Comparing pharmacotherapy in MINOCA versus medically managed obstructive acute coronary syndrome.

Most prior studies have compared myocardial infarction with non-obstructive coronary arteries (MINOCA), to obstructive acute coronary syndrome (ACS) often requiring revascularisation. However, these were subject to treatment bias given the significant differences in management. This study uniquely compares the management and outcomes of MINOCA patients with a medically managed obstructive ACS (M-ACS) population. We retrospectively analysed registry data for consecutive patients admitted to the Gold Coast University Hospital with ACS requiring coronary angiography and identified patients with MINOCA and M-ACS. Baseline characteristics, pharmacological therapy and in-hospital outcomes were compared. In hospital outcomes were composite NACE, heart failure, stroke and major bleeding. Multivariate regression analysis was also performed to identify independent predictors of MINOCA. Multivariate regression analysis was also performed to identify independent predictors of MINOCA. We identified 139 patients with MINOCA and 142 patients with medically managed obstructive ACS (M-ACS). Multivariate regression analysis also identified female sex and cancer as independent predictors of MINOCA with odds ratios of 5.57 and 3.01, respectively. MINOCA patients were significantly less likely to receive cardioprotective medications at admission and discharge, specifically aspirin, beta-blockers, ACE-I and statins, compared to those with M-ACS. While mortality was higher among M-ACS patients (0.0% vs. 3.6%; p = 0.03), no significant differences were noted for composite NACE, heart failure, stroke and major bleeding. MINOCA patients have similar outcomes to M-ACS. Despite this, we noted a discrepancy in the use of cardioprotective medications. We also identified female sex and cancer were independent predictors of MINOCA. This may represent a missed opportunity to prevent adverse events among patients with MINOCA. Large, randomised trials are required to provide more definitive evidence.

Mortality in spontaneous coronary artery dissection: A systematic review and meta-analysis.

OBJECTIVE: The aim of this systematic review and meta-analysis was to provide a comprehensive estimate for spontaneous coronary artery dissection (SCAD) related mortality, and explore factors associated with an increased risk of death. BACKGROUND: SCAD is an infrequent but increasingly recognized cause of acute coronary syndrome. Despite a growing body of evidence, there have been few detailed examinations of SCAD associated mortality. METHODS: We searched MEDLINE, EMBASE, Cochrane, Web of Science and Google Scholar databases through May 7, 2020. We included studies reporting mortality data, confirmed SCAD with coronary angiography and included ≥10 participants. We excluded non-English studies, conference abstracts, review articles and duplicate datasets. Random-effects meta-analysis and meta-regression were used to evaluate estimates and predictors of mortality. RESULTS: From an initial 1,131 articles, 34 studies with 2,817 patients were eligible for inclusion. The weighted mean age was 50 years, and 84% of participants were female. The pooled estimate for SCAD mortality was 1% (Proportion 0.01; 95% CI, 0.00-0.02). The mean duration of follow-up was 33 months. Meta-regression showed male sex was associated with 3.5-fold increased odds of mortality (OR, 3.50; 95% CI, 1.22-10.03). In addition, smoking (current or previous) was associated with a 15-fold increased risk of mortality (OR 15.32; 95% CI, 2.88-81.41). CONCLUSIONS: This meta-analysis has shown that SCAD is associated with favorable survival outcomes with an estimated mortality of 1% over a mean follow-up period of 33 months. We also found male sex and smoking were associated with an increased risk of mortality.

Association Between Indigenous Status and Severity of Coronary Artery Disease: A Comparison of Coronary Angiogram Findings in Patients With Chest Pain Presenting to a Regional Hospital Emergency Department.

BACKGROUND: Coronary artery disease (CAD) remains the leading cause of death amongst Indigenous Australians accounting for 12.1% of all deaths in this population. However, there is little evidence to suggest that Indigenous status is an independent risk factor for the development of coronary artery disease. This study assessed the association between Indigenous status and the severity of CAD in patients presenting with chest pain at a regional hospital emergency department. METHODS: This was a retrospective single-centre audit over 12 months from January to December 2017. Charts were reviewed for both Indigenous and non-Indigenous patients 18 years and older who presented with chest pain and subsequently underwent an invasive coronary angiogram. Multivariable logistic regression was performed to examine the association of Indigenous status with the severity of CAD. RESULTS: Indigenous patients are 2.7 times more likely to experience significant CAD compared to non-Indigenous patients (Adjusted odds ratio [AOR]=2.73, 95% CI [1.38, 5.39], p≤0.001) even after adjusting for other risk factors. Those aged 65 years and older are more prone to significant CAD (AOR=2.96, 95% CI [1.12, 7.78], p=0.03), while women were less likely to have significant CAD compared to men, (AOR=0.46, 95% CI [0.27, 0.78], p<0.01). CONCLUSION: In this study cohort, our analysis indicates that there is a strong association between Indigenous status and significant coronary artery disease, independent of the increased burden of traditional cardiovascular risk factors among Indigenous Australians.

Coronavirus disease 2019 outcomes in heart transplant recipients: A large Australian cohort.

Heart transplant recipients have been reported to be at a significantly elevated risk of poor outcomes from coronavirus disease 2019 (COVID-19) infection owing to their underlying comorbidities and immunosuppression. We conducted a single-center retrospective cohort of all heart transplant recipients who were known to have contracted COVID-19 between January 2020 and September 2022. Electronic medical records were used to collect baseline demographics, vaccination status, COVID-19 treatment received, hospitalization data, and mortality. Our primary end point was mortality, and our secondary endpoint was hospitalization. Between January 2020 and September 2022, 132 heart transplant recipients at our single-center contracted COVID-19 infection. Our population had high rates of vaccination, with 124 patients (94%) having received at least 2 vaccines. We found significantly lower rates of mortality and hospitalization than had been previously reported earlier in the pandemic, with a mortality rate of 8/132 (6%) and hospitalization rate of 21/132 (16%).

Burden of ischemic heart disease and its attributable risk factors in 204 countries and territories, 1990-2019.

AIMS: To report the prevalence, deaths, and disability-adjusted life years (DALYs) associated with ischemic heart disease (IHD) and its attributable risk factors in 204 countries and territories from 1990 to 2019, by age, sex, and socio-demographic index (SDI). METHODS AND RESULTS: Ischemic heart disease was defined as acute myocardial infarction (MI) and chronic IHD (angina; asymptomatic IHD following MI). Cause of death ensemble modelling was used to produce fatality estimates. The prevalence of the non-fatal sequalae of IHD was estimated using DisMod MR 2.1. All estimates were presented as counts and age-standardized rates per 100 000 population. In 2019, IHD accounted for 197.2 million (177.7-219.5) prevalent cases, 9.1 million (8.4-9.7) deaths, and 182.0 million (170.2-193.5) DALYs worldwide. There were decreases in the global age-standardized prevalence rates of IHD [-4.6% (-5.7, -3.6)], deaths [-30.8% (-34.8, -27.2)], and DALYs [-28.6% (-33.3, -24.2)] from 1990 to 2019. In 2019, the global prevalence and death rates of IHD were higher among males across all age groups, while the death rate peaked in the oldest group for both sexes. A negative association was found between the age-standardized DALY rates and SDI. Globally, high systolic blood pressure (54.6%), high low-density lipoprotein cholesterol (46.6%), and smoking (23.9%) were the three largest contributors to the DALYs attributable to IHD. CONCLUSION: Although the global age-standardized prevalence, death, and DALY rates all decreased. Prevention and control programmes should be implemented to reduce population exposure to risk factors, reduce the risk of IHD in high-risk populations, and provide appropriate care for communities.

Systematic review and meta-analysis of the incidence of recurrence of spontaneous coronary artery dissection.

AIM: Recurrence is a well-established complication of spontaneous coronary artery dissection (SCAD). However, the exact incidence and correlates of recurrence are unknown. We, therefore, performed a systematic review and meta-analysis to determine and consolidate the evidence on the global incidence of SCAD recurrence. METHODS: A comprehensive search of the four major databases (EMBASE, OVID Medline, PubMed and Google Scholar) was performed from their inception to 17 January 2019. We included original research studies, recruiting ≥10 participants, with ≥12 months follow-up that reported data on recurrence in patients with SCAD. RESULTS: Out of 556 studies searched, 19 cohorts (1538 SCAD patients) were included in the analysis. There were 153 cases of de novo recurrence over a mean follow-up period of 31.2 months (95% confidence interval, 25-41 months). Type 1, 2 and 3 SCAD was noted in 33.2, 73.2 and 5.3%, respectively. The involved coronary artery was LMCA, LAD, RCA, LCx and multi-vessel CAD respectively in 3.5%, 53.4%, 19.8%, 20.4% and 12.6% of cases. The overall SCAD de novo recurrence was 7% (ES 0.07, 95% confidence interval, 0.04-0.10, I2 = 65.3%). On meta-regression, we found discharge medications at index admission, including ß-blockers, ACE inhibitors, statins, as well as baseline cardiac risk factors, did not correlate with recurrence. CONCLUSION: SCAD recurrence is common, occurring in 7% of patients over medium-term follow up. No specific medications at discharge were found to reduce recurrence. Further long-term and prospective data are required.

Geographic variation in the statin trials: Underrepresentation of Asian populations.

BACKGROUND: Globalisation has seen a shift towards international multicentre randomised controlled trials (RCTs). The amalgamation of heterogenous patient populations is thought to be responsible for the geographic variation in treatment effect noted in recent trials. Furthermore, there is significant underrepresentation of lower- income countries in cardiovascular disease (CVD) research. These issues raise important questions about the generalisability of these trial results. Given the central role of statin therapy in CVD risk reduction, we evaluated for geographic variation in treatment effect in the primary and secondary prevention statin RCTs. METHODS: We conducted a comprehensive literature search using the terms: "statin", "coronary disease", "reduce" and "cholesterol". We included statin RCTs with >1000 participants, therapy >2 years and CVD outcomes. We analysed each study for regional recruitment data and geographic subgroup analysis. RESULTS: From an initial 2154 studies, we identified 20 eligible for inclusion. This amounted to 138,612 participants across multiple continents including Europe 69,086 (49.8%), Asia 14,672 (10.6%), South America 5128 (3.7%), North America 33,393 (24.1%), Oceania 9445 (6.8%) and Africa 2801 (2%). Data were unavailable for 4087 (2.9%) participants. Despite together comprising 35% of the world's population, China and India represented only 2.7% and 1.3% of the studied population respectively. None of the 6 multi-continent trials provided regional analysis. CONCLUSION: We were unable to identify significant geographic variation in the outcomes of the statin RCTs, primarily due to a lack of data. We also observed regarding statin RCT data, there is limited involvement of countries with the greatest burden of CVD.