HEART-score can be simplified without loss of discriminatory power in patients with chest pain - Introducing the HET-score.

BACKGROUND: The History, Electrocardiogram (ECG), Age, Risk factors and Troponin, (HEART) score is useful for early risk stratification in chest pain patients. The aim was to validate previous findings that a simplified score using history, ECG and troponin (HET-score) has similar ability to stratify risk. METHODS: Patients presenting with chest pain with duration of ≥10 min and an onset of last episode ≤12 h but without ST-segment elevation on ECG at 6 emergency departments were eligible for inclusion. The HEART-score and the simplified HET-score were calculated. The endpoint was a composite of myocardial infarction (MI) as index diagnosis, readmission due to new MI or death within 30 days. RESULTS: HEART-score identified 32% as low risk (0-2p), 47% as intermediate risk (3-5p), and 20% as high risk (6-10p) patients. The endpoint occurred in 0.5%, 7.3% and 35.7%, respectively. HET-score identified 39%, 42% and 19% as low- (0p), intermediate- (1-2p) and high-risk (3-6p) patients, with the endpoint occurring in 0.6%, 6.2% and 43.2%, respectively. When all variables included in the HEART-score were included in a multivariable logistic regression analysis, only History (OR, CI [95%]): 2.97(2.16-4.09), ECG (1.61[1.14-2.28]) and troponin level (5.21[3.91-6.95]) were significantly associated with cardiovascular events. When HEART- and HET-score were compared in a ROC-analysis, HET-score had a significantly larger AUC (0.887 vs 0.853, p < 0.001). CONCLUSIONS: Compared with HEART-score, HET-score is simpler and appears to have similar ability to discriminate between chest pain patients with and without cardiovascular event.

A Rule-Out Strategy Based on High-Sensitivity Troponin and HEART Score Reduces Hospital Admissions.

STUDY OBJECTIVE: We evaluate whether a combination of a 1-hour high-sensitivity cardiac troponin algorithm and History, ECG, Age, Risk Factors, and Troponin (HEART) score reduces admission rate (primary outcome) and affects time to discharge, health care-related costs, and 30-day outcome (secondary outcomes) in patients with symptoms suggestive of an acute coronary syndrome. METHODS: This prospective observational multicenter study was conducted before (2013 to 2014) and after (2015 to 2016) implementation of a strategy including level of high-sensitivity cardiac troponin T or I at 0 and 1 hour, combined with the HEART score. Patients with a nonelevated baseline high-sensitivity cardiac troponin level, a 1-hour change in high-sensitivity cardiac troponin T level less than 3 ng/L, or high-sensitivity cardiac troponin I level less than 6 ng/L and a HEART score less than or equal to 3 were considered to be ruled out of having acute coronary syndrome. A logistic regression analysis was performed to adjust for differences in baseline characteristics. RESULTS: A total of 1,233 patients were included at 6 centers. There were no differences in regard to median age (64 versus 63 years) and proportion of men (57% versus 54%) between the periods. After introduction of the new strategy, the admission rate decreased from 59% to 33% (risk ratio 0.55 [95% confidence interval {CI} 0.48 to 0.63]; odds ratio 0.33 [95% CI 0.26 to 0.42]; adjusted odds ratio 0.33 [95% CI 0.25 to 0.42]). The median hospital stay was reduced from 23.2 to 4.7 hours (95% CI of difference -20.4 to -11.4); median health care-related costs, from $1,748 to $1,079 (95% CI of difference -$953 to -$391). The number of clinical events was very low. CONCLUSION: In this before-after study, clinical implementation of a 1-hour high-sensitivity cardiac troponin algorithm combined with the HEART score was associated with a reduction in admission rate and health care burden, with very low rates of adverse clinical events.

Cerebral microembolism during coronary angiography: a randomized comparison between femoral and radial arterial access.

BACKGROUND AND PURPOSE: Microemboli observed during coronary angiography can cause silent ischemic cerebral lesions. The aim of this study was to investigate if the number of particulate cerebral microemboli during coronary angiography is influenced by access site used. METHODS: Fifty-one patients with stable angina pectoris referred for coronary angiography were randomized to right radial or right femoral arterial access. The number of particulate microemboli passing the middle cerebral arteries was continuously registered with transcranial Doppler. RESULTS: The median (minimum-maximum range) numbers of particulate emboli were significantly higher with radial 10 (1-120) than with femoral 6 (1-19) access. More particulate microemboli passed the right middle cerebral artery with the radial access. CONCLUSIONS: This study indicates that the radial access used for coronary angiography generates more particulate cerebral microemboli than the femoral access and thus may influence the occurrence of silent cerebral injuries.

Early Comprehensive Cardiovascular Magnetic Resonance Imaging in Patients With Myocardial Infarction With Nonobstructive Coronary Arteries.

OBJECTIVES: The objective of the SMINC-2 (Stockholm Myocardial Infarction With Normal Coronaries 2) study was to determine if more than 70% of patients with myocardial infarction with nonobstructed coronary arteries (MINOCA), investigated early with comprehensive cardiovascular magnetic resonance (CMR), could receive a diagnosis entirely by imaging. BACKGROUND: The etiology of MINOCA is heterogeneous, including coronary, cardiac, and noncardiac causes. Patients with MINOCA, therefore, represent a diagnostic challenge where CMR is increasingly used. METHODS: The SMINC-2 study was a prospective study of 148 patients with MINOCA imaged with 1.5-T CMR with T1 and extracellular volume mapping early after hospital admission, compared to 150 patients with MINOCA imaged using 1.5-T CMR without mapping techniques from the SMINC-1 study as historic controls. RESULTS: CMR was performed at a median of 3 (SMINC-2) versus 12 (SMINC-1) days after hospital admission. In total, 77% of patients received a diagnosis with CMR imaging in the SMINC-2 study compared to 47% in the SMINC-1 study (p < 0.001). Compared to SMINC-1, CMR in SMINC-2 detected higher proportions of myocarditis (17% vs. 7%; p = 0.01) and takotsubo syndrome (35% vs. 19%; p = 0.002) but similar proportions of myocardial infarction (22% vs. 19%; p = 0.56) and other cardiomyopathies (3% vs. 2%; p = 0.46). CONCLUSIONS: The results of the SMINC-2 study show that 77% of all patients with MINOCA received a diagnosis when imaged early with CMR, including advanced tissue characterization, which was a considerable improvement in comparison to the SMINC-1 study. This supports the use of early CMR imaging as a diagnostic tool in the investigation of patients with MINOCA. (Stockholm Myocardial Infarction With Normal Coronaries [SMINC]-2 Study on Diagnosis Made by Cardiac MRI [SCMINC-2]; NCT02318498).

Plasma catecholamine levels in the acute and subacute stages of takotsubo syndrome: Results from the Stockholm myocardial infarction with normal coronaries 2 study.

AIMS: It is well-accepted that takotsubo syndrome (TS) is characterized by a massive surge of plasma catecholamines despite lack of solid evidence. The objective of this study was to examine the hypothesis of a massive catecholamine elevation in TS by studying plasma-free catecholamine metabolites in patients participating in the Stockholm myocardial infarction (MI) with normal coronaries 2 (SMINC-2) study where TS constituted more than one third of the patients. METHODS AND RESULTS: The patients included in the SMINC-2 study were classified, according to cardiac magnetic resonance (CMR) imaging findings (148 patients), which was performed at a median of 3 days after hospital admission. Plasma-free catecholamine metabolites; metanephrine, normetanephrine, and methoxy-tyramine were measured on day 2-4 after admission. Catecholamine metabolite levels were available in 125 patients. One hundred and ten (88%) of the 125 patients included in SMINC-2 study, and 38 (86.4%) of the 44 patients with TS had completely normal plasma metanephrine and normetanephrine levels. All patients had normal plasma methoxy-tyramine levels. Fourteen (11.2%) of the 125 patients included in SMINC-2 study, and 5 (11.6%) of the 43 patients with TS had mild elevations (approximately 1.2 times the upper normal limits) of either plasma metanephrine or normetanephrine. One patient with pheochromocytoma-triggered TS had marked elevation of plasma metanephrine and mild elevation of plasma normetanephrine. There were no significant differences between the number or degree of catecholamine metabolite elevations between the different groups of patients with CMR imaging diagnosis included in SMINC-2 study. CONCLUSION: There was no evidence of massive catecholamine elevations in the acute and subacute stages of TS apart from one patient with pheochromocytoma-induced TS. Most of the TS patients had normal catecholamine metabolites indicating that blood-borne catecholamines do not play a direct role in the pathogenesis of TS.

Does Coronary Angiography and Percutaneous Coronary Intervention Affect Cognitive Function?

Cerebral microemboli are frequently observed during coronary angiography (CA) and percutaneous coronary intervention (PCI), and their numbers have been related to the vascular access site used. Although cerebral microemboli can cause silent cerebral lesions, their clinical impact is debated. To study this, 93 patients referred for CA or PCI underwent serial cognitive testing using the Montreal Cognitive Assessment (MoCA) test to detect postprocedural cognitive impairment. Patients were randomized to radial or femoral access. In a subgroup of 35 patients, the number of cerebral microemboli was monitored with transcranial Doppler technique. We found the median precatheterization result of the MoCA test to be 27, and it did not change significantly 4 and 31 days, respectively, after the procedure. There was no significant correlation between the number of cerebral microemboli and the difference between preprocedural and postprocedural MoCA tests. The test results did not differ between vascular access sites. One-third of the patients had a precatheterization median MoCA test result <26 corresponding to mild cognitive impairment. In conclusion, using the MoCA test, we could not detect any cognitive impairment after CA or PCI, and no significant correlations were found between the results of the MoCA test and cerebral microemboli or vascular access site, respectively. In patients with suspected coronary heart disease, mild cognitive impairment was common.

Guidewire withdrawal in ascending aorta increases cerebral microembolism during coronary angiography: a randomized comparison of two guidewire techniques.

BACKGROUND: Microemboli are frequently detected entering the middle cerebral arteries during coronary angiography (CA). Recent studies have reported that cerebral microemboli, especially particulate cerebral microemboli, may cause silent ischemic cerebral lesions. AIMS: To investigate whether the occurrence of particulate cerebral microemboli during diagnostic CA is influenced by which guidewire technique is used. METHODS: Patients with stable angina pectoris or non-ST elevation acute coronary syndrome, referred for CA, were randomized to initial advancement of catheters with a leading guidewire over the aortic arch or to initial guidewire withdrawal in the descending aorta with advancement of catheters alone. After completed CA (part 1), new catheters and guidewires were advanced with guidewire technique contrary to the one first used (part 2). Patients were continuously monitored with transcranial Doppler (TCD), and cerebral microemboli were automatically counted and differentiated. RESULTS: Statistical analysis was performed on 41 patients. The results in part 1 were confirmed in part 2. The median number (interquartile range) of particulate cerebral microemboli was significantly higher when catheters were advanced with, compared to without, a guidewire over the aortic arch; overall, 6 (IQR, 1-9) vs 1 (IQR, 0-3); P=.01. CONCLUSIONS: Advancement of catheters with a leading guidewire over the aortic arch with subsequent flushing in the ascending aorta consistently generated more particulate cerebral microemboli, implying that the choice of guidewire technique has an impact on the risk for cerebral lesions during CA.

Glycaemic control and restenosis after percutaneous coronary interventions in patients with diabetes mellitus: a report from the Insulin Diabetes Angioplasty study.

OBJECTIVE: We investigated the impact of glucose control on target lesion restenosis after PCI in patients with type 2 diabetes. METHODS: Ninety-three consecutive patients with type 2 diabetes accepted for PCI were randomised to intensified glucose control based on insulin (I-group; n=44) or to continue ongoing glucose-lowering treatment (C-group; n=49).The treatment target was a FBG of 5-7 mmol/L and HbA1c <6.5%. Information on target lesion restenosis after six months was available in 82 patients. RESULTS: At baseline HbA1c and FBG did not differ between the I- and C-groups, respectively (HbA1c: 6.5 vs. 6.5%; p=1.0 and FBG: 7.0 vs. 7.3 mmol/L; p=0.3). After six months there was no significant change in HbA1c or FBG in either group (change in HbA1c: -0.2 vs.-0.1%; p=0.3 and in FBG: +0.2 vs. -0.3 mmol/L; p=0.3 in the I- and C-groups, respectively). Target lesion restenosis at six months did not differ, I vs. C = 41 and 44% (p=0.8). Independent predictors for restenosis were previous myocardial infarction (OR 8.0, 95% CI 2.5-25.7; p=<0.001) and FBG at baseline (OR for an increase by 1 mmol/L = 1.4, 95% CI 1.1-1.9; p=0.015). CONCLUSIONS: Restenosis was predicted by baseline FBG suggesting that it would be of interest to target glucose normalisation in future trials. Intensified insulin treatment did not influence the rate of restenosis indicating that the main focus should be on lowering glucose rather than the tool to normalise glucose.

Catheter-based transendocardial myocardial gene transfer.

BACKGROUND AND AIM: Local modulation of myocardial function by gene transfer or cell depositions constitutes a potential method of cardiac treatment. This study tested the morphology of myocardial plasmid gene transfer by catheter-based transendocardial injection (NOGA). METHODS: Left ventricular morphology and electrical and mechanical characteristics were mapped in three dimensions. In two pigs, 0.10 mL of toluidine blue was injected at ten sites. In seven pigs, seven to ten injections of 0.10 mL saline containing 0.10 mg pCMV-LacZ expressing the enzyme beta-galactosidase and 0.10 mg phVEGF-A165 were given. The pigs were sacrificed after 3 days and gene expression was determined. RESULTS: Macroscopically on the endocardial surface, all identified spots were located in the target area. However, along the transmyocardial axis, injections with color and plasmid were located randomly throughout the left ventricular wall from the endocardium to the epicardium. In each detected spot, gene expression of beta-galactosidase was observed in an approximate myocardial volume of 5 x 5 x 5 mm. Microscopically, the transfected cells were located typically at the tip of the injection scar. As a rule, 10 to 20 transfected cells were located at the end of the injection scar. In sections where expression of both transcripts was observed, 42% of the cells expressed both beta-galactosidase and vascular endothelial growth factors (VEGF), 32% only beta-galactosidase, and 26% only VEGF. CONCLUSIONS: Myocardial gene transfer following magnetic guidance can be located precisely on the left ventricular inner surface. Within the myocardium, gene expression is local around the distal tip of the injection scar and is located randomly at every level of depth of the left ventricular wall.

Nonsurgical direct delivery of plasmid DNA into rat heart: time course, dose response, and the influence of different promoters on gene expression.

Transfer of genes encoding therapeutic proteins into the myocardium shows great potential for treatment of coronary artery disease. To quantitatively elucidate the behavior of plasmid DNA following cardiac gene transfer, time kinetics, dose-response relationship, systemic spread to the liver, and the influence of different promoters on plasmid DNA gene expression in rat hearts were examined using a novel nonsurgical direct delivery method that enables testing of large numbers of animals. Plasmids encoding either vascular endothelial growth factor A 165 or a fusion protein between enhanced green fluorescent protein (EGFP) luciferase were injected directly in rat hearts under echocardiographic guidance. The results show that gene expression is dose related and that the duration of gene expression is transient. These findings underscore the necessity to explore other efficient vectors or alternative methods of gene delivery to achieve increased and prolonged gene expression.