Plaque Ruptures Are Related to High Plaque Stress and Strain Conditions: Direct Verification by Using In Vivo OCT Rupture Data and FSI Models.

BACKGROUND: While it has been hypothesized that high plaque stress and strain may be related to plaque rupture, its direct verification using in vivo coronary plaque rupture data and full 3-dimensional fluid-structure interaction models is lacking in the current literature due to difficulty in obtaining in vivo plaque rupture imaging data from patients with acute coronary syndrome. This case-control study aims to use high-resolution optical coherence tomography-verified in vivo plaque rupture data and 3-dimensional fluid-structure interaction models to seek direct evidence for the high plaque stress/strain hypothesis. METHODS: In vivo coronary plaque optical coherence tomography data (5 ruptured plaques, 5 no-rupture plaques) were acquired from patients using a protocol approved by the local institutional review board with informed consent obtained. The ruptured caps were reconstructed to their prerupture morphology using neighboring plaque cap and vessel geometries. Optical coherence tomography-based 3-dimensional fluid-structure interaction models were constructed to obtain plaque stress, strain, and flow shear stress data for comparative analysis. The rank-sum test in the nonparametric test was used for statistical analysis. RESULTS: Our results showed that the average maximum cap stress and strain values of ruptured plaques were 142% (457.70 versus 189.22 kPa; P=0.0278) and 48% (0.2267 versus 0.1527 kPa; P=0.0476) higher than that for no-rupture plaques, respectively. The mean values of maximum flow shear stresses for ruptured and no-rupture plaques were 145.02 dyn/cm2 and 81.92 dyn/cm2 (P=0.1111), respectively. However, the flow shear stress difference was not statistically significant. CONCLUSIONS: This preliminary case-control study showed that the ruptured plaque group had higher mean maximum stress and strain values. Due to our small study size, larger scale studies are needed to further validate our findings.

An update on the mechanisms of Takotsubo syndrome: "At the end an acute coronary syndrome".

Takotsubo syndrome (TTS) is an acute reversible form of myocardial dysfunction, often preceded by a physical or emotional stressful event, that acts as a trigger. Despite, recent advances in the comprehension of the mechanisms leading to TTS, its pathophysiology is far from being completely understood. However, several studies seem to suggest that an acute coronary microvascular dysfunction may represent a crucial pathogenic mechanism involved in TTS occurrence. In this article, we aim to review the complex pathophysiology of TTS and the possible different mechanisms underlying this clinical condition, focusing on the role of coronary microvascular dysfunction and the remaining knowledge's gaps in the field.

Prospective Bidirectional Relationship Between Sleep Duration and Posttraumatic Stress Disorder Symptoms After Suspected Acute Coronary Syndrome.

OBJECTIVE: Sleep disturbance is a "hallmark" symptom of posttraumatic stress disorder (PTSD). Poor sleep (including short sleep) after combat-related trauma can also predict subsequent PTSD. Less is known about the association between sleep duration and PTSD symptoms when PTSD is induced by acute coronary syndrome (ACS). We examined the bidirectional relationship between sleep duration and PTSD symptoms over the year after hospital evaluation for ACS. METHODS: Participants were enrolled in this observational study after emergency department evaluation for ACS. Sleep duration ("During the past month, how many hours of actual sleep did you get at night?") and cardiac event or hospitalization-induced PTSD symptoms (PTSD Checklist) were assessed at 1, 6, and 12 months after hospital discharge. Cross-lagged path analysis was used to model the effects of sleep duration and PTSD symptoms on each other. Covariates included age, sex, race/ethnicity, cardiac severity, baseline depression symptoms, and early acute stress disorder symptoms. RESULTS: The sample included 1145 participants; 16% screened positive for probable PTSD (PTSD Checklist score ≥33). Mean sleep duration across time points was 6.1 hours. Higher PTSD symptoms predicted shorter sleep duration at the next time point (i.e., 1-6 and 6-12 months; B = -0.14 hours/10-point difference, SE = 0.03, p < .001). Shorter sleep duration was associated with higher PTSD symptoms at the next time point (B = -0.25 points/hour, SE = 0.12, p = .04). CONCLUSIONS: Short sleep duration and PTSD symptoms are mutually reinforcing across the first year after ACS evaluation. Findings suggest that sleep, PTSD symptoms, and their relationship should be considered in the post-ACS period.

Continuous thermodilution and microvascular resistance reserve during the index procedure in acute coronary syndrome without obstructive coronary artery disease: A pilot study.

BACKGROUND: In 5%-25% of non-ST-elevation acute coronary syndrome (NSTE-ACS) patients, coronary angiography reveals no obstructive coronary arteries (MINOCA). Coronary microvascular disease (CMD) is a potential causal pathophysiological mechanism in these patients and can be diagnosed by continuous thermodilution assessment. Recently, the microvascular resistance reserve (MRR) has been introduced as a novel index to assess the vasodilatory capacity of the microcirculation. However, continuous thermodilution and MRR have never been investigated in the acute setting in MINOCA patients and invasive assessment of the microcirculation in these patients are currently lacking. AIMS: The objectives of the study were to investigate the incidence of CMD (MRR ≤ 2.7) in patients with MINOCA and to evaluate the feasibility and safety of continuous thermodilution-based assessment during index coronary angiography in the acute setting. METHODS: This study was a prospective, observational, pilot study investigating coronary physiology in the acute setting in MINOCA patients. Patients admitted with a diagnosis of NSTE-ACS were eligible for inclusion. RESULTS: In total, 19 MINOCA patients were included in this analysis; the mean age was 70 ± 9 years, and 79% were females. CMD was present in 6 patients (32%). Qrest was significantly higher in the MRR ≤ 2.7 group compared to the MRR > 2.7 group (0.076 [0.057-0.100] vs. 0.049 [0.044-0.071] L/min, p = 0.03). Rµ,rest was significantly lower in the MRR ≤ 2.7 group compared to the MRR > 2.7 group (1083 [710-1510] vs. 1563 [1298-1970] WU, p = 0.04). No periprocedural complications or hemodynamic instability have occurred during continuous thermodilution assessment during the index coronary angiography. CONCLUSION: In patients admitted for MINOCA undergoing immediate coronary angiography, continuous thermodilution assessment and MRR are feasible and safe in the acute setting, and evidence of functional CMD could be observed in one-third of the MINOCA patients.

Pseudo precordial ST-segment depression.

We present a case with acute coronary syndrome and very unusual QRS widening in the acute phase. The case highlights that non-specific intraventricular conduction delay should be considered as a high risk ECG pattern predicting poor prognosis.

Effect of Oral Care on Endothelial Dysfunction in Patients with Acute Coronary Syndrome.

Periodontitis is a common chronic infection and is associated with cardiovascular disease. This study evaluated whether basic oral care for periodontal disease could improve endothelial function in patients with acute coronary syndrome (ACS).This study enrolled 54 patients with acute coronary syndrome admitted to Kagoshima City Hospital and who had undergone percutaneous coronary intervention. Flow-mediated endothelium-dependent dilatation (FMD) was measured before discharge (initial FMD) and at 8 months after percutaneous coronary intervention (follow-up FMD). The following periodontal characteristics were measured: periodontal pocket depth (PPD, mm), plaque control record (%), and bleeding on probing (%). All patients received basic oral care instructions from dentists. The oral health condition was generally poor in the participants and there were 24 patients (44.4%) who had severe PPD. Despite the intervention of basic oral care, the periodontal characteristics did not improve during the study period; initial FMD and follow-up FMD did not significantly differ (4.38 ± 2.74% versus 4.56 ± 2.51%, P = 0.562). However, the follow-up FMD was significantly lower in patients with severe PPD (≥ 6.0 mm, n = 24) than in patients without severe PPD (≤ 5.0 mm, n = 30) (FMD: 3.58 ± 1.91% versus 5.37 ± 2.67%, P = 0.007). FMD tended to be worse in patients with severe PPD than in patients without severe PPD (ΔFMD: -0.55 ± 2.12 versus 0.81 ± 2.77 %, P = 0.055). In conclusion, during the use of basic oral care, endothelial function improved in patients without severe PPD, while it worsened in patients with severe PPD.

Angiogenic content of microparticles in patients with diabetes and coronary artery disease predicts networks of endothelial dysfunction.

BACKGROUND: Elevated endothelial microparticles (EMPs) levels are surrogate markers of vascular dysfunction. We analyzed EMPs with apoptotic characteristics and assessed the angiogenic contents of microparticles in the blood of patients with type 2 diabetes (T2D) according to the presence of coronary artery disease (CAD). METHODS: A total of 80 participants were recruited and equally classified as (1) healthy without T2D, (2) T2D without cardiovascular complications, (3) T2D and chronic coronary artery disease (CAD), and (4) T2D and acute coronary syndrome (ACS). MPs were isolated from the peripheral circulation, and EMPs were characterized using flow cytometry of CD42 and CD31. CD62E was used to determine EMPs' apoptotic/activation state. MPs content was extracted and profiled using an angiogenesis array. RESULTS: Levels of CD42- CD31 + EMPs were significantly increased in T2D with ACS (257.5 ± 35.58) when compared to healthy subjects (105.7 ± 12.96, p < 0.01). There was no significant difference when comparing T2D with and without chronic CAD. The ratio of CD42-CD62 +/CD42-CD31 + EMPs was reduced in all T2D patients, with further reduction in ACS when compared to chronic CAD, reflecting a release by apoptotic endothelial cells. The angiogenic content of the full population of MPs was analyzed. It revealed a significant differential expression of 5 factors in patients with ACS and diabetes, including TGF-ß1, PD-ECGF, platelet factor 4, serpin E1, and thrombospondin 1. Ingenuity Pathway Analysis revealed that those five differentially expressed molecules, mainly TGF-ß1, inhibit key pathways involved in normal endothelial function. Further comparison of the three diabetes groups to healthy controls and diabetes without cardiovascular disease to diabetes with CAD identified networks that inhibit normal endothelial cell function. Interestingly, DDP-IV was the only differentially expressed protein between chronic CAD and ACS in patients with diabetes. CONCLUSION: Our data showed that the release of apoptosis-induced EMPs is increased in diabetes, irrespective of CAD, ACS patients having the highest levels. The protein contents of MPs interact in networks that indicate vascular dysfunction.

Diagnosis and Treatment of Acute Coronary Syndromes: A Review.

IMPORTANCE: Acute coronary syndromes (ACS) are characterized by a sudden reduction in blood supply to the heart and include ST-segment elevation myocardial infarction (STEMI), non-STEMI (NSTEMI), and unstable angina. Each year, an estimated more than 7 million people in the world are diagnosed with ACS, including more than 1 million patients hospitalized in the US. OBSERVATIONS: Chest discomfort at rest is the most common presenting symptom of ACS and affects approximately 79% of men and 74% of women presenting with ACS, although approximately 40% of men and 48% of women present with nonspecific symptoms, such as dyspnea, either in isolation or, more commonly, in combination with chest pain. For patients presenting with possible ACS, electrocardiography should be performed immediately (within 10 minutes of presentation) and can distinguish between STEMI and non-ST-segment elevation ACS (NSTE-ACS). STEMI is caused by complete coronary artery occlusion and accounts for approximately 30% of ACS. ACS without significant ST-segment elevation on electrocardiography, termed NSTE-ACS, account for approximately 70% of ACS, are caused by partial or intermittent occlusion of the artery and are associated with ST-segment depressions (approximately 31%), T-wave inversions (approximately 12%), ST-segment depressions combined with T-wave inversions (16%), or neither (approximately 41%). When electrocardiography suggests STEMI, rapid reperfusion with primary percutaneous coronary intervention (PCI) within 120 minutes reduces mortality from 9% to 7%. If PCI within 120 minutes is not possible, fibrinolytic therapy with alteplase, reteplase, or tenecteplase at full dose should be administered for patients younger than 75 years without contraindications and at half dose for patients 75 years or older (or streptokinase at full dose if cost is a consideration), followed by transfer to a facility with the goal of PCI within the next 24 hours. High-sensitivity troponin measurements are the preferred test to evaluate for NSTEMI. In high-risk patients with NSTE-ACS and no contraindications, prompt invasive coronary angiography and percutaneous or surgical revascularization within 24 to 48 hours are associated with a reduction in death from 6.5% to 4.9%. CONCLUSIONS AND RELEVANCE: Each year, an estimated more than 7 million people are diagnosed with ACS worldwide. For patients with STEMI, coronary catheterization and PCI within 2 hours of presentation reduces mortality, with fibrinolytic therapy reserved for patients without access to immediate PCI. For high-risk patients with NSTE-ACS without contraindications, prompt invasive coronary angiography followed by percutaneous or surgical revascularization is associated with lower rates of death.

Effect of Adding Ticagrelor to Standard Aspirin on Saphenous Vein Graft Patency in Patients Undergoing Coronary Artery Bypass Grafting (POPular CABG): A Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: Approximately 15% of saphenous vein grafts (SVGs) occlude during the first year after coronary artery bypass graft surgery (CABG) despite aspirin use. The POPular CABG trial (The Effect of Ticagrelor on Saphenous Vein Graft Patency in Patients Undergoing Coronary Artery Bypass Grafting Surgery) investigated whether ticagrelor added to standard aspirin improves SVG patency at 1 year after CABG. METHODS: In this investigator-initiated, randomized, double-blind, placebo-controlled, multicenter trial, patients with ≥1 SVGs were randomly assigned (1:1) after CABG to ticagrelor or placebo added to standard aspirin (80 mg or 100 mg). The primary outcome was SVG occlusion at 1 year, assessed with coronary computed tomography angiography, in all patients that had primary outcome imaging available. A generalized estimating equation model was used to perform the primary analysis per SVG. The secondary outcome was 1-year SVG failure, which was a composite of SVG occlusion, SVG revascularization, myocardial infarction in myocardial territory supplied by a SVG, or sudden death. RESULTS: Among 499 randomly assigned patients, the mean age was 67.9±8.3 years, 87.1% were male, the indication for CABG was acute coronary syndrome in 31.3%, and 95.2% of procedures used cardiopulmonary bypass. Primary outcome imaging was available in 220 patients in the ticagrelor group and 223 patients in the placebo group. The SVG occlusion rate in the ticagrelor group was 10.5% (51 of 484 SVGs) versus 9.1% in the placebo group (43 of 470 SVGs), odds ratio, 1.29 [95% CI, 0.73-2.30]; P=0.38. SVG failure occurred in 35 (14.2%) patients in the ticagrelor group versus 29 (11.6%) patients in the placebo group (odds ratio, 1.22 [95% CI, 0.72-2.05]). CONCLUSIONS: In this randomized, placebo-controlled trial, the addition of ticagrelor to standard aspirin did not reduce SVG occlusion at 1 year after CABG. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02352402.

Apabetalone and hospitalization for heart failure in patients following an acute coronary syndrome: a prespecified analysis of the BETonMACE study.

BACKGROUND: Patients with diabetes and acute coronary syndrome (ACS) are at high risk for subsequent heart failure. Apabetalone is a selective inhibitor of bromodomain and extra-terminal (BET) proteins, epigenetic regulators of gene expression. Preclinical data suggest that apabetalone exerts favorable effects on pathways related to myocardial structure and function and therefore could impact subsequent heart failure events. The effect of apabetalone on heart failure events after an ACS is not currently known. METHODS: The phase 3 BETonMACE trial was a double-blind, randomized comparison of apabetalone versus placebo on the incidence of major adverse cardiovascular events (MACE) in 2425 patients with a recent ACS and diabetes. This prespecified secondary analysis investigated the impact of apabetalone on hospitalization for congestive heart failure, not previously studied. RESULTS: Patients (age 62 years, 74.4% males, 90% high-intensity statin use, LDL-C 70.3 mg/dL, HDL-C 33.3 mg/dL and HbA1c 7.3%) were followed for an average 26 months. Apabetalone treated patients experienced the nominal finding of a lower rate of first hospitalization for heart failure (2.4% vs. 4.0%, HR 0.59 [95%CI 0.38-0.94], P = 0.03), total number of hospitalizations for heart failure (35 vs. 70, HR 0.47 [95%CI 0.27-0.83], P = 0.01) and the combination of cardiovascular death or hospitalization for heart failure (5.7% vs. 7.8%, HR 0.72 [95%CI 0.53-0.98], P = 0.04). CONCLUSION: Apabetalone treatment was associated with fewer hospitalizations for heart failure in patients with type 2 diabetes and recent ACS. Future studies are warranted to define the potential for BET inhibition with apabetalone to prevent heart failure in patients with diabetes and ACS.

Triglyceride-Glukose Index Predicts Adverse Events in Patients with Acute Coronary Syndrome: A Meta-Analysis of Cohort Studies.

The triglyceride-glucose (TyG) index, a recently proposed indicator for insulin resistance, has been related with cardiovascular risks. We aimed to summarize the association between TyG index and incidence of major adverse cardiovascular events (MACEs) in patients with acute coronary syndrome (ACS). Cohort studies demonstrating the association between TyG index and incidence of MACEs in ACS patients with multivariate adjusted analyses were identified by search of PubMed, Embase, and Web of Science databases. A random-effekt model incorporating the heterogeneity was applied to pool the results. Eight cohort studies with 19 611 participants were included. Results showed that compared to those with the lowest category of TyG index, ACS patients with the highest category of TyG index were independently associated with higher risk of MACEs [risk ratio (RR): 1.94, 95% confidence interval (CI): 1.47-2.56, I2=85%, p <0.001). Subgroup analyses showed consistent results in patients with ST-segment elevated myocardial infarction or non-ST segment elevated ACS, in patients with or without diabetes, and in patients after percutaneous coronary intervention. Results were consistent in studies with TyG index analyzed as continuous variable (RR for per standard deviation increment of TyG index: 1.59, 95% CI: 1.38-1.83, I2=24%, p <0.001). In conclusion, higher TyG index may be independently associated with higher incidence of MACEs in patients with ACS.

Reassessing the Mechanisms of Acute Coronary Syndromes.

The mechanisms that underlie superficial erosion, a cause of coronary thrombosis distinct from plaque rupture, have garnered recent interest. In an era of improved control of traditional risk factors, such as LDL (low-density lipoprotein), plaque erosion may assume greater clinical importance. Plaques complicated by erosion tend to be matrix-rich, lipid-poor, and usually lack prominent macrophage collections, unlike plaques that rupture, which characteristically have thin fibrous caps, large lipid pools, and abundant foam cells. Thrombi that complicate superficial erosion seem more platelet-rich than the fibrinous clots precipitated by plaque rupture. The pathogenesis of plaque rupture probably does not pertain to superficial erosion, a process heretofore little understood mechanistically. We review here data that support a substantial shift in the mechanisms of the thrombotic complications of atherosclerosis. We further consider pathophysiologic processes recently implicated in the mechanisms of erosion. Multiple processes likely predispose plaques to superficial erosion, including experiencing disturbed flow, basement membrane breakdown, endothelial cell death, and detachment potentiated by innate immune activation mediated through pattern-recognition receptors and endothelial-to-mesenchymal transition. Monocytes/macrophages predominate in the pathogenesis of plaque rupture and consequent thrombosis, but polymorphonuclear leukocytes likely promote endothelial damage during superficial erosion. The formation of neutrophil extracellular traps probably perpetuates and propagates intimal injury and potentiates thrombosis due to superficial erosion. These considerations have profound clinical implications. Acute coronary syndromes because of erosion may not require immediate invasive therapy. Understanding the biological bases of erosion points to novel therapies for acute coronary syndrome caused by erosion. Future research should probe further the mechanisms of superficial erosion, and develop point-of-care tests to distinguish acute coronary syndromes provoked by erosion versus rupture that may direct more precision management. Future clinical investigations should evaluate intervening on the targets that have emerged from experimental studies and the management strategies that they inform.

Pharmacologic Prevention of Myocardial Ischemia-Reperfusion Injury in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention.

ABSTRACT: Establishing efficient perfusion into the myocardium is the main purpose in patients with acute coronary syndrome, but the process of reperfusion is not without risk and can damage the myocardium paradoxically. Unfortunately, there is no effective treatment for reperfusion injury, and efforts to find an efficient preventive approach are still ongoing. In the past 3 decades, there have been many successful animal studies on how to prevent reperfusion injury; nonetheless, translation to the clinical setting has almost always proven disappointing. In this article, we review clinical studies on the prevention of reperfusion injury in patients with acute coronary syndrome undergoing primary percutaneous coronary intervention in a pharmacologic-based approach. We categorize all the agents that are evaluated for the prevention of myocardial reperfusion injury based on their mechanisms of action into 5 groups: drugs that can reduce oxidative stress, drugs that can affect cellular metabolism, rheological agents that target microvascular obstruction, anti-inflammatory agents, and agents with mixed mechanisms of action. Then, review all the clinical studies of these agents in the setting of primary percutaneous coronary intervention. Finally, we will discuss the possible reasons for the failure in translation of studies into practice and propose potential solutions to overcome this problem.

Sex-differences in the management and clinical outcome among patients with acute coronary syndrome.

BACKGROUND: The current study was to compare the management and clinical outcome between women and men with acute coronary syndrome (ACS). METHOD: This was a retrospective study. Patients with ACS presented to the emergency department were enrolled. Management and clinical outcomes (including mortality and acute decompensated heart failure [ADHF]) were compared between women and men. RESULTS: A total of 686 patients were included and women accounted for 38.5% (n = 264). Women were less likely to receive ticagrelor at the emergency department (18.2% vs 25.1%). Duration from arrival at the emergency department to undergo electrocardiogram was longer in women (7.5 min vs 5.3 min). The duration from symptom onset to undergo percutaneous coronary intervention was longer in women (14.4 h vs 7.2 h). After adjusting for covariates, odds ratio (OR) for cardiovascular mortality was 0.42 (95% confidence interval [CI] 0.37-1.02) and ADHF was 0.63 (95% CI 0.55-1.01) for women vs men. Socioeconomic status, duration from symptom onset to arrive at the emergency department, and management at the emergency department were the important factors contributing to the sex-differences in clinical outcome. CONCLUSION: Among ACS patients undergoing PCI, there was no sex-difference in in-hospital clinical outcome after adjusting for covariates. Future studies are needed to evaluate whether improving management at the emergency department can improve clinical outcomes in women and men with ACS.

The effect of patient education based on health belief model on hospital readmission preventive behaviors and readmission rate in patients with a primary diagnosis of acute coronary syndrome: a quasi-experimental study.

BACKGROUND: The health belief model is one of the applicable methods of training health preventive behaviors, especially in patients with cardiovascular diseases. Therefore, this study aimed to determine the effect of patient education based on the health belief model on readmission preventive behaviors and readmission rate in patients with a primary diagnosis of acute coronary syndrome. METHODS: The present quasi-experimental study was conducted in 2020 on patients with a primary diagnosis of acute coronary syndrome who were discharging from Seyed Al-Shohada Hospital, Urmia, Iran. In this study, a total of 70 samples were recruited using convenience sampling and then randomly assigned to two groups of intervention and control (n = 35 in each group). A total of 7 face-to-face group training sessions were held with the participation of the patients and one of their family members during 14 days after hospital discharge. These sessions were conducted along with concentration on the structures of the health belief model. Data were collected at three time points of immediately before, one month, and three months after the intervention using a demographic questionnaire, a researcher-made questionnaire of readmission preventive behaviors in cardiovascular diseases, and a checklist of hospital readmission. Data were analyzed using SPSS Statistics for Windows, version 17.0 (SPSS Inc., Chicago, Ill., USA). RESULTS: The results showed that there was a statistically significant difference in the mean score of preventive behaviors between the two groups at time points of one month and three months after the intervention (p < .05). However, there was no statistically significant difference in the readmission rate between the two groups after the intervention (p > .05). CONCLUSION: Health belief model-based education was shown to be effective on readmission preventive behaviors in patients with acute coronary syndrome, although this model had no effect on the readmission rate in these patients. Other factors affecting the readmission rate are recommended to be investigated.

Post-operative blood pressure and 3-year major adverse cardiac events in Chinese patients undergoing PCI.

BACKGROUND: There is no clear evidence for the target value of blood pressure control after Percutaneous coronary intervention (PCI). Therefore, our study was designed to explore the relationship between blood pressure after PCI and major adverse cardiac events (MACE) during 3-year follow-up. METHODS: This study is a prospective study. We included the patients who were diagnosed with acute coronary syndrome and underwent PCI stent implantation operation. The study initially collected information of 552 patients. The start and end times of the study are from January 1, 2017 to December 31, 2020. The independent variables of this study are the average systolic blood pressure and the average diastolic blood pressure after PCI. The dependent variable is the occurrence of MACE events in patients within 3 years after PCI. MACE is defined as acute myocardial infarction, recurring chest pain, heart failure, stroke, revascularization and cardiac death. RESULTS: A total of 514 subjects met the inclusion criteria. The average age of the study subjects is 61.92 ± 9.49 years old, of which 67.12% are male. 94 subjects had a MACE event within 3 years, and the occurrence rate was 18.29%. There is no significant non-linear or linear relationship between diastolic blood pressure and MACE events. There is a curvilinear relationship between the average systolic blood pressure of patients after PCI and MACE events within 3 years and the inflection point is 121. On the left side of the inflection point, the effect size and 95% CI are 1.09 and 1.01-1.18, respectively (P = 0.029). The impact size and 95% CI at the right inflection point were 1.00 and 0.98-1.02(P = 0.604), respectively. CONCLUSION: There is a curvilinear relationship between systolic blood pressure and prognosis of patients after PCI. Under the premise of ensuring the safety of patients, maintaining lower blood pressure after surgery is beneficial to improve the prognosis of patients.

Significance of day-to-day glucose variability in patients after acute coronary syndrome.

BACKGROUND: Several studies have recently addressed the importance of glycemic variability (GV) in patients with acute coronary syndrome (ACS). Although daily GV measures, such as mean amplitude of glycemic excursions, are established predictors of poor prognosis in patients with ACS, the clinical significance of day-to-day GV remains to be fully elucidated. We therefore monitored day-to-day GV in patients with ACS to examine its significance. METHODS: In 25 patients with ACS, glucose levels were monitored for 14 days using a flash continuous glucose monitoring system. Mean of daily differences (MODD) was calculated as a marker of day-to-day GV. N-terminal pro-brain natriuretic peptide (NT-proBNP) was evaluated within 4 days after hospitalization. Cardiac function (left ventricular end-diastolic volume, left ventricular ejection fraction, stroke volume) was assessed by echocardiography at 3-5 days after admission and at 10-12 months after the disease onset. RESULTS: Of the 25 patients, 8 (32%) were diagnosed with diabetes, and continuous glucose monitoring (CGM)-based MODD was high (16.6 to 42.3) in 17 patients (68%). Although MODD did not correlate with max creatine kinase (CK), there was a positive correlation between J-index, high blood glucose index, and NT-proBNP (r = 0.83, p < 0.001; r = 0.85, p < 0.001; r = 0.41, p = 0.042, respectively). CONCLUSIONS: In patients with ACS, MODD was associated with elevated NT-proBNP. Future studies should investigate whether day-to-day GV in ACS patients can predict adverse clinical events such as heart failure.

The association between atrial fibrillation and in-hospital outcomes in chronic kidney disease patients with acute coronary syndrome: findings from the improving care for cardiovascular disease in China-acute coronary syndrome (CCC-ACS) project.

BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia in patients with chronic kidney disease (CKD) and acute coronary syndrome (ACS). This study aimed to explore the frequency and impact of AF on clinical outcomes in CKD patients with ACS. METHODS: CKD inpatients with ACS between November 2014 and December 2018 were included based on the improving care for cardiovascular disease in China-ACS (CCC-ACS) project. Included patients were divided into an AF group and a non-AF group according to the discharge diagnosis. Multivariable logistic regression was used to adjust for potential confounders. RESULTS: A total of 16,533 CKD patients with ACS were included. A total of 1418 (8.6%) patients had clinically recognized AF during hospitalization, 654 of whom had an eGFR of 45 to < 60 ml/min/1.73 m2, and 764 had an estimated glomerular filtration rate (eGFR) < 45 ml/min/1.73 m2. Compared with the non-AF group, the AF group had a higher risk of in-hospital mortality [OR 1.250; 95% CI (1.001-1.560), P = 0.049] and major adverse cardiovascular events (MACEs) [OR 1.361; 95% CI (1.197-1.547), P < 0.001]. We also found that compared with patients with eGFR 45 to < 60 ml/min/1.73 m2, patients with eGFR < 45 ml/min/1.73 m2 had a 1.512-fold increased risk of mortality and a 1.435-fold increased risk of MACEs. CONCLUSIONS: AF was a risk factor affecting the short-term prognosis of ACS patients in the CKD population. Furthermore, the lower the eGFR, the higher the risk of in-hospital mortality and MACEs in CKD patients with ACS. TRIAL REGISTRY: Clinicaltrial.gov, NCT02306616. Registered 29 November 2014, https://clinicaltrials.gov/ct2/show/NCT02306616?term=NCT02306616&draw=2&rank=1.

Effects of clinical depression on left ventricular dysfunction in patients with acute coronary syndrome.

Depression is associated with heart failure independent of traditional cardiovascular disease risk factors. Enhanced platelet activation has been suggested as a potential mechanism and has been associated with negative inotropic effects that can affect left ventricular ejection fraction (LVEF). We examined 131 consecutive acute coronary syndrome (ACS) patients to assess whether depression increased the risk for developing LV dysfunction, and to determine the effects of platelet serotonin signaling in this relationship. Major depression was assessed using the Structured Clinical Interview and depressive symptoms were measured using the Beck Depression Inventory (BDI), with BDI ≥ 10 defined as abnormal. LV dysfunction was defined as LVEF ≤ 45%. Platelet serotonin response was measured by serotonin augmented platelet aggregation and platelet serotonin receptor density. Mean age of ACS participants was 59 years, 78.6% male and 74.0% Caucasian. 34.4% of patients had a reduced LVEF ≤ 45% on presentation. Almost half (47.0%) of patients had BDI ≥ 10 and 18.0% had major depressive disorder. Platelet serotonin response was found to be augmented in depressed patients with low LVEF compared to depressed patients with normal LVEF (p < 0.020). However, the presence of LV dysfunction was found to be similar in both depressed (32.3%) and non-depressed (36.2%) patients (p = 0.714). This suggests alternative factors contribute to poor cardiovascular outcomes in depressed patients that are independent of LV function in post ACS patients.