Unidirectional conduction characterizing epicardial connections in patients with atrial tachyarrhythmias.

INTRODUCTION: Electrophysiological characteristics of epicardial connections (ECs) in atria and pulmonary veins (PVs) are unclear despite their important contributions to atrial fibrillation (AF). Unidirectional conduction associated with source-sink mismatch can occur in ECs due to their fine fibers with abrupt changes in orientation. We detailed the prevalence and electrophysiological characteristics of unidirectional conduction in the atria and investigated its association with the clinical manifestation of AF. METHODS: This study retrospectively reviewed electrophysiological studies and radiofrequency catheter ablation in 261 consecutive patients with AF. RESULTS: Unidirectional conduction was observed during ablation encircling the PVs in eight (3.1%) patients, and all occurred in the suspected (N = 4) or definitively (N = 4) recognized ECs. These ECs included three intercaval bundles, four septopulmonary bundles, and one Marshall bundle, and were first manifested in a second procedure in 6 (75%) patients. The unidirectional property was from PV to atrium (exit conduction) in all intercaval bundles and three septopulmonary bundles, and from atrium to PV (entrance conduction) in the remaining two bundles. Intercaval bundles acted as a limb of bi-atrial macro-reentrant tachycardia (50%, three of the six including previous cases). Ablation of the exit outside the PVs, including the right atrium, eliminated ECs in three (38%) patients. All patients remain free from arrhythmia recurrence after a mean 13-month follow-up. CONCLUSION: A unidirectional conduction property was closely associated with the EC, as estimated by histological findings. Recognition of this fact by electrophysiologists may help to clarify mechanisms for AF and atrial tachycardia and guide the creation of efficient and safe ablation lesion sets.

Impact of catheter ablation and subsequent recurrence of atrial fibrillation on glucose status in patients undergoing continuous glucose monitoring.

Although glucose metabolism and atrial fibrillation (AF) have complex interrelationships, the impact of catheter ablation of AF on glucose status has not been well evaluated. Continuous glucose monitoring (CGM) with a FreeStyle Libre Pro (Abbott) was performed for 48 h pre-procedure, during the procedure, and for 72 h post-procedure in 58 non-diabetes mellitus (DM) patients with symptomatic AF and 20 patients with supraventricular or ventricular arrhythmias as a control group. All ablation procedures including pulmonary vein isolation were performed successfully. Glucose levels during procedures consistently increased in the AF and control groups (83.1 ± 16.1 to 110.0 ± 20.5 mg/dL and 83.3 ± 14.7 to 98.6 ± 16.3 mg/dL, respectively, P < 0.001 for both), and Δ glucose levels (max minus min/procedure) were greater in the AF group than control group (P < 0.001). There was a trend toward higher mean glucose levels at 72 h after the procedures compared with those before the procedures in both the AF and control groups (from 103.4 ± 15.6 to 106.1 ± 13.0 mg/dL, P = 0.063 and from 100.2 ± 17.1 to 102.9 ± 16.9 mg/dL, P = 0.052). An acute increase in glucose level at the time of early AF recurrence (N = 9, 15.5%) could be detected by simultaneous CGM and ECG monitoring (89.7 ± 18.0 to 108.3 ± 30.5 mg/dL, P = 0.001). In conclusion, although AF ablation caused a statistically significant increase in the glucose levels during the procedures, it did not result in a pathologically significant change after ablation in non-DM patients. Simultaneous post-procedure CGM and ECG monitoring alerted us to possible acute increases in glucose levels at the onset of AF recurrence.

Case of a pregnant woman with probable prolonged SARS-CoV-2 viral shedding 221 days after diagnosis.

We describe a case of probable prolonged severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Alpha(B.1.1.7) variant shedding for 221 days from the diagnosis, in a healthy 20-year-old Japanese pregnant woman with a normal delivery. To our knowledge, this is the longest duration of SARS-CoV-2 shedding reported in an immunocompetent individual to date.

Predictors of Recurrence after Catheter Ablation of Paroxysmal Atrial Fibrillation in Different Follow-Up Periods.

Background and objectives: Pulmonary vein (PV) reconnection is a major reason for recurrence after catheter ablation of paroxysmal atrial fibrillation (PAF). However, the timing of the recurrence varies between patients, and recurrence >1 year after ablation is not uncommon. We sought to elucidate the characteristics of atrial fibrillation (AF) that recurred in different follow-up periods. Materials and Methods: Study subjects comprised 151 consecutive patients undergoing initial catheter ablation of PAF. Left atrial volume index (LAVi) and atrial/brain natriuretic peptide (ANP/BNP) levels were systematically measured annually over 3 years until AF recurred. Results: Study subjects were classified into four groups: non-recurrence group (n = 84), and short-term- (within 1 year) (n = 30), mid-term- (1-3 years) (n = 26), and long-term-recurrence group (>3 years) (n = 11). The short-term-recurrence group was characterized by a higher prevalence of diabetes mellitus (hazard ratio 2.639 (95% confidence interval, 1.174-5.932), p = 0.019 by the Cox method), frequent AF episodes (≥1/week) before ablation (4.038 (1.545-10.557), p = 0.004), and higher BNP level at baseline (per 10 pg/mL) (1.054 (1.029-1.081), p < 0.0001). The mid-term-recurrence group was associated with higher BNP level (1.163 (1.070-1.265), p = 0.0004), larger LAVi (mL/m2) (1.033 (1.007-1.060), p = 0.013), and longer AF cycle length at baseline (per 10 ms) (1.194 (1.058-1.348), p = 0.004). In the long-term-recurrence group, the ANP and BNP levels were low throughout follow-up, as with those in the non-recurrence group, and AF cycle length was shorter (0.694 (0.522-0.924), p = 0.012) than those in the other recurrence groups. Conclusions: Distinct characteristics of AF were found according to the time to first recurrence after PAF ablation. The presence of secondary factors beyond PV reconnections could be considered as mechanisms for the recurrence of PAF in each follow-up period.

Short-duration triple antithrombotic therapy for atrial fibrillation patients who require coronary stenting: results of the SAFE-A study.

AIMS: We aimed to determine whether shortening the duration of P2Y12 inhibitor therapy can reduce the risk of bleeding without increasing the risk of major adverse cardiovascular events following coronary stenting in patients with atrial fibrillation (AF). METHODS AND RESULTS: The SAFE-A is a randomised controlled trial that compared one-month and six-month P2Y12 inhibitor therapy, in combination with aspirin and apixaban for patients with AF who require coronary stenting. The primary endpoint was the incidence of any bleeding events, defined as Thrombolysis In Myocardial Infarction major/minor bleeding, bleeding with various Bleeding Academic Research Consortium grades, or bleeding requiring blood transfusion within 12 months after stenting. The study aimed to enrol 600 patients but enrolment was slow. Enrolment was terminated prematurely after enrolling 210 patients (72.7±8.2 years; 81% male). The incidence of the primary endpoint did not differ between the one-month and six-month groups (11.8% vs 16.0%; hazard ratio [HR] 0.70, 95% confidence interval [CI]: 0.33-1.47; p=0.35). CONCLUSIONS: The study evaluated the safety of withdrawing the P2Y12 inhibitor from triple antithrombotic prescription one month after coronary stenting. However, enrolment was prematurely terminated because it was slow. Therefore, statistical power was not sufficient to assess the differences in the primary endpoint.

Interatrial distance predicts the necessity of additional carina ablation to isolate the right-sided pulmonary veins.

BACKGROUND: Ablation of the pulmonary vein (PV) carina is occasionally required for PV isolation (PVI). Marshall bundle and epicardial connections between the right-sided PV (RtPV) carina and right atrium (RA) may be one of the mechanisms that necessitates carina ablation. OBJECTIVE: We sought to clarify anatomical characteristics predictive of the necessity of carina ablation. METHODS: Forty-five consecutive patients undergoing radiofrequency catheter ablation of atrial fibrillation were prospectively included in this study. Left atrial (LA) and PV size and morphology, and interatrial distance in the posterior aspect, were measured on cardiac computed tomography (CT) images. RESULTS: For right-sided PVI, the patients were divided into 2 groups based on the necessity of RtPV carina ablation, Carina-ABL group (n = 21) and Non-Carina-ABL group (n = 24). The distance between the anterior portion of the RtPV carina and RA was shorter in the Carina-ABL group vs in the Non-Carina-ABL group (7.7 ± 1.7 mm/m2 vs 9.5 ± 2.3 mm/m2; P = .005), whereas other anatomical parameters (LA and RA volumes, right inferior PV angle, and ostial diameters of the RtPVs) did not differ between the groups. For left-sided PVI, the ostial diameter and circumference of the left superior PV were smaller in the Carina-ABL group (n = 13) vs the Non-Carina-ABL group (n = 32) (8.6 ± 2.1 mm/m2 vs 7.3 ± 1.5 mm/m2; P = .044, and 34.9 ± 6.0 mm/m2 vs 30.1 ± 5.1 mm/m2; P = .017, respectively). CONCLUSIONS: A shorter interatrial distance for right-sided PVI and a smaller PV ostium for left-sided PVI were associated with the necessity of additional carina ablation. The presence and location of the epicardial fibers may be affected by the atrial and PV geometry.

Upgrade of cardiac resynchronization therapy by utilizing additional His-bundle pacing in patients with inotrope-dependent end-stage heart failure: a case series.

BACKGROUND: His-bundle pacing (HBP) alone may become an alternative to conventional cardiac resynchronization therapy (CRT) utilizing right ventricular apical (RVA) and left ventricular (LV) pacing (BiVRVA+LV) in selected patients, but the effects of CRT utilizing HBP and LV pacing (BiVHB+LV) on cardiac resynchronization and heart failure (HF) are unclear. CASE SUMMARY: We presented two patients with inotrope-dependent end-stage HF in whom the upgrade from conventional BiVRVA+LV to BiVHB+LV pacing by the addition of a lead for HBP improved their HF status. Patient 1 was a 32-year-old man with lamin A/C cardiomyopathy, atrial fibrillation, and complete atrioventricular (AV) block. Patient 2 was a 70-year-old man with ischaemic cardiomyopathy complicated by AV block and worsening of HF resulting from ablation for ventricular tachycardia storm. The HF status of both patients improved dramatically following the upgrade from BiVRVA+LV to BiVHB+LV pacing. DISCUSSION: End-stage HF patients suffer from diffuse intraventricular conduction defect not only in the LV but also in the right ventricle (RV). The resulting dyssynchrony may not be sufficiently corrected by conventional BiVRVA+LV pacing or HBP alone. Right ventricular apical pacing itself may also impair RV synchrony. An upgrade to BiVHB+LV pacing could be beneficial in patients who become non-responsive to conventional BiV pacing as the His-Purkinje conduction defect progresses.

Blunt cardiac rupture due to kicking on the lateral side of the right chest.

Blunt cardiac rupture can be caused by an indirect blow to the heart during sports. Clinicians should consider the possibility of cardiac injury regardless of the severity of trauma. Confirming the diagnosis and reaching a decision to operate as soon as possible is the only way to rescue the patient.

Structural relation between the superior vena cava and pulmonary veins in patients with atrial fibrillation.

The superior vena cava (SVC) is a main source of non-pulmonary vein (PV) ectopies that initiate atrial fibrillation (AF). Although the critical role of structural remodeling of the left atrium (LA) in the occurrence of AF was extensively investigated by atrial voltage mapping, that of PVs and the SVC has been less explored. Study subjects comprised 47 patients undergoing catheter ablation of lone AF. During sinus rhythm, PV, SVC, and atrial voltage maps were acquired, and sleeve length of each PV and SVC was determined by an electroanatomical mapping system. The sleeves of the superior PVs were significantly longer than those of the inferior PVs (left superior PV (LSPV): 21 ± 5, left inferior PV: 14 ± 4, right superior PV (RSPV): 19 ± 5, right inferior PV: 15 ± 5, and SVC: 23 ± 10 mm, p < 0.0001). The LSPV sleeve was longer in men than in women (22 ± 6 vs. 19 ± 4 mm, p < 0.05). The sleeve length in the LSPV correlated positively with the body surface area (BSA) (p = 0.003, R = 0.42). Of note, there was a significant correlation in sleeve length between the RSPV and SVC (p < 0.0001, R = 0.64). In conclusion, not right- but left-sided PV sleeves were associated with the BSA of the patients, whereas a structural relation between the right-sided PVs and the SVC was implied based on sleeve mapping. This novel finding may provide mechanistic implications for the development of AF in future studies.

Epicardial connection between the right-sided pulmonary venous carina and the right atrium in patients with atrial fibrillation: A possible mechanism for preclusion of pulmonary vein isolation without carina ablation.

BACKGROUND: Ablation of the pulmonary venous carina is occasionally required for pulmonary vein isolation (PVI) despite its nonessential role in ipsilateral PVI from the anatomical (endocardial) viewpoint. Although the Bachmann bundle (BB) is a common and main interatrial band, local variations in small tongues of muscular fibers were frequently found in autopsy studies. OBJECTIVE: We sought to clarify the effect of the electrical conduction pattern from the right atrium (RA) to the left atrium (LA) during sinus rhythm on the necessity of performing right-sided pulmonary venous carina ablation to achieve PVI. METHODS: Study subjects comprised 37 consecutive patients undergoing initial catheter ablation of lone atrial fibrillation. During sinus rhythm, RA and LA activation maps were acquired using an electroanatomical mapping system. LA breakthroughs were classified into 3 sites: BB, fossa ovalis (FO), and right-sided pulmonary venous carina. Patients were divided into the carina-ABL (ablation) or non-carina-ABL group on the basis of the necessity of pulmonary venous carina ablation to achieve PVI. RESULTS: Patients were classified in the non-carina-ABL group (n = 26 [70%]) and carina-ABL group (n = 8 [22%]) after excluding 3 patients (8%) because of their complex ablation lesion sets. Breakthrough occurred in the BB (n = 21 patients [62%]), FO (n = 7 [21%]), carina (n = 1 [3%]), carina and BB (n = 3 [9%]), and carina and FO (n = 2 [6%]). Carina breakthrough occurred in 6 patients (75%) in the carina-ABL group but in no patients in the non-carina-ABL group (P < .0001). CONCLUSION: PVI was not achievable without carina ablation in one-fifth of patients, probably because of epicardial connections present between the right-sided pulmonary venous carina and the RA.

Mechanistic implication of decreased plasma atrial natriuretic peptide level for transient rise in the atrial capture threshold early after ICD or CRT-D implantation.

PURPOSE: Despite the use of steroid-eluting leads, a transient but not persistent rise in the atrial/ventricular capture threshold (TRACT/TRVCT) can occur early after pacemaker implantation in patients with sick sinus syndrome. This study aimed to assess the prevalence, predictors, and mechanisms of TRACT/TRVCT in patients with heart failure undergoing implantable cardioverter defibrillator (ICD) or cardiac resynchronization therapy (CRT) implantation. METHOD: One hundred twenty consecutive patients underwent ICD (N = 70) or CRT (N = 50) implantation. Capture threshold was measured at implantation, 7-day, 1-month, and 6-month post-implantation. TRACT/TRVCT was defined as a threshold rise at 7 days by more than twice the height of the threshold at implantation, with full recovery during follow-up. Atrial and brain natriuretic peptide (ANP and BNP) levels were measured before implantation. RESULTS: TRACT and TRVCT were observed in 13 (11%) and 10 (8%) patients, respectively. Patients with TRACT had lower ANP level (median 72 [42-105] vs. 99 [49-198] pg/mL, P = 0.06), lower ANP/BNP ratio (0.29 [0.20-0.36] vs. 0.50 [0.33-0.70], P < 0.01), lower atrial sensing amplitude (2.0 ± 0.8 vs. 2.7 ± 1.3 mV, P = 0.02), and lower left ventricular ejection fraction (32 ± 12 vs. 40 ± 14%, P = 0.04) than those without TRACT. TRACT recovered within 1 month, whereas TRVCT recovered within 6 months. In multivariable analysis, ANP/BNP ratio was the only independent predictor of TRACT (OR, 0.018; 95% CI, 0.001-0.734; P = 0.034). CONCLUSIONS: Atrial degenerative change characterized by lower ANP/BNP ratio was associated with the occurrence of TRACT in patients with heart failure. TRVCT could also occur, but it required a longer recovery time than TRACT.

Underrecognized entity of the transient rise in the atrial capture threshold early after dual-chamber pacemaker implantation.

BACKGROUND: Steroid-eluting pacemaker leads suppress acute rises in pacing threshold by preventing inflammatory processes. However, we occasionally encounter not persistent but transient rise in the atrial capture threshold (TRACT) early after pacemaker implantation. We believe that this phenomenon is underrecognized in clinical practice and may potentially lead to unnecessary reintervention. We aimed to clarify the prevalence, predictors, and possible mechanisms of TRACT. METHODS AND RESULTS: We reviewed clinical records from 239 consecutive patients who underwent dual-chamber pacemaker implantation for sick sinus syndrome (SSS) (N = 102) or atrioventricular block (AVB) (N = 137). Atrial capture threshold was measured at implantation and 7 days, 2 months, and 8 months postimplantation. TRACT was defined as a rise in the threshold at day 7 to ≥twice that at implantation, with an absolute value ≥1.0 V/0.4 ms, and full recovery by 8 months into follow-up. TRACT was observed in 15 patients (6%), of whom13 (87%) suffered from SSS but not AVB. Patients with TRACT had greater body mass index (BMI) (25 ± 5 kg/m2 vs 23 ± 4 kg/m2 , P = 0.01), larger left atrium (42 ± 5 mm vs 38 ± 7 mm, P = 0.03), and were more likely to suffer from paroxysmal atrial fibrillation (60% vs 31%, P = 0.02) than those without TRACT. In multivariable logistic regression analysis, BMI and SSS were the independent predictors of TRACT (odds ratio [OR], 1.172; 95% confidence interval [CI], 1.019-1.349; P = 0.03 and OR, 11.53; 95% CI, 2.010-66.21; P = 0.006, respectively). CONCLUSIONS: The distinct phenomenon of TRACT was not rare in clinical practice early after dual-chamber pacemaker implantation, and its occurrence was strongly associated with SSS.

Electrophysiological relation between the superior vena cava and right superior pulmonary vein in patients with paroxysmal atrial fibrillation.

INTRODUCTION: The superior vena cava (SVC) is a main source of nonpulmonary vein (PV) ectopies initiating atrial fibrillation (AF). Empiric SVC isolation may improve rhythm outcomes after catheter ablation of AF. Because the SVC passes immediately adjacent to the right superior PV (RSPV), an electrophysiological relation could be present between the two structures. The present study aimed to estimate the interrelation between the SVC and RSPV by evaluating arrhythmogenic activities observed during catheter ablation of AF. METHODS AND RESULTS: Study subjects comprised 121 consecutive patients referred for catheter ablation of paroxysmal AF. Isoproterenol infusion was used to induce ectopies and AF. Patients were divided into two groups depending on the presence of arrhythmogenic SVC: arrhythmogenic-SVC (A-SVC) and nonarrhythmogenic SVC (Non-A-SVC) groups. The prevalence of females was higher and body surface area was smaller in the A-SVC group (N = 22) than Non-A-SVC group (N = 99). Arrhythmogenic activities were observed in 60 (49%) RSPVs, 24 (20%) right inferior PVs, 72 (59%) left superior PVs, and 31 (25%) left inferior PVs. Arrhythmogenic RSPVs were more prevalent in the A-SVC group than Non-A-SVC group (86% vs. 41%, P = 0.0001), whereas these prevalences in the other three PVs were not different between groups (P >0.3). In multivariable analysis, arrhythmogenic RSPV was the only independent predictor of arrhythmogenicity of the SVC (OR, 8.53; 95% CI 2.31-31.46; P = 0.001). CONCLUSIONS: An electrophysiological interrelation may be present between the SVC and RSPV in patients with paroxysmal AF. Semiempiric SVC isolation limited to patients with an arrhythmogenic RSPV may be a more efficient treatment strategy.

Hemodynamic collapse due to the stenosis of four pulmonary veins in a patient with mediastinal tumor.

Cardiogenic shock can occur due to compression of the four pulmonary veins and the left atrium by a mediastinal tumor. Steroid infusion can be a temporary alternative therapy before obtaining a definite diagnosis and performing an intervention with stents to dilate the pulmonary veins.

Comparison of Pulmonary Venous and Left Atrial Remodeling in Patients With Atrial Fibrillation With Hypertrophic Cardiomyopathy Versus With Hypertensive Heart Disease.

Left ventricular diastolic dysfunction in hypertrophic cardiomyopathy (HC) increases susceptibility to atrial fibrillation. Although phenotypical characteristics of the hypertrophied left ventricle are clear, left atrial (LA) and pulmonary venous (PV) remodeling has rarely been investigated. This study aimed to identify differences in LA and PV remodeling between HC and hypertensive heart disease (HHD) using 3-dimensional computed tomography. Included were 33 consecutive patients with HC, 25 with HHD, and 29 without any co-morbidities who were referred for catheter ablation of atrial fibrillation. Pre-ablation plasma atrial and brain natriuretic peptide levels, post-ablation troponin T level, and LA pressure were measured, and LA and PV diameters were determined 3 dimensionally. LA transverse diameter in the control group was smaller than that in the HHD or HC group (55 ± 6 vs 63 ± 9 vs 65 ± 12 mm, p = 0.0003). PV diameter in all 4 PVs was greatest in the HC group and second greatest in the HHD group (21.0 ± 3.1 vs 23.8 ± 2.8 vs 26.8 ± 4.1 mm, p <0.0001 for left superior PV). Differences in PV size between the HHD and HC groups were enhanced by indexing to the body surface area (12.4 ± 1.9 vs 13.1 ± 1.4 vs 16.1 ± 3.3 mm/m2, p <0.0001). The PV/LA diameter ratio was greater in the HC than in the other groups (0.38 ± 0.06 vs 0.38 ± 0.05 vs 0.42 ± 0.07, p = 0.01). Atrial natriuretic peptide, brain natriuretic peptide, troponin T levels, and LA pressure were highest in the HC group (all p <0.05). In conclusion, the stiff LA caused from atrial hypertrophy may account for higher levels of biomarkers, higher LA pressure, and PV-dominant remodeling in HC.

[Acquired Left Ventricular-right Atrial Communication due to Infective Endocarditis;Report of a Case].

A 77-year-old woman presented with a 3-week history of low grade fever, appetite loss and dizziness. An electrocardiogram showed complete heart block. Echocardiography demonstrated severe aortic valve stenosis and a mass of probable vegetation 2 cm in diameter on the atrioventricular septum in the right atrium (RA), but no obvious intra-cardiac fistula. There was no growth of organism in blood cul tures. In the 4th week after admission, a harsh and continuous cardiac murmur was detected for the 1st time. Portable echocardiography revealed disappearance of the mass in the RA, and showed an intra-cardiac shunt from the left ventricle( LV) to RA. The shunt was closed by autologous pericardial patch form LV side and directly with mattress suture form RA side during the emergency operation. The aortic valve was replaced with bio-prosthetic valve (SJM Trifecta 19 mm). No organism was detected in the excised tissue, but antibiotics were continued for 2 months until a permanent pacemaker was inserted.

Gender differences in the association between serum uric acid and prognosis in patients with acute coronary syndrome.

BACKGROUND: Increased levels of uric acid (UA) have been associated with cardiovascular disease. This association is generally stronger in women than men. However, gender differences in the prognostic value of UA in patients with acute coronary syndrome (ACS) are unknown. We investigated gender differences in the relationship between UA level and the prognosis in patients with ACS. METHOD: This was an observational analysis of patients with ACS undergoing percutaneous coronary intervention enrolled in the Ibaraki Cardiac Assessment Study (ICAS) registry. We analyzed 1380 patients (330 women, 1050 men) with ACS who had information on UA. We assessed the association between UA and the incidence of major cardiovascular adverse events (MACE), defined as all-cause death, congestive heart failure, reinfarction, and stroke. Patients were divided according to gender-specific UA quartile. RESULTS: The mean UA level in women was significantly lower than that in men (4.9mg/dl vs 5.9mg/dl, p<0.001). After a median duration of follow-up period of 437 days (interquartile range 222-801 days), MACE had occurred in 186 (13%) patients [56 (17%) events in women; 130 (12%) events in men]. Kaplan-Meier analysis for MACE-free survival demonstrated that a higher quartile of UA was associated with MACE in both women and men (p<0.001, p=0.002, respectively). Multivariate Cox regression analysis revealed that the highest quartile of UA, as compared with the lowest quartile of UA, was an independent predictor of MACE in women [hazard ratio (HR), 2.84; 95% CI, 1.19-6.77; p=0.018] but not in men (HR, 1.32; 95% CI, 0.66-2.64; p=0.422). CONCLUSIONS: An increased level of UA was associated with MACE more strongly in women than in men with ACS. These results suggest that there are gender differences in the association of UA level with the prognosis in patients with ACS.