT2i and GLP1ra) with monotherapy regarding hospitalization or/and death for cancer in a general population and a subgroup of patients with cardiovascular disease (CVD). Methods Retrospective observational study of patients who were prescribed SGLT2i, GLP1ra, or both drugs. Multinomial propensity score was performed in all the population and in a subgroup of patients with CVD (atrial fibrillation [AF], heart failure [HF], coronary artery disease [CAD], peripheral arterial disease [PAD], or cerebrovascular accident [CVA]). The following variables were included to adjust the three groups: Sex, Age, Obesity, diabetes mellitus (DM), high blood pressure (HBP), dyslipidemia (DLP), CAD, HF, AF, and CVA. The three primary outcomes were (i) hospitalization for any cancer, (ii) death for any cancer, and (iii) the combined event in the included population and the subgroup of patients with CVD. The multivariate Cox regression analysis determined the hazard rate (HR) of age, sex, risk factors, and treatment for each outcome. Results We included 14709 patients (11366 with SGLT2i, 1016 with GLP1ra, and 2327 with both treatments) from the treatment initiation. The subgroup with CVD included 4957 (33.7%) patients (Fig 1). After 33 months of median follow-up, the incidence of cancer events was similar between patients with and without CVD (3.4% or 3.7%, respectively). Sex (male) and age were the main risk factors for the 3 outcomes in both groups. Combined treatment and its duration had a protector role for cancer mortality regarding monotherapy with SGLT2i or GLP1ra in all population (HR [95%CI]) 0.2216 [0.106-0.459]; p<0.001 or 0.1928 [0.071-0.519]; p=0.001, respectively) (Fig 2a) and in the subgroup of patients with CVD (HR [95%CI]) 0.279 [0.078-0.994]; p<0.049 or 0.129 [0.024-0.668]; p=0.014, respectively) (Fig 2b), but these results were not found for the outcome of hospitalization for cancer. The combined therapy concerning SGLT2i and duration of treatment showed a protective role against the combined event (HR [95%CI]) 0.709 [0.521-0.967]; p=0.029) and (HR [95%CI]) 0.991 [0.983-0.999]; p=0.032) in the general population but not in the group of CVD. A higher survival rate for any cancer mortality was observed in those patients with the combined therapy respect to monotherapy (SGLT2i or GLP1ra) in the general population (Fig 2c) and the subgroup of patients with CVD (Fig 2d). Conclusions Initiation of combined therapy vs. monotherapy was associated with a lower rate of cancer mortality in the general population and patients with CVD. Future clinical trials and mechanistic studies will clarify the possible role of these drugs on carcinogenesis.Figure 1Figure 2

The prognostic utility of troponin T levels in patients undergoing PCI during initial hospitalisation for STEMI

Abstract The prognostic utility of presentation or "peak" high-sensitivity troponin T (hsTnT) levels following ST-segment elevation myocardial infarction (STEMI) has been previously reported, but hsTnT, unlike other bio-markers of myocyte damage, have a 2nd or ‘plateau-phase’ of release which lasts over a week. We have reported correlations between plateau-phase hsTnT levels, and cardiac MRI determined infarct size, though whether these levels are more highly associated with late mortality than "peak" (or highest) levels, needs clarification. Methods Hence we determined late mortality and the combination of cardiovascular death, myocardial infarction and cerebrovascular accident [CD/MI/CVA] among patients with STEMI, and an HsTnT level >36 hours after symptom onset (plateau phase), who underwent percutaneous coronary intervention (PCI), either primary or pharmaco-invasive, during initial hospitalisation between October 2003 and December 2021. HsTnT levels and other potential prognostic factors were determined. Results Amongst 1955 patients, 119 patients (6%) had died by 2 years and 192 (10%) patients experienced CD/MI/Stroke. The highest quartile of plateau phase hsTnT levels (³ 3786 ng/L ng/L), were more highly associated with 2-year mortality, than the highest quartile of "peak" hsTnT levels (³ 7687 ng/L ng/L). The Figure shows Peak and plateau hs-TnT levels in quartile groups were assessed by rank test to obtain p-values. Patients lost to follow-up or with less than 2-years of follow up were considered censored. Peak quartile 1; hs-TnT £ 1611 ng/L, peak quartile 2; hs-TnT 1612 – 3900 ng/L, peak quartile 3; hs-TnT 3901 – 7686 ng/L; peak quartile 4; hs-TnT ³ 7687 ng/L. Plateau quartile 1; hs-TnT £ 1060 ng/L, plateau quartile 2; hs-TnT 1061 – 2135 ng/L; plateau quartile 3; hs-cTnT 2136 – 3785 ng/L. Log rank mortality analyses are shown in the Figure. Peak quartile 1; hs-TnT <1611 ng/L, peak quartile 2; hs-TnT 1612 – 3900 ng/L, peak quartile 3; hs-TnT 3901 – 7686 ng/L; peak quartile 4; hs-TnT ³ 7687 ng/L. Plateau quartile 1; hs-TnT £ 1060 ng/L, plateau quartile 2; hs-TnT 1061 – 2135 ng/L; plateau quartile 3; hs-cTnT 2136 – 3785 ng/L, plateau quartile 4; hs-TnT >3786 ng/L. Multivariate Cox regression analysis incorporating age, sex, smoking status, hypertension, renal function, cardiogenic shock and heart failure hospitalisation found plateau hs-TnT levels (HR, 3.564; 95% CI, 1.674 – 7.590; P = 0.001) were an independent predictor of all-cause mortality at 2-years post-STEMI, whereas peak hs-cTnT levels (HR, 1.965; 95% CI, 0.959 – 4.025; P = 0.065) were not. Conclusions Plateau phase hsTnT levels were of prognostic significance in STEMI patients treated with PCI. Thus, measurement of plateau hs-cTnT levels following STEMI could be an accurate, inexpensive method of long-term prognostic risk stratification.

Examining prognostic scores for short-term major adverse cardiovascular events prediction following primary PCI: a comparative analysis

Abstract Background Accurately predicting short-term MACE (major adverse cardiac events) following primary PCI remains a clinical challenge. This study aims to assess the effectiveness of four established risk scores in predicting short-term MACE after primary PCI (percutaneous coronary intervention). Methodology We enrolled a cohort of consecutive adult patients diagnosed with STEMI (ST elevation myocardial infarction) undergoing primary PCI in this prospective observational study. Patients were followed at the interval of 3 months up for up to 12 months, and MACE events were recorded. Additionally, we obtained TIMI, PAMI, CADILLAC, and GRACE scores. Results A total of 2839 patients (79.3% male, mean age 55.6 ± 11.2 years) were included. Over a median follow-up of 244 days, the composite MACE rate was 18.3% (519). All-cause mortality was 13.5% (384), re-infarction requiring revascularization was 4.3% (121), heart failure-related re-hospitalization was 2.6% (74), stent thrombosis occurred in 5.6% (160), and CVA (cerebrovascular accident) events were documented in 1% (28). The AUC (area under the curve) for TIMI, PAMI, CADILLAC, and GRACE scores were 0.658 [0.630-0.685], 0.658 [0.632-0.684], 0.669 [0.644-0.695], and 0.675 [0.649-0.701], respectively, for the prediction of MACE. On multivariable Cox regression, medium and high-risk categories based on GRACE score were independent predictors of MACE with adjusted HR (hazard ratio) of 1.52 [1.21-1.92]; p<0.001 and 1.92 [1.34-2.75]; p<0.001, respectively. Conclusion A significant proportion of patients experienced short-term MACE after primary PCI. While none of the assessed scores demonstrated significant predictive power, the GRACE score exhibited comparatively better predictive ability than TIMI, PAMI, and CADILLAC scores

Ablation outcome in patients with atrial fibrillation undergoing ICE-guided pulsed-field ablation

Abstract Background Prior experiences from preclinical studies indicate the critical need of catheter-tissue- contact for creation of consistent transmural lesions in pulsed-field ablation (PFA). Intracardiac echocardiography (ICE) not only provide real-time visualization of cardiac structures, but also ensure adequate contact with the tissue. Objective We evaluated ablation outcome and reconnection rate following ICE-guided PFA procedure in patients with atrial fibrillation (AF). Methods Consecutive patients receiving ICE-guided PFA procedure were included in this multi-center analysis. All patients received isolation of PVs (PVI). Additional ablation of left atrial posterior wall (LAPW) was decided based on operator’s discretion. Concentric overlapping lesions were placed in the LAPW. Number of applications were determined on a case-by-case basis. ICE and fluoroscopy were used to optimize contact between the PFA catheter and the targeted tissue. All procedures were performed under uninterrupted anticoagulation. Mapping was done before and after ablation to confirm electrical isolation. Arrhythmia-monitoring was done for 1-year with periodic clinic visits, event recorders and 7-day Holter monitoring. Results A total of 372 patients [age: 62.69 ± 10.41 years, male: 201 (71.3%), paroxysmal AF: 67 (18%)] were included in this analysis of which 48 (12.9%) underwent PVI-only and the remaining subjects received additional ablation of LAPW. Mean number of applications were 34.67 ± 8.88 and 73.65 ± 37.21 for PVI-only and PVI+LAPWI cohorts respectively (p<0.001). No major procedural complications such as esophageal injury, atrio-esophageal fistula, pericardial effusion requiring drainage or cerebrovascular accidents were reported. During 1-year follow-up, 38 (10.2%) patients underwent repeat procedure for recurrence. Reconnection of PV and LAPW were found in only 2 (5.2%) patients. In all 38 patients, new triggers initiating AF were detected to be originating from interatrial septum: 25 (65.8%), superior vena cava: 9 (23.7%), coronary sinus: 7 (18.4%) and left atrial appendage: 6 (15.8%). Conclusion ICE-guided PFA procedures are safe and produce durable lesions leading to very low reconnection rate. The recurrence was mostly due to new triggers initiating AF.

Predisposing and precipitating factors of post-operative delirium after transfemoral TAVI

Abstract Background Transcatheter aortic valve implantation (TAVI) represents the treatment of choice for aortic stenosis (AS) patients at higher age (> 75y) or with relevant comorbidities. Post-operative delirium (POD) is a frequent complication which has been associated with worse outcome. Thus, preventive options are highly needed. The aim of our single-center study was to investigate predisposing and precipitating factors of POD after transfemoral TAVI, with a focus on the influence of anaesthesia. Methods Risk factors for POD after TAVI were analysed in 2 merged cohorts of 480 study patients (43% women; mean age 80 years), enrolled in 2017-2022 (n=375, TAVI in 95% in general anaesthesia) and in 2022-2024 (n=105, TAVI in 91% in local anaesthesia). Incidence of POD was evaluated retrospectively by nursing documentation, medical records, and DRG coding. The association of demographics, comorbidities, echo parameters, procedural parameters, anaesthesia, and peri-procedural complications with POD incidence was investigated. Results In total, 29 patients (6%) developed POD, with a tendency towards a lower incidence in the later cohort (6.7% vs. 3.8%; p=0.28). Regarding baseline characteristics, patients experiencing POD were more likely to be male (p=0.03), frail (Katz Index <6, p=0.049), and to suffer from low-gradient AS (p=0.005 for paradoxical, p=0.02 for classical low-flow, low-gradient AS; see also fig. 1A). Total procedure time was significantly longer in patients with POD (median, 86 vs. 62 min, p=0.004; fig 1B), and a tendency towards a more frequent implantation of other than ballon-expandable valves could be observed (p=0.07). Concerning the role of anaesthesia, POD did not differ significantly after general anaesthesia (n=24/360, 6.7%), conscious sedation (n=1/19, 5.3%), and local anaesthesia (n=4/100, 4%) (p=0.38). Regarding procedural complications, POD patients were characterized by lower minimum hemoglobin post-TAVI (9.3 vs. 10.1 g/dl, p=0.05; fig. 1C) and higher incidences of intra-procedural resuscitation (11% vs. 2%, p=0.03), cerebrovascular accidents (10% vs. 2%, p=0.04) and new permanent pacemaker implantations (25% vs. 10%, p=0.02). In POD patients, long-term survival after TAVI was significantly reduced, with a median survival of only 2 years (Kaplan-Meier curves in fig. 2; p=0.001). Conclusions POD after TAVI stays common and unfavourable. The role of anaesthesia seems less pronounced than expected. Total procedure time and relevant anaemia after TAVI emerged as most important modifiable risk factors. Future research is warranted, since strategies to reduce precipitating factors for POD may have a significant impact on post-TAVI outcomes.Selected risk factors for PODConsequence of POD: Reduced Survival

Systemic inflammation in patients with atherosclerotic cardiovascular and chronic kidney disease in Spain: a population-based study using electronic medical records from a primary care database

Abstract Background Systemic inflammation (SI) is recognized as a critical driver of atherosclerotic cardiovascular disease (ASCVD), and it is frequently observed in ASCVD patients with comorbid chronic kidney disease (CKD). Elevated C-reactive protein (CRP) levels, a common biomarker for SI, have been associated with poor prognosis in ASCVD and CKD patients, increased risk of major adverse cardiovascular events and renal disease progression, as well as greater mortality. Purpose To estimate the prevalence of SI in patients with ASCVD in Spain overall and by CKD status, and to describe patients’ clinical characteristics. Methods In this population-based observational study, data from THIN Spain, a database of electronic medical records from a large network of general practitioners, were used to identify adult patients with a diagnosis code of ASCVD (atherosclerotic coronary or cerebrovascular event, peripheral arterial disease, or other atherosclerotic vascular event) and ≥1 eligible CRP measurement between January 1st 2014 to July 31st 2023 (latest data available at time of data extraction).[Figure] SI was defined as CRP ≥ 2mg/L. Point prevalence of SI at the end of the study (among patients alive with ≥1 CRP in the prior 18 months) and the proportion of patients with evidence of SI during the study period (2014-2023) were estimated overall and by CKD status (defined as CKD stage 3+, or eGFR <60 mL/min/1.73m², or urinary albumin-to-creatinine ratio ≥30 mg/g). Patients’ comorbidities (defined using primary care diagnoses), and laboratory values were reported by SI status at first CRP measurement during the study period. Results Among 76,423 patients with ASCVD diagnosis, 15,798 patients (20.7%) were included in the study (mean age: 71.1 years; 43% females), of whom 5,111 (34%) had CKD at first eligible CRP (n=975 with unknown CKD status). Mean CRP in ASCVD patients with CKD was 24% higher than in those without CKD (4.36 vs 3.53 mg/L, p<0.001). The proportion of ASCVD patients with SI at first CRP measurement was 58% overall (65% among CKD patients; 55% among patients without CKD; p<0.001). The point prevalence of SI at the end of the study was 56% among ASCVD patients overall (62% among CKD patients; 52% among patients without CKD; p<0.001), while 64% of ASCVD patients had evidence of SI at any time during the study period (72% among CKD patients; 59% among patients without CKD; p<0.001). Compared to ASCVD patients without SI, higher proportion of SI patients were smokers and with comorbidities. Also, ASCVD patients with SI had lower baseline eGFR levels and higher levels of LDL-C and triglycerides than ASCVD patients without SI.[Table] Conclusions SI prevalence is high among patients with ASCVD in Spain, especially among patients with comorbid CKD. Strategies to target SI may have beneficial effects in prevention of cardiovascular events and mortality in ASCVD patients.

The impact of pre-myocardial infarction exercise frequency on prognosis in Non-ST segment elevation myocardial infarction patients

Abstract Background Non-ST segment elevation myocardial infarction (NSTEMI) presents a significant challenge in cardiovascular care, often requiring urgent management. Understanding the impact of exercise frequency prior to the onset of NSTEMI on post-event prognosis is crucial for developingmedical strategies. Purpose This study aimed to investigate the clinical characteristics and outcomes of NSTEMI patients based on their exercise frequency before experiencing NSTEMI, comparing those with regular exercise (once or more per week) versus those with infrequent or no exercise. Methods This study included acute myocardial infarction cohorts from 71 secondary or tertiary hospitals between January 1, 2010 and June 30, 2023. Inclusion criteria comprised NSTEMI patients evaluated for exercise frequency using the Community Health Questionnaire before hospitalization. The primary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE), net adverse clinical events (NACE), and all-cause mortality, with secondary outcomes comprising the individual components of MACCE and NACE. Propensity score matching (PSM) was employed to adjust for differences in clinical characteristics between the two groups. Multivariable Cox regression and robust multivariable Cox regression were conducted before and after PSM to evaluate the impact of exercise frequency on outcomes. Results The final study population consisted of 38753 participants (42.7% in the High-frequency exercise group). The median follow-up duration was 1518 days, the mean age was 67.80±11.47 years, 61.6% were male. Compared to individuals with infrequent exercise before NSTEMI, those with regular exercise exhibited significantly lower risks of MACCE [aHR 0.93(0.90-0.96), p<0.001], NACE [aHR 0.91(0.88-0.95), p<0.001], and all-cause mortality [aHR 0.88(0.85-0.92), p<0.001]. However, regular exercise before NSTEMI was associated with an increased risk of coronary revascularization [aHR 1.14(1.06-1.23), p<0.001]. These findings remained consistent in the robust multivariate Cox regression analysis conducted after adjusting for differences between the two groups with PSM (Figure 1). After PSM, survival analysis indicated that the incidence of primary outcomes was lower in individuals with high exercise frequency before NSTEMI compared to those with low exercise frequency before NSTEMI, with all-cause mortality rates of 26.9% vs. 30.8%, MACCE rates of 37.2% vs. 38.5%, and NACE rates of 37.9% vs. 39.1%, all with log-rank p-values <0.001. Conclusion This study highlights the protective role of regular physical activity befor NSTEMI in reducing adverse post-NSTEMI outcomes. Promoting pre-NSTEMI physical activity can be a key element in preventive cardiology, potentially improving prognosis and decreasing the likelihood of cardiovascular events post-NSTEMI.Figure 1

The short-term prognosis of salvianolate use during hospitalization in patients with acute myocardial infarction

Abstract Background Salvianolate, derived from Salvia miltiorrhiza Bunge, is a traditional Chinese medicine known for its potential to promote blood circulation and eliminate blood stasis, often prescribed for cardiovascular system illnesses. This study aims to explore the impact of salvianolate treatment on the prognosis of patients with myocardial infarction during hospitalization. Methods This study included an acute myocardial infarction cohort from 71 secondary or tertiary hospitals between January 1, 2010 and June 30, 2023. Patients were divided into NSTEMI and STEMI groups. Clinical outcomes included cardiac death and major adverse cardiovascular and cerebrovascular events (MACCE, composite of cardiac death, myocardial infarction, ischemic stroke) within 30 days. Cox multivariable regression analyzed the association between salvianolate use and outcomes in STEMI/NSTEMI patients. Propensity score matching (PSM) adjusted for demographic and clinical differences between salvianolate and non-salvianolate groups. The matching factors including sex, age, Killip class, previous diseases (diabetes, hypertension, stroke, and renal insufficiency), previous percutaneous coronary intervention (PCI), in-hospital aspirin, clopidogrel, ticagrelor, lipid-lowering agents, nitrates, PCI, and thrombolytic therapy. Results A total of 76,157 STEMI patients and 74,373 NSTEMI patients were assessed. Among the STEMI group, 7,636 patients used salvianolate and 68,521 did not. Multivariate Cox regression analysis revealed that salvianolate use during hospitalization reduced cardiac death (aHR = 0.707, 95%CI = 0.623-0.803, P < 0.001) and MACCE (aHR = 0.730, 95%CI = 0.651-0.820, P < 0.001) at 30 days. These findings remained consistent in the matched population (n = 15,264) (cardiac death: aHR = 0.669, 95%CI = 0.569-0.786, P < 0.001; MACCE: aHR = 0.679, 95%CI = 0.586-0.787, P < 0.001). In the NSTEMI group, 6,461 patients used salvianolate, while67,912 did not. After matching, salvianolate use during hospitalization showed no significant difference in cardiac death and MACCE compared to not use. Conclusions Patients with STEMI treated with salvianolate exhibited improved short-term cardiovascular and cerebrovascular outcomes, while NSTEMI patients did not experience significant short-term prognosis enhancement.

Differential prognostic significance of platelet reactivity based on ischemic risk after percutaneous coronary intervention

Abstract Background High platelet reactivity (HPR) in patients underwent percutaneous coronary intervention (PCI) is a potential risk factor of adverse cardiovascular events. It is not well understood in which patients HPR is particularly clinically important. Purpose We aimed to elucidate the prognostic value of high platelet reactivity (HPR), across varying levels of ischemic risk categorized by the CHADS-P2A2RC score in a large registry. Methods We retrospectively analyzed 11,714 patients who underwent PCI in the PTRG-DES registry. Ischemic risk was stratified using the CHADS-P2A2RC score into low (score ≤ 1), moderate (score 2–3), and high (score ≥ 4) groups. HPR was defined as a P2Y12 Reaction Unit (PRU) value ≥252. The incidence of major adverse cardiac and cerebrovascular events (MACCE) during 5- year follow-up was the primary outcome. Results During the median follow-up of 37.6 months (IQR, 12.0–60.8), a total of 709 MACCEs (6.1%) (392 deaths [3.3%], 172 non-fatal MI [1.5%], 62 ST [0.5%] and 181 non-fatal stroke [1.5%]), and 324 cases of major bleeding (2.8%) occurred. The high-risk group has the highest incidence of MACCE during 5-year follow-up unadjusted HR of 4.206, 95% CI 3.204–5.521. Among the 2,577 low-risk patients, HPR did not significantly affect MACCE incidence (HR 1.366, 95% CI 0.798–2.336, p=0.253). In the moderate-risk cohort of 5,417 patients, HPR conferred a modest increase in MACCE risk (HR 1.289, 95% CI 1.008–1.649, p=0.043). Notably, the high-risk group demonstrated a significant association between HPR and MACCE (HR 1.385, 95% CI 1.135–1.692, p<0.001). Conclusion HPR is a potent risk factor of long-term outcomes following PCI, especially in patients with a high ischemic risk based on CHADS-P2A2RC scoring. The results highlight the varying impact of platelet reactivity depending on the level of ischemic risk, indicating the importance of tailored antiplatelet therapy in high-risk group to improve clinical outcomes.

Sex-specific associations between remnant cholesterol and cardiovascular risk in patients undergoing percutaneous coronary intervention: a 5-year large-sample study from the real world

Abstract Background Differences in the pathophysiological characteristics and cardiovascular risk between female and male patients with coronary artery disease (CAD) are well-established. Recent studies on the relationship between remnant cholesterol (RC) and cardiovascular risk in coronary artery disease patients have gained popularity. To date, little is known about the RC-related cardiovascular risk disparities between males and females. Purpose The aim is to investigate sex-specific differences in the association between RC and cardiovascular risk among CAD patients undergoing percutaneous coronary intervention (PCI). Methods A prospective cohort study was conducted among 10,724 CAD patients undergoing PCI from January to December in 2013. RC was calculated as total cholesterol minus low-density lipoprotein cholesterol and high-density lipoprotein cholesterol. The primary outcome was major adverse cardiovascular and cerebrovascular events (MACCE, including cardiac mortality, revascularization and ischemic stroke) and the secondary outcomes were each component of MACCE. Results Among 9,587 PCI patients included (the average age was 58.43 ± 10.26 years and 2,181 (22.70%) were female), 1,864 (19.4%) MACCEs were recorded during the 5-year follow-up. For primary outcome, a significant interaction was observed between RC levels and sex (P for interaction = 0.007 and 0.011, for continuous and categorical RC variables, respectively). Specifically, in male patients, no significant MACCE risk was observed at any RC level (both P > 0.05) (Figure 1). However, in female patients, both continuous RC levels (hazard ratio [HR] 1.412, 95% confidence interval [CI] 1.103-1.807) and the upper two quartiles of RC relative to the lowest quartile (Q3: HR 1.458, 95% CI 1.062-2.001; Q4: HR 1.496, 95% CI 1.081-2.070) were associated with higher MACCE risk. For secondary outcomes, higher RC levels were linked to an increased risk of cardiac mortality and revascularization in female patients but not in males (Table 1). Conclusions In a large-scale 5-year follow-up study from the real world, we are the first to demonstrate that RC-related cardiovascular risk is specifically observed in female CAD patients undergoing PCI, suggesting that female patients merit closer surveillance and more aggressive RC management to reduce cardiovascular risk.

Ticagrelor vs. clopidogrel in ST elevation myocardial infarction patients with hemoglobin > 160

Abstract Background While some studies have provided therapeutic guidance for antiplatelet therapy in acute coronary syndrome (ACS) patients with anemia, research regarding ACS patients with elevated hemoglobin remains scarce. Purpose This study aims to evaluate the prognostic impact of different dual antiplatelet therapy (DAPT) regimens in ST-segment elevation infarction (STEMI) patients with hemoglobin > 160 g/L. Methods The data for this study were derived from the 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. A total of 3372 patients were included in the study. Patients were divided into either the ticagrelor group or the clopidogrel group based on their priscribed antiplatelet regimens. The primary endpoint was defined as major adverse cardiovascular and cerebrovascular events (MACCE), comprising of cardiac death, myocardial infarction, and ischemic stroke within one month. Secondary endpoints included all-cause death at one-year, net adverse clinical events (NACE) defined as cardiac death, recurrent MI, Bleeding Academic Research Consortium (BARC) level 3 or greater, and revascularization, and cardiac death at one year. Propensity score matching (PSM) was utilized to balance clinical characteristics between the two groups. Multivariable Cox regression analysis was conducted post PSM to evaluate the impact of different antiplatelet regimens. Result The study population comprised 3372 patients, with 2200 receiving clopidogrel and 1172 with ticagrelor. The median age in the clopidogrel group was 54.83 years, while in the ticagrelor group, it was 53.61 years (P = 0.005). The clopidogrel group had a higher proportion of females compared to the ticagrelor group (3.9% vs. 2.0%, p=0.003). After PSM, 1086 well-matched pairs were identified. The ticagrelor group demonstrated a significantly lower rate of one-year all-cause mortality (1.38% VS 2.85%, LogRank p = 0.018), MACCE events (6.53% VS 9.48%, LogRank p = 0.015), and cardiac death (1.29% VS 2.76%, LogRank p = 0.015), compared to the clopidogrel group. However, there was no significant difference in the incidence of NACE events between the two groups (8.38% VS 7.76%, p = 0.300). Multivariate Cox regression analysis showed that ticagrelor treatment was associated with a reduced risk of all-cause mortality ( aHR 0.408, 95%CI: 0.214-0.775, p = 0.006), MACCE events (aHR 0.640, 95%CI: 0.473-0.869, p = 0.042), cardiac death (aHR 0.384, 95%CI: 0.198-0.743, p = 0.004). Conclusions Among STEMI patients with hemoglobin > 160 g/L, treatment with ticagrelor was associated with significantly lower rates of all-cause mortality, MACCE, and cardiac death compared to the treatment with clopidogrel.