Highlights of Cardiovascular Disease Prevention Studies Presented at the 2024 American College of Cardiology Conference.

PURPOSE OF REVIEW: To summarize selected late-breaking science on cardiovascular (CV) disease prevention presented at the 2024 Scientific Session of the American College of Cardiology (ACC) conference. RECENT FINDINGS: The LIBerate-HR trial showed the efficacy and safety of lerodalcibep, a subcutaneous injection that prevents binding of Pro-Protein Convertase Subtilisin/Kexin (PCSK) 9 to low-density lipoprotein (LDL)-receptors resulting in LDL-cholesterol (LDL-C) lowering in patients at very high risk or high risk of atherosclerotic CV disease (ASCVD). The AEGIS-II randomized patients with type 1 myocardial infarction (MI) with multivessel coronary artery disease and additional CV risk factors and found no benefit in major adverse CV events (MACE) with CSL112, an apolipoprotein A1 infusion shown to increase cholesterol efflux capacity. The Bridge-TIMI 73a trial showed a significant reduction in triglyceride (TG) levels with olezarsen, an antisense mRNA, in patients with moderate hyperTG with elevated CV risk. The BE ACTIVE trial showed significant improvement in step counts in patients given behavioral and financial incentives. The DRIVE study showed a significant increase in the prescription of either sodium-glucose co-transporter-2 inhibitors or glucagon-like peptide-1 receptor agonists in patients with type 2 diabetes mellitus (T2DM) at elevated CV or renal risk with a remote team-based, non-licensed navigator and clinical pharmacist approach. The TACTiC trial showed increased and sustained use of statin therapy by patient-driven use of a web-based portal that calculated the ASCVD risk score and gave prompts. The VICTORIAN-INITIATE trial showed efficacy and safety in early use of inclisiran in patients with ASCVD who did not reach target LDL-C < 70 mg/dL despite maximally tolerated statin therapy. The ARISE-HF trial showed no difference in change of peak oxygen consumption with the use of an oral aldose reductase inhibitor, AT-001, in patients with well-controlled T2DM and diabetic cardiomyopathy with high-risk features compared to placebo. The PREVENT trial showed a significant reduction in target vessel failure at 2 years in patients with non-flow limiting vulnerable plaques with percutaneous coronary intervention and optimal medical therapy (OMT) compared to OMT alone. The late-breaking clinical science presented at the 2024 Scientific Session of the ACC paves the way for an evidence-based alternative to statin therapy and provides data on several common clinical scenarios encountered in daily practice.

Epicardial fat volume is associated with primary coronary slow-flow phenomenon in patients with severe aortic stenosis undergoing transcatheter valve implantation.

BACKGROUND: Primary coronary slow flow (CSF) is defined as delayed opacification of the distal epicardial vasculature during coronary angiography in the absence of relevant coronary artery stenoses. Microvascular disease is thought to be the underlying cause of this pathology. Epicardial fat tissue (EFT) is an active endocrine organ directly surrounding the coronary arteries that provides pro-inflammatory factors to the adjacent tissue by paracrine and vasocrine mechanisms. The aim of the present study was to investigate a potential association between EFT and primary CSF and whether EFT can predict the presence of primary CSF. METHODS: Between 2016 and 2017, n = 88 patients with high-grade aortic stenosis who were planned for transcatheter aortic valve implantation (TAVI) were included in this retrospective study. EFT volume was measured by pre-TAVI computed tomography (CT) using dedicated software. The presence of primary CSF was defined based on the TIMI frame count from the pre-TAVI coronary angiograms. RESULTS: Thirty-nine of 88 TAVI patients had CSF (44.3%). EFT volume was markedly higher in patients with CSF (142 ml [IQR 107-180] vs. 113 ml [IQR 89-147]; p = 0.009) and was strongly associated with the presence of CSF (OR 1.012 [95%CI 1.002-1.021]; p = 0.014). After adjustment, EFT volume was still an independent predictor of CSF (OR 1.016 [95%CI 1.004-1.026]; p = 0.009). CONCLUSION: Primary CSF was independently associated with increased EFT volume. Further studies are needed to validate this finding and elucidate whether a causal relationship exists.

Predictors of non-obstructive coronary slow flow in poorly controlled type 2 diabetes mellitus: a cross-sectional study.

BACKGROUND: Coronary slow flow (CSF) can occur due to various factors, such as inflammation, small vessel disease, endothelial dysfunction, and inadequate glucose control. However, the exact pathological mechanisms behind CSF remain incompletely understood. The objective of this study was to identify the risk factors associated with slow coronary flow in individuals with Type 2 Diabetes Mellitus (T2DM) who have non-obstructive coronary artery disease (CAD) and experience CSF. METHODS: We conducted a prospective cohort study involving 120 patients with T2DM who were referred for invasive coronary angiography due to typical chest pain or inconclusive results from non-invasive tests for myocardial ischemia. Using a 2 × 2 design, we categorized patients into groups based on their glycemic control (adequate or poor) and the presence of CSF (yes or no), defined by a TIMI frame count > 27. All patients had non-obstructive CAD, characterized by diameter stenosis of less than 40%. We identified many variables associated with CSF. RESULTS: Our investigation revealed no significant differences in age, sex, family history of coronary artery disease, ECG ischemia abnormalities, or echocardiographic (ECHO) data between the groups. In patients with adequate glycemic control, hypertension increased the risk of CSF by 5.33 times, smoking by 3.2 times, while dyslipidemia decreased the risk by 0.142. Additionally, hematocrit increased the risk by 2.3, and the platelet-to-lymphocyte ratio (PLR) increased the risk by 1.053. Among patients with poor glycemic control, hematocrit increased the risk by 2.63, and the Neutrophil-to-Lymphocyte Ratio (NLR) by 24.6. Notably, NLR was positively correlated with glycemic control parameters in T2DM patients with CSF. CONCLUSIONS: In T2DM patients with CSF, various factors strongly correlate with glycemic control parameters and can be employed to predict the likelihood of CSF. These factors encompass hypertension, smoking, increased body mass index (BMI), elevated platelet count, hematocrit, NLR, PLR, and C-reactive protein (CRP). TRIAL REGISTRATION: Registry: ZU-IRB (ZU-IRB#9419-3-4-2022), Registered on: 3 April 2022, Email: IRB_123@medicine.zu.edu.eg.

Intravenous antiplatelet therapy in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention : A report from the INVEST-STEMI group.

The use of intravenous antiplatelet therapy during primary percutaneous coronary intervention (PPCI) is not fully standardized. The aim is to evaluate the effectiveness and safety of periprocedural intravenous administration of cangrelor or tirofiban in a contemporary ST-segment elevation myocardial infarction (STEMI) population undergoing PPCI. This was a multicenter prospective cohort study including consecutive STEMI patients who received cangrelor or tirofiban during PPCI at seven Italian centers. The primary effectiveness measure was the angiographic evidence of thrombolysis in myocardial infarction (TIMI) flow < 3 after PPCI. The primary safety outcome was the in-hospital occurrence of BARC (Bleeding Academic Research Consortium) 2-5 bleedings. The study included 627 patients (median age 63 years, 79% males): 312 received cangrelor, 315 tirofiban. The percentage of history of bleeding, pulmonary edema and cardiogenic shock at admission was comparable between groups. Patients receiving cangrelor had lower ischemia time compared to tirofiban. TIMI flow before PPCI and TIMI thrombus grade were comparable between groups. At propensity score-weighted regression analysis, the risk of TIMI flow < 3 was significantly lower in patients treated with cangrelor compared to tirofiban (adjusted OR: 0.40; 95% CI: 0.30-0.53). The risk of BARC 2-5 bleeding was comparable between groups (adjusted OR:1.35; 95% CI: 0.92-1.98). These results were consistent across multiple prespecified subgroups, including subjects stratified for different total ischemia time, with no statistical interaction. In this real-world multicenter STEMI population, the use of cangrelor was associated with improved myocardial perfusion assessed by coronary angiography after PPCI without increasing clinically-relevant bleedings compared to tirofiban.

Determinants of serious in-hospital complications in patients with Killip class 1/2 ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention.

Killip classification has been used to stratify the risk of patients with acute myocardial infarction (AMI). There were many reports that Killip class 3 or 4 is closely associated with poor clinical outcomes. In other words, Killip class 1 or 2 is associated with favorable clinical outcomes in patients with AMI, especially when patients received primary percutaneous coronary intervention (PCI). However, some patients with Killip class 1/2 suffer from serious in-hospital complications. This study aimed to identify factors associated with serious in-hospital complications of ST-segment elevation myocardial infarction (STEMI) in patients with Killip class 1/2. The primary endpoint was serious in-hospital complications defined as the composite of in-hospital death and mechanical complications. We included 809 patients with STEMI, and divided them into the non-complication group (n = 791) and the complication group (n = 18). In-hospital death was observed in 14 patients (1.7%), and mechanical complications were observed in 4 patients (0.5%). Final TIMI flow ≤ 2 was more frequently observed in the complication group (33.3%) than in the non-complication group (5.4%) (p < 0.001). Multivariate logistic regression analysis revealed that serious in-hospital complication was associated with final TIMI flow grade ≤ 2 (Odds ratio 6.040, 95% confidence interval 2.042-17.870, p = 0.001). In conclusion, serious in-hospital complication of STEMI was associated with insufficient final TIMI flow grade in patients with Killip class 1/2. If final TIMI flow grade is suboptimal after primary PCI, we may recognize the potential risk of serious complications even when patients presented as Killip class 1/2.

Postdilatation after stent deployment during primary percutaneous coronary intervention: a systematic review and meta-analysis.

BACKGROUND: The utilization of postdilatation in primary percutaneous coronary intervention (PCI) is feared to induce suboptimal coronary blood flow and compromise the outcome of the patients. This meta-analysis sought to verify whether postdilatation during primary PCI is associated with worse angiographic or long-term clinical outcomes. METHODS: Systematic literature searches were conducted on PubMed, The Cochrane Library, ClinicalTrials.gov, EBSCO, and Europe PMC on 10 March 2024. Eligible studies reporting the outcomes of postdilatation among ST-segment elevation myocardial infarction patients were included. The primary outcome was no-reflow condition during primary PCI based on angiographic finding. The secondary clinical outcome was major adverse cardiovascular events (MACEs) comprising all-cause death, myocardial infarction, target vessel revascularization (TVR), and stent thrombosis. RESULTS: Ten studies were finally included in this meta-analysis encompassing 3280 patients, which was predominantly male (76.6%). Postdilatation was performed in 40.7% cases. Postdilatation was associated with increased risk of no-reflow during primary PCI [Odd Ratio (OR) = 1.33, 95% Confidence Interval (CI): 1.12-1.58; P = .001)]. Conversely, postdilatation had a tendency to reduce MACE (OR = 0.70, 95% CI: 0.51-0.97; P = .03) specifically in terms of TVR (OR = 0.41, 95% CI: 0.22-0.74; P = .003). No significant differences between both groups in relation to mortality (OR = 0.58, 95% CI: 0.32-1.05; P = .07) and myocardial infarction (OR = 1.5, 95% CI: 0.78-2.89; P = .22). CONCLUSIONS: Postdilatation after stent deployment during primary PCI appears to be associated with an increased risk of no-reflow phenomenon after the procedure. Nevertheless, postdilatation strategy has demonstrated a significant reduction in MACE over the course of long-term follow-up. Specifically, postdilatation significantly decreased the occurrence of TVR. Key messages: What is already known on this topic?  Optimizing stent deployment by performing postdilatation during percutaneous coronary intervention (PCI) is essential for long-term clinical outcomes. However, its application during primary PCI is controversial due to the fact that it may provoke distal embolization and worsen coronary blood flow. What this study adds?  In this systematic review and meta-analysis of 10 studies, we confirm that postdilatation during primary PCI is associated with worse coronary blood flow immediately following the procedure. On the contrary, this intervention proves advantageous in improving long-term clinical outcomes, particularly in reducing target vessel revascularization. How this study might affect research, practice, or policy?  Given the mixed impact of postdilatation during primary PCI, this strategy should only be applied selectively. Future research should focus on identifying patients who may benefit from such strategy.

Pretransfer Aspirin Administration and Its Impact on Angiographic Outcomes for Patients with ST-Elevation Myocardial Infarction.

Although guidelines recommend early aspirin administration after diagnosis of ST-elevation myocardial infarction (STEMI), the decision of pretransfer aspirin administration is at the discretion of the primary physicians. Therefore, this study aimed to determine whether pretransfer aspirin administration was associated with better angiographical outcomes in patients with STEMI. This study compared the angiographic findings of thrombolysis in myocardial infarction (TIMI) flow grade in the infarct-related artery before percutaneous coronary intervention (PCI) between patients who received pretransfer aspirin and those who did not. In total, 28 patients (11.2%) were administered aspirin before transfer and 219 (88.8%) were administered aspirin upon arrival at the hospital. Propensity score matching yielded 135 patients [27 patients (20%) who were administered aspirin before transfer and 108 patients (80%) who were administered aspirin upon arrival at the hospital]. Patients who received pretransfer aspirin had a higher rate of TIMI-3 flow before PCI compared to those who did not receive pretransfer aspirin [8 (28.6%) versus 15 (6.8%), P < 0.01, in all study patients; 8 (26.6%) versus 7 (6.5%), P < 0.01, in propensity-score-matched patients]. Multivariable logistic regression analysis revealed that pretransfer aspirin administration was significantly associated with the presence of TIMI-3 flow before PCI, independent of age, gender, transfer time, and statin use (OR: 5.43, 95% CI: 1.94-15.2, P < 0.01, in all study patients; OR: 6.17, 95% CI: 1.86-20.46, P < 0.01, in propensity-score-matched patients). Pretransfer aspirin administration could lead to the early restoration of coronary blood flow in patients with STEMI, supporting its active use in STEMI care.

Angiographic characteristics of culprit lesions in infarct related artery and correlation of TIMI score with SYNTAX score to predict extent and severity of coronary artery disease in patients undergoing primary percutaneous coronary interventions.

Objective: The current study was designed to explore the relationship of TIMI and SYNTAX risk score to predict the CAD extent and severity in STEMI patients. Methods: For this cross-sectional study, 304 STEMI patients undergoing PPCI were enrolled at Department of Interventional Cardiology NICVD Karachi from September 2021 to January 2022. and the TIMI risk score was determined at enrolment. Based on these scorings, the patients were grouped as low, intermediate, and high risk, i.e., a score of ≤ 3, 4 to 7, and ≥ 8, respectively. The SYNTAX scores were utilized to assess the extent of CAD. Results: Statistically significant difference was found in symptoms to balloon time (p=0.001), history of diabetes (p=0.006), angina (p=0.011), obesity (p=0.048), STEMI type (p=0.003), Killip classes (p=0.000), Infarct-Related Artery (p=0.006), number of diseased vessels (p<0.01), LMS > 50% (p=0.000), PCI type (p<0.01), collateral circulation (p<0.01), In-hospital mortality (p<0.01), LV support (p<0.01), and post-procedural TIMI flow (p=0.013), among the three TIMI risk groups. Significant correlation was found among TIMI risk score and SYNTAX score. Conclusion: It is observed that the TIMI risk scores are highly correlated with the SYNTAX Score in predicting the CAD severity in STEMI patients.

The association between cardiovascular risk profile and ocular microvascular changes in patients with non-ST elevation myocardial infarction.

PURPOSE: We aimed to evaluate the association between ocular microvasculature (vascular density) on optical coherence tomography-angiography (OCT-A) and the cardiovascular risk profile of patients hospitalized for non-ST-elevation myocardial infarction (NSTEMI) patients. METHODS: Patients admitted to the intensive care unit with the diagnosis of NSTEMI and undergoing coronary angiography were divided into 3 groups as low, intermediate, and high risk according to the SYNTAX score. OCT-A imaging was performed in all three groups. Right-left selective coronary angiography images of all patients were analyzed. The SYNTAX and TIMI risk scores of all patients were calculated. RESULTS: This study included opthalmological examination of 114 NSTEMI patients. NSTEMI patients with high SYNTAX risk scores had significantly lower deep parafoveal vessel density (DPD) than patients with low-intermediate SYNTAX risk scores (p < 0.001). ROC curve analysis found that a DPD threshold below 51.65 % was moderately associated with high SYNTAX risk scores in patients with NSTEMI. In addition, NSTEMI patients with high TIMI risk scores had significantly lower DPD than patients with low-intermediate TIMI risk scores (p < 0.001). CONCLUSIONS: OCT-A may be a non-invasive useful tool to assess the cardiovascular risk profile of NSTEMI patients with a high SYNTAX and TIMI score.

A systematic review and meta-analysis of the effect of high-intensity statin on coronary microvascular dysfunction.

OBJECTIVE: The purpose of this meta-analysis is to evaluate the role of high-intensity statin pretreatment on coronary microvascular dysfunction in patients with coronary heart disease undergoing percutaneous coronary intervention (PCI). METHODS: PubMed, Cochrane, and Embase were searched. This meta-analysis selection included randomized controlled trials (RCTs), involving high-intensity statin pretreatment as active treatment, and measurement of thrombolysis in myocardial infarction (TIMI), myocardial blush grade (MBG) or index of microvascular resistance (IMR) in coronary heart disease (CHD) patients undergoing PCI. I2 test was used to evaluate heterogeneity. Pooled effects of continuous variables were reported as Standard mean difference (SMD) and 95% confidence intervals (CI). Pooled effects of discontinuous variables were reported as risk ratios (RR) and 95% confidence intervals (CI). Random-effect or fix-effect meta-analyses were performed. The Benefit was further examined based on clinical characteristics including diagnosis and statin type by using subgroup analyses. Publication bias was examined by quantitative Egger's test and funnel plot. We performed sensitivity analyses to examine the robustness of pooled effects. RESULTS: Twenty RCTs were enrolled. The data on TIMI < 3 was reported in 18 studies. Comparing with non-high-intensity statin, high-intensity statin pretreatment significantly improved TIMI after PCI (RR = 0.62, 95%CI: 0.50 to 0.78, P < 0.0001). The data on MBG < 2 was reported in 3 studies. The rate of MBG < 2 was not different between groups (RR = 1.29, 95% CI: 0.87 to 1.93, P = 0.21). The data on IMR was reported in 2 studies. High-dose statin pretreatment significantly improved IMR after PCI comparing with non-high-dose statin (SMD = -0.94, 95% CI: -1.47 to -0.42, P = 0.0004). There were no significant between-subgroup differences in subgroups based on statin type and diagnosis. Publication bias was not indicated by using quantitative Egger's test (P = 0.97) and funnel plot. Sensitivity analyses confirmed the robustness of these findings. CONCLUSIONS: Comparing with non-high-intensity statin, high-intensity statin pretreatment significantly improved TIMI and IMR after PCI. In the future, RCTs with high quality and large samples are needed to test these endpoints.

Circulating IGF-1 and IGFBP-2 may be biomarkers for risk stratification in patients with acute coronary syndrome: A prospective cohort study.

BACKGROUND AND AIM: The involvement of insulin-like growth factor-1 (IGF-1) and insulin-like growth factor binding protein-2 (IGFBP-2) following acute coronary syndrome (ACS) is rarely studied in clinical practice. Therefore, we sought to evaluate the relationship between IGF-1 and IGFBP-2 concentrations at admission and risk stratification based on the Thrombolysis in Myocardial Infarction (TIMI) risk score in patients with ACS. METHODS AND RESULTS: In all, 304 patients diagnosed with ACS were included in this study. Plasma IGF-1 and IGFBP-2 were measured using commercially available ELISA kits. The TIMI risk score was calculated and the study population was stratified into high (n = 65), medium (n = 138), and low (n = 101) risk groups. Levels of IGF-1 and IGFBP-2 were analyzed for their predictive ability of risk stratification based on the TIMI risk scores. Correlation analysis showed that IGF-1 levels were negatively correlated with TIMI risk levels (r = -0.144, p = 0.012), while IGFBP-2 levels were significantly and positively correlated with TIMI risk levels (r = 0.309, p < 0.001). In multivariate logistic regression analysis, IGF-1 (odds ratio [OR]: 0.995; 95% confidence interval [CI]: 0.990-1.000; p = 0.043) and IGFBP-2 (OR: 1.002; 95%CI: 1.001-1.003; p < 0.001) were independent predictors of high TIMI risk levels. In receiver operating characteristic curves, the area under the curve values for IGF-1 and IGFBP-2 in the prediction of high TIMI risk levels were 0.605 and 0.723, respectively. CONCLUSIONS: IGF-1 and IGFBP-2 levels are excellent biomarkers for risk stratification in patients with ACS, which provides further guidance for clinicians to identify patients at high risk and to lower their risk.

Differences in cardiac testing resource utilization using two different risk stratification schemes.

OBJECTIVE: Assess whether changing an emergency department (ED) chest pain pathway from utilizing the Thrombolysis in Myocardial Infarction (TIMI) score for risk stratification to an approach utilizing the History, EKG, Age, Risk, Troponin (HEART) score was associated with reductions in healthcare resource utilization. METHODS: A retrospective, quasi-experimental study using difference-in-differences and interrupted time series specifications evaluated all ED patients with a chest pain encounter from 8/2015 to 7/2019 at a large academic medical center. We included patients age ≥ 18 with negative troponin testing discharged from the ED. Our standardized care pathway utilized TIMI for risk stratification until 09/2017 and HEART thereafter. We evaluated patients undergoing hospital-based cardiac diagnostic testing (CDT), length of stay (LOS), and 30-day Major Adverse Cardiovascular Events (MACE) at the intervention site before and after the pathway change and compared these outcomes to a similar control site within the health system for the difference-in-differences specification. RESULTS: During the study period, 6.3% (450 of 7117) of patients in the TIMI cohort and 7.2% (546 of 7623) in the HEART cohort among 400,965 total ED visits underwent CDT. In a multivariable analysis, transition to the HEART pathway was associated with greater odds of receiving CDT (odds ratio 2.88 [95% CI 1.21 to 6.86]), a reduction in LOS of 34 min (95% CI 2.2 to 67.6), and no significant difference in 30-day MACE. CONCLUSION: The transition from TIMI to HEART was associated with mixed consequences for healthcare resource utilization, including increased CDT but reduced length of stay.

The Relationship Between TIMI Flow and MAPH Score in Patients Undergoing Primary Percutaneous Coronary Intervention for STEMI.

The MAPH (mean platelet volume, age, total protein and hematocrit) score is a newly developed simple scoring system for patients with STEMI that has been associated with satisfactory predictive values to determine thrombus burden in STEMI patients. Therefore, the aim of our study was to determine the relationship between the MAPH risk score and TIMI flow in patients with STEMI.The study included 260 patients who underwent primary percutaneous coronary intervention between December 2019 to July 2022, and had TIMI 0 flow in the responsible coronary artery due to STEMI. According to the TIMI flow score after stent implantation, the patients were classified into either the no-reflow group (n = 59) or the normal flow group (n = 201). In order to calculate the MAPH score, ROC analysis was performed to find the cutoff point for each component of the MAPH score. MAPH scores were calculated (MPV + Age + Protein + Hematocrit) for both groups. Our study was a retrospective, observational study.In the multivariable regression analysis, the MAPH score (OR: 0.567; 95%CI: 0.330-0.973, P = 0.04) and glycoprotein IIb/IIIa inhibitors (OR: 0.249; 95%CI: 0.129-0.483, P < 0.001) were parameters found to be independent predictors of TIMI flow. An MAPH score value > 2.5 predicted the presence of low TIMI coronary flow in patients with STEMI, with 78% specificity and 45% sensitivity (ROC area under curve: 0.691, 95% CI: 0.617-0.766, P < 0.001).The MAPH risk score is simple, inexpensive, and quick to calculate. A high MAPH score may be an indicator of coronary no-reflow in patients with STEMI.

Angiographic flow velocity predicts lower limb outcomes after endovascular therapy: Application of the frame count method.

INTRODUCTION: Several factors related to lesion characteristics and endovascular therapy (EVT) procedures have been reported to affect primary patency after EVT. However, it is unknown why these factors were associated with primary patency. We hypothesized patency failure was related to poor blood flow in affected arteries. METHODS: This retrospective study included 131 consecutive patients who had received EVT with bare metal stents for peripheral artery disease caused by femoropopliteal artery lesions. Based on the tertile post-EVT flow velocity of the superficial femoral artery (SFA), patients were divided into high (n = 43), middle (n = 44), and low (n = 44) flow velocity groups. Flow velocity was measured using the frame count method. We measured incidence of major adverse limb events (MALE), composed of target lesion revascularization (TLR), non-TLR, and major amputation. RESULTS: At a median follow-up period of 22.7 months, MALE had occurred in 7 (16.3%), 10 (22.7%), and 29 (65.9%) of patients from the high, middle, and low SFA flow velocity groups, respectively (p < 0.001). Kaplan-Meier analysis showed incidence of MALE was significantly higher in the patients of low SFA flow velocity (log-rank test χ2 = 38.8, p < 0.001). Multivariate analysis found low SFA flow velocity to be an independent predictor for MALE (hazard ratio: 4.42; 95% CI: 2.27 to 8.60; p < 0.001) as was ankle-brachial index. CONCLUSION: Post-EVT SFA flow velocity for femoropopliteal artery lesions treated with bare metal stents is an independent predictor of limb patency. The frame count method for assessing arterial flow velocity is convenient and has potential for wide applications in EVT.

Comparison of GRACE and TIMI risk scores in the prediction of in-hospital and long-term outcomes among East Asian non-ST-elevation myocardial infarction patients.

BACKGROUND: Risk stratification in non-ST segment elevation myocardial infarction (NSTEMI) determines the intervention time. Limited study compared two risk scores, the Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) risk scores in the current East Asian NSTEMI patients. METHODS: This retrospective observational study consecutively collected patients in a large academic hospital between 01/01 and 11/01/2017 and followed for 4 years. Patients were scored by TIMI and GRACE scores on hospital admission. In-hospital endpoints were defined as the in-hospital composite event, including mortality, re-infarction, heart failure, stroke, cardiac shock, or resuscitation. Long-term outcomes were all-cause mortality and cardiac mortality in 4-year follow-up. RESULTS: A total of 232 patients were included (female 29.7%, median age 67 years), with a median follow-up of 3.7 years. GRACE score grouped most patients (45.7%) into high risk, while TIMI grouped the majority (61.2%) into medium risk. Further subgrouping the TIMI medium group showed that half (53.5%) of the TIMI medium risk population was GRACE high risk (≥ 140). Compared to TIMI medium group + GRACE < 140 subgroup, the TIMI medium + GRACE high-risk (≥ 140) subgroup had a significantly higher in-hospital events (39.5% vs. 9.1%, p < 0.05), long-term all-cause mortality (22.2% vs. 0% p < 0.001) and cardiac death (11.1% vs. 0% p = 0.045) in 4-year follow-up. GRACE risk scores showed a better predictive ability than TIMI risk scores both for in-hospital and long-term outcomes. (AUC of GRACE vs. TIMI, In-hospital: 0.82 vs. 0.62; long-term mortality: 0.89 vs. 0.68; long-term cardiac mortality: 0.91 vs. 0.67, all p < 0.05). Combined use of the two risk scores reserved both the convenience of scoring and the predictive accuracy. CONCLUSION: GRACE showed better predictive accuracy than TIMI in East Asian NSTEMI patients in both in-hospital and long-term outcomes. The sequential use of TIMI and GRACE scores provide an easy and promising discriminative tool in predicting outcomes in NSTEMI East Asian patients.

Relationship between increased systemic immune-inflammation index and coronary slow flow phenomenon.

BACKGROUND: Systemic immune-inflammation index (SII, platelet × neutrophil/lymphocyte ratio), a new marker of inflammation, is associated with adverse cardiovascular events, but its relationship with coronary slow flow phenomenon (CSFP) is unclear. Therefore, we aimed to investigate the relationship between SII and CSFP. METHODS: We enrolled consecutive patients who presented with chest pain, with normal/near-normal coronary angiography findings (n = 89 as CSFP group; n = 167 as control group). The baseline characteristics, laboratory parameters and angiographic characteristics of the two groups were compared. RESULTS: SII levels were significantly higher in the CSFP group than in the control group (409.7 ± 17.7 vs. 396.7 ± 12.7, p < 0.001). A significant positive correlation between SII and the mean thrombolysis in myocardial infarction frame count (mTFC) was found (r = 0.624, p < 0.001). SII increased with the number of coronary arteries involved in CSFP. In multivariate logistic regression analysis, SII/10 was an independent predictor of CSFP (odds ratio: 1.739, p < 0.001). In addition, the SII level > 404.29 was a predictor of CSFP with 67.4% sensitivity and 71.9% specificity. CONCLUSIONS: SII can predict the occurrence of CSFP.

A comparison of risk scores' long-term predictive abilities for patients diagnosed with ST elevation myocardial infarction who underwent early percutaneous coronary intervention.

Objective. To compare the long-term (5 year) prognostic values of commonly used risk scores on major adverse cardiovascular events (MACE) in a cohort of patients who underwent primary PCI for STEMI. Design. We created a composite endpoint of MACE, defined as the occurrence of any of the following events within 5 years: ischemic or hemorrhagic stroke, target vessel revascularization, nonfatal myocardial infarction, cardiovascular death. We dichotomized risk scores into high risk and not high risk according to the literature's pre-existing cutoffs as follows: GRACE score >127 = high risk, SYNTAX I score ≥33 = high risk, SYNTAX II ≥32 high risk, TIMI >8 = high risk. We utilized the area under the receiver operating characteristic curve (AUC) as the metric for predictive ability. Results. There were 768 patients in this study and 416 (54.2%), 209 (27.2%), 511 (66.5%), and 74 (9.6%) were at high risk according to the GRACE, SYNTAX I, SYNTAX II, and TIMI scores, respectively. The AUCs for 5-year MACE were 0.54 (95% confidence interval (CI): 0.49-0.59, p = .0947), 0.79 (95% CI: 0.75-0.83, p < .0001), 0.58 (95% CI: 0.54-0.62, p = .0004), and 0.5 (95% CI: 0.48-0.53, p = .7259), respectively. Conclusion. SYNTAX I score was superior in predicting MACE in patients with STEMI and a high burden of CAD. Utilizing the basal SYNTAX I score in STEMI patients with significant non-culprit CAD may improve risk stratification, decision-making, and outcomes.

Association between thrombolysis in myocardial infarction grade and clinical outcome after emergent percutaneous coronary intervention in patients with acute myocardial infarction who have suffered out-of-hospital cardiac arrest: the Yamagata AMI registry.

Despite improvements in the survival rate of acute myocardial infarction (AMI), out-of-hospital cardiac arrest (OHCA) due to AMI is still a devastating condition. Thrombolysis in myocardial infarction (TIMI) grade is used to classify coronary reperfusion after percutaneous coronary intervention (PCI), but it remains unclear whether TIMI grade after emergent PCI is associated with short-term mortality in patients with AMI who have suffered OHCA. We analyzed data collected from 2012 to 2017 and recorded in the Yamagata AMI registry, which is a multicenter surveillance conducted in all institutions in Yamagata prefecture. Among 3332 patients with AMI, 254 had suffered OHCA. There were 564 deaths during the 30 days after the onset of AMI. The survival rate was lower in patients who had suffered OHCA than in those who had not (40% vs. 87%; P < 0.0001). Patients with AMI who had suffered OHCA were divided into three groups based on TIMI grade (TIMI III group, n = 70; TIMI ≤ II group, n = 21; and no coronary angiography [non-CAG] group, n = 163). The survival rates in the TIMI III, TIMI ≤ II, and non-CAG groups were 87%, 38%, and 5%, respectively. Kaplan-Meier analysis demonstrated that the survival rate was highest in the TIMI III group. Multivariate Cox proportional hazard regression analysis demonstrated that TIMI III was closely associated with survival after adjustment for confounding factors. Achieving TIMI grade III during emergent PCI is crucial to improve survival in patients with AMI who have suffered OHCA.

Comparison of the T-MACS score with the TIMI score in patients presenting to the emergency department with chest pain.

OBJECTIVES: Guidelines recommend the use of risk scoring in patients with chest pain. In this study, we aimed to compare the thrombolysis in myocardial infarction risk index (TIMI) score with the Troponin Only Manchester Acute Coronary Syndrome Score (T-MACS) score and to investigate the usability of the T-MACS score in the emergency department. METHODS: In our study; The TIMI and T-MACS scores of 310 patients with suspected NSTEMI who applied to the emergency department with chest pain and met the inclusion and exclusion criteria were prospectively evaluated. The primary outcome was MACE at 30 days including acute coronary syndromes, need for revascularization and deaths. Descriptive data and TIMI and T-MACS scores for predicting MACE and ACS was evaluated by calculating sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). ROC (Receiver Operating Characteristic) analysis was also performed to determine TIMI and T-MACS risk class. RESULTS: In our study, the mean age of the patients was 49.7 ± 19.4 years, the 1-month mortality rate was 1.3%, majör adverse cardiac event (MACE) rate was 6.5%, and acute coronary syndrome (ACS) rate was 5.5%. T-MACS risk class for predicting MACE sensitivity 100%, selectivity 51.72, PPV 12.5% (for very low risk), NPV was calculated as 100%; sensitivity for TIMI risk class low risk 35%, selectivity 88.97%, PPV was calculated as 17.9%, NPV was calculated as 95.2%. T-MACS high risk class for predicting MACE; sensitivity was 60%, selectivity 99.66%, PPV 92.3% and NPV was 97.3%; TIMI high risk class for predicting MACE; sensitivity was 10%, selectivity was 97.93%, PPV was 25% and NPV was 94%. CONCLUSIONS: The findings obtained in this study suggest that the T-MACS score is more successful than the TIMI score in determining the low risk (very low risk for T-MACS score), high risk, and estimated 1-month MACE risk in cases who presented to the emergency department with chest pain.

Assessment of triglyceride/glucose index with respect to coronary slow flow.

BACKGROUND: Coronary slow flow (CSF) is determined by delayed opacification of the epicardial coronary arteries without obstructive disease. The triglyceride glucose index (TGI) has been suggested as a useful marker of insulin resistance. Previous studies have shown that TGI is associated with cardiovascular disease, but no study has examined the relationship between TGI and CSF. OBJECTIVES: Therefore, the primary objective of the present study was to investigate the relationship between TGI and CSF. METHODS: This study retrospectively evaluated patients who were admitted to our clinic with complaints of chest pain and underwent coronary angiography between January and December 2018. A total of 1100 coronary angiography images were assessed, and 72 patients with CSF were detected. Coronary flow was quantified objectively using the TIMI (thrombolysis in myocardial infarction) frame count (TFC) method as described by Gibson et al. TGI was calculated as follows: ln [fasting triglycerides (mg/dL) × fasting glucose (mg/dL)/2]. RESULTS: The CSF group had significantly higher glucose levels (mg/dl) [ (114.92±30.92), (125.61±33.22), than the control and CSF groups, respectively, p=0.0001], TGI [ (9.02±0.56), (9.26±0.54), p=0.0001], and triglyceride levels (mg/dl) [ (170.67±110.81), (201.19±136.93), p=0.002]. There was no statistically significant correlation between TGI and left anterior descending artery TFC, circumflex artery TFC, right coronary artery TFC (r/p values; 0.24/0.06; 0.32/0.08; 0.18/0.36, respectively). TGI, HDL, HT, age, and sex were examined with a multiple logistic model, and TGI was found to be statistically significant for the risk of CSF (p=0.0001; O.R:7.459). CONCLUSION: TGI was statistically significantly higher in the CSF group than the control group. According to the multivariate logistic regression analysis, only TGI was independently associated with the risk of CSF, but higher TGI did not predict more slow coronary flow. Prospective studies are needed to clarify the prognostic relationship of TGI and CSF in terms of future cardiovascular events (Tab. 2, Fig. 1, Ref. 19).