Downstream cangrelor versus upstream ticagrelor in patients with ST-segment elevation myocardial infarction: A propensity score-matched analysis.

BACKGROUND: Pretreatment with a P2Y12 inhibitor may be considered in patients with ST-segment elevation myocardial infarction (STEMI) referred to percutaneous coronary intervention (PCI). Intravenous cangrelor is an alternative in this setting, where oral absorption can be hindered. The aim of this study was to compare cangrelor administered after coronary angiography (i.e., "downstream") and ticagrelor pretreatment (i.e., "upstream"). METHODS: STEMI patients undergoing PCI from October 2019 to June 2023 were included. The primary outcome was the composite of in-hospital major adverse cardiovascular events (MACE). Secondary outcomes included individual components of the primary outcome and in-hospital major bleeding. Univariable and multivariable regression analyses were performed in unmatched and propensity-matched cohorts. RESULTS: Of 6086 patients enrolled in the prospective CAST registry, 761 were included: 383 (50.3 %) received downstream cangrelor and 378 (49.7 %) upstream ticagrelor. In the matched population, no between-group differences were observed in MACE (odds ratio [OR] 1.30; 95 % confidence interval [CI] 0.79-2.17; P 0.308), all-cause death (OR 1.91; 95 % CI 0.87-4.54; P 0.124), myocardial infarction (OR 2.64; 95 % CI 0.76-12.14; P 0.154), stent thrombosis (OR 0.38; 95 % CI 0.06-1.80; P 0.255), unplanned repeat revascularization (OR 1.22; 95 % CI 0.32-4.98; P 0.766) and major bleeding (OR 0.98; 95 % CI 0.50-1.93; P 0.955). Cardiogenic shock and bailout administration of glycoprotein IIb/IIIa inhibitors were independent predictors of MACE, while radial access showed an inverse association with the primary outc. CONCLUSIONS: In P2Y12-naïve STEMI patients undergoing primary PCI, no significant differences were noted in the risk of in-hospital ischemic and bleeding events between downstream cangrelor and upstream ticagrelor.

Maturation of pluripotent stem cell-derived cardiomyocytes: limitations and challenges from metabolic aspects.

Acute coronary syndromes, such as myocardial infarction (MI), lack effective therapies beyond heart transplantation, which is often hindered by donor scarcity and postoperative complications. Human induced pluripotent stem cells (hiPSCs) offer the possibility of myocardial regeneration by differentiating into cardiomyocytes. However, hiPSC-derived cardiomyocytes (hiPSC-cardiomyocytes) exhibit fetal-like calcium flux and energy metabolism, which inhibits their engraftment. Several strategies have been explored to improve the therapeutic efficacy of hiPSC-cardiomyocytes, such as selectively enhancing energy substrate utilization and improving the transplantation environment. In this review, we have discussed the impact of altered mitochondrial biogenesis and metabolic switching on the maturation of hiPSC-cardiomyocytes. Additionally, we have discussed the limitations inherent in current methodologies for assessing metabolism in hiPSC-cardiomyocytes, and the challenges in achieving sufficient metabolic flexibility akin to that in the healthy adult heart.

Great debate: pre-diabetes is not an evidence-based treatment target for cardiovascular risk reduction.

With the increasing burden of diabetes as a cause of macro- and microvascular disease linked to the epidemics of obesity, attention is being paid to dysglycaemic states that predict and precede the development of type 2 diabetes. Such conditions, termed pre-diabetes, are characterized by fasting plasma glucose, or plasma glucose levels on an oral glucose tolerance test, or values of glycated haemoglobin intermediate between 'normal' values and those characterizing diabetes. These last are by definition associated, in epidemiological terms, with a higher incidence of microvascular disease-mostly retinopathy. Pre-diabetes overlaps with the components of the 'metabolic syndrome'-among which are excess visceral adiposity; hypertension; hypertriglyceridaemia; high levels of small, dense low-density lipoproteins; and metabolic-associated fatty liver disease. There is little doubt that pre-diabetes has important prognostic implications, especially for the occurrence of myocardial infarction, ischaemic stroke, and peripheral arterial disease. It is disputed, however, whether pre-diabetes is itself an actionable disease entity, in addition to the risk factors characterizing it. Because of this uncertainty, the latest European Society of Cardiology guidelines chose not to include pre-diabetes as a treatment target for atherosclerotic cardiovascular disease, at variance from the three previous editions of such guidelines. This is spurring a debate, the Pro and Contra arguments featured in the present debate article.

Assessment of ChatGPT's Compliance with ESC-Acute Coronary Syndrome Management Guidelines at 30-Day Intervals.

Background: Despite ongoing advancements in healthcare, acute coronary syndromes (ACS) remain a leading cause of morbidity and mortality. The 2023 European Society of Cardiology (ESC) guidelines have introduced significant improvements in ACS management. Concurrently, artificial intelligence (AI), particularly models like ChatGPT, is showing promise in supporting clinical decision-making and education. Methods: This study evaluates the performance of ChatGPT-v4 in adhering to ESC guidelines for ACS management over a 30-day interval. Based on ESC guidelines, a dataset of 100 questions was used to assess ChatGPT's accuracy and consistency. The questions were divided into binary (true/false) and multiple-choice formats. The AI's responses were initially evaluated and then re-evaluated after 30 days, using accuracy and consistency as primary metrics. Results: ChatGPT's accuracy in answering ACS-related binary and multiple-choice questions was evaluated at baseline and after 30 days. For binary questions, accuracy was 84% initially and 86% after 30 days, with no significant change (p = 0.564). Cohen's Kappa was 0.94, indicating excellent agreement. Multiple-choice question accuracy was 80% initially, improving to 84% after 30 days, also without significant change (p = 0.527). Cohen's Kappa was 0.93, reflecting similarly high consistency. These results suggest stable AI performance with minor fluctuations. Conclusions: Despite variations in performance on binary and multiple-choice questions, ChatGPT shows significant promise as a clinical support tool in ACS management. However, it is crucial to consider limitations such as fluctuations and hallucinations, which could lead to severe issues in clinical applications.

IVUS-Guided vs Angiography-Guided PCI in Patients With Diabetes With Acute Coronary Syndromes: The IVUS-ACS Trial.

BACKGROUND: Intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) reduces the risk for clinical events in patients with acute coronary syndromes (ACS), compared with angiographic guidance. However, the benefits of IVUS guidance in high-risk patients with diabetes with ACS is uncertain. OBJECTIVES: The aim of this prespecified stratified subgroup analysis from the IVUS-ACS randomized trial was to determine the effectiveness of IVUS-guided PCI vs angiography-guided PCI in patients with diabetes with ACS. METHODS: From August 20, 2019, to October 27, 2022, 1,105 patients with diabetes with ACS were randomized, including 554 patients in the IVUS-guided group and 551 in the angiography-guided group. The primary endpoint was the rate of target vessel failure (TVF) at 1 year, defined as the composite of cardiac death, target vessel myocardial infarction, or clinically driven target vessel revascularization. RESULTS: At 1-year follow-up, TVF occurred in 20 patients in the IVUS guidance group and in 46 patients in the angiographic guidance group (Kaplan-Meier rates 3.6% vs 8.3%; HR: 0.46; 95% CI: 0.27-0.81; P = 0.007), driven by a reduction in clinically driven target vessel revascularization (0.9% vs 3.8%; P = 0.003). IVUS-guided PCI also reduced the risk for TVF without procedural myocardial infarction (2.0% vs 6.7%; HR: 0.29; 95% CI: 0.15-0.57; P < 0.001) and all-cause mortality (HR: 0.30; 95% CI: 0.10-0.93; P = 0.037). There were no significant differences in the rates of stent thrombosis or major bleeding between the groups. CONCLUSIONS: In the large-scale IVUS-ACS trial, IVUS-guided PCI improved 1-year clinical outcomes in high-risk patients with diabetes with ACS. (1-Month vs 12-Month DAPT for ACS Patients Who Underwent PCI Stratified by IVUS: IVUS-ACS and ULTIMATE-DAPT Trials; NCT03971500).

The role of chronic total occlusions in non-infarct-related arteries in acute coronary syndrome patients: a systematic review.

Aim: This systematic review evaluated the impact of a chronic total occlusion (CTO) in a non-infarct-related artery (non-IRA) on clinical outcomes in acute coronary syndrome (ACS) patients and assessed the benefits of staged revascularization.Methods: We performed a comprehensive systematic review to provide further insight into the impact of a CTO in a non-IRA on clinical outcomes after ACS. Moreover, we review the currently available evidence on the clinical significance of staged revascularization for a CTO in a non-IRA patients with ACS and propose whether prophylactic CTO percutaneous coronary intervention (PCI) could improve outcomes in patients who subsequently develop an ACS.Results: Our search identified 999 studies, from which 30 were selected and ten were included in the analysis. The results showed a trend of higher all-cause mortality and major adverse cardiac event rates in the culprit-only-PCI group compared with the multivessel (MV)-PC I group in ST elevation myocardial infarction patients, with varying statistical significance across different outcomes.Conclusion: This review highlights the significant impact of non-IRA CTOs in ACS. Successful CTO revascularization may provide benefits, particularly in ST elevation myocardial infarction, but the optimal management approach remains uncertain. The presence of a non-IRA CTO, especially in cardiogenic shock, predicts worse outcomes. Further research is warranted to determine the effective strategies to improve survival.

Heart attacks occur when blood flow to the heart is blocked. Some people have a long-standing complete blockage in a heart artery, called a chronic total occlusion (CTO). This review examined studies on heart attack patients, who also had a CTO in a different artery.The review found that having a CTO makes heart attacks more dangerous, increasing the risk of serious complications or death. Treating the CTO might benefit some patients, potentially reducing future heart problems. However, the optimal timing for CTO treatment remains unclear, some doctors prefer immediate treatment, while others advocate waiting.For very sick heart attack patients in cardiogenic shock, a CTO further increases risks. These patients may require specialized treatments to support heart function.Although fixing CTOs might help, more research is needed to determine their effectiveness for all patients. Currently, treatment decisions are made based on each patient's situation.In conclusion, CTOs pose a significant challenge in heart attack treatment. Further studies are necessary to establish the safest and most effective approach for managing heart attack patients with CTOs.

Clinical Utility of Synthesized 18-Lead Electrocardiography.

Eighteen-lead electrocardiography (18-ECG) includes, in addition to those in standard 12-lead ECG (12-ECG), six additional chest leads: V7-V9 and V3RV5R. Leads V7-V9 require the patient to be in a lateral decubitus position for the electrodes to be attached to the back. Synthesized 18-ECG (syn18-ECG) is a method that only records 12-ECG and uses computational logic to record the posterior wall (V7-V9) and right-sided (V3R-V5R) leads. We review the clinical utility of syn18-ECG in conditions including acute coronary syndromes, arrhythmias, acute pulmonary embolism, and Duchenne muscular dystrophy. The syn18-ECG waveform correlates well with the actual 18-ECG waveform, indicating that syn18-ECG is an excellent substitute for 18-ECG, excluding negative T waves. ST elevation in leads V7-V9 has the effect of reducing missed acute coronary syndromes in the posterior wall. In cases of arrhythmia, syn18-ECG can accurately estimate the target site of radiofrequency catheter ablation using a simple algorithm. The use of additional leads in Duchenne muscular dystrophy is expected to provide new insights. To facilitate gaining more knowledge regarding diseases that have not yet been investigated, it is imperative that the cost of syn18-ECG is reduced in the future.

Heart failure biomarkers and prediction of early left ventricle remodeling after acute coronary syndromes.

INTRODUCTION: Several biomarkers are characteristically elevated in patients with acute heart failure (AHF). Our hypothesis was they could predict early changes in left ventricular (LV) characteristics in acute coronary syndrome (ACS) patients. The objective of this study was two-fold: a) compare circulating concentrations of NT-pro BNP, CA-125, ST2, galectin-3 and pro-adrenomedullin among 4 groups of individuals (healthy controls; patients with ACS without AHF; patients with ACS and AHF and patients admitted for AHF); and b) evaluate whether these biomarkers predict adverse LV remodeling and ejection fraction changes in ACS. METHODS: 6 biomarkers (NT-pro BNP, CA-125, ST2, galectin-3, pro-adrenomedullin and C-reactive) were measured within the first 48 h of admission. Echocardiograms were performed during admission and at 3 months. Variables associated with LV end-diastolic volume (EDV) and ejection fraction (LVEF) change were assessed by multivariate linear regression. RESULTS: We analyzed 51 patients with ACS, 16 with AHF and, 20 healthy controls. NT-pro BNP and ST2 concentrations were elevated at similar values in patients admitted for AHF and ACS complicated with HF but CA-125 concentrations were higher in AHF patients. NT-pro BNP concentrations were positively correlated with CA-125 (rho = 0.58; p < 0.001), ST2 (rho = 0.58; p < 0.001) and galectin-3 (rho = 0.37; p < 0.001) Median change (median days was 83 days after) in EDV and LVEF was 5 %. CA-125 concentrations were positively associated to LV EDV change (ß-coefficient 1.56) and negatively with LVEF trend (ß-coefficient = -0.86). No other biomarker predicted changes in EDV or LVEF. CONCLUSIONS: CA-125 correlates with early LV remodeling and LVEF deterioration in ACS patients.

Invasive and conservative management of elderly patients presenting with acute coronary syndrome: A meta-analysis of randomized controlled trials and adjusted observational studies.

BACKGROUND: Elderly patients are often under-represented in studies about coronary revascularization in acute coronary syndromes (ACS) and undertreated in clinical practice. We sought to evaluate differences in outcomes between an initial invasive or conservative strategy in this subset of patients, METHODS: The analysis was performed following PRISMA guidelines. Randomized controlled trials (RCTs) and adjusted observational studies comparing an invasive and conservative strategy in old patients with ACS were systematically identified. Random or fixed effect model was used accordingly to heterogeneity testing results. Short-term mortality was the primary outcome. 30-day and longer-term re-infarction, MACE and all-cause mortality were secondary endpoints. Sensitivity analysis including RCTs only were performed for the primary endpoint and 1 year mortality and another analysis, stratifying NSTEMI and STEMI studies, was performed for short-term mortality. RESULTS: Invasive management was associated with lower short and long-term mortality (30 days OR 0.64, 95 % CI 0.54-0.76, p < 0.001; 1 year HR 0.60, 95 % CI 0.52-0.78, p < 0.001; Long-term HR 0.62, 95 % CI 0.55-0.71, p < 0.001) compared to a conservative strategy. In the short-term follow-up, the benefit was preserved when differentiating for NSTEMI or STEMI studies but not when considering only RCTs. Major bleedings were more frequent in the invasive group (30 days OR 1.61, 95 % CI 1.39-1.87, p < 0.001). The mean difference in length of stay was not significantly different between the two strategies (mean difference in days 0.14, 95 % CI -0.79 to 1.06, p = 0.77). CONCLUSION: An initial invasive strategy might lead to reduced short and long-term mortality in elderly patients presenting with acute coronary syndrome but it is associated with increased bleeding events rate. No difference in hospital stay length was observed. Results were mainly driven by non-randomized studies.

External validation of the BE-ALIVE score for predicting 30-day mortality in patients presenting with acute coronary syndromes.

INTRODUCTION: The BE-ALIVE score is an additive scoring system for estimating 30-day mortality in patients presenting with an acute coronary syndrome (ACS) [1]. However, it had only previously been tested on an internal validation cohort. The aim was to assess the scoring system on an external validation cohort. METHODS: The scoring system comprises six domains: (1) Base Excess (1 point for < -2 mmols/L), (2) Age (<65 years: 0 points, 65-74: 1 point, 75-84: 2 points, ≥ 85: 3 points), (3) Lactate (<2 mmols/L: 0 points, 2-4.9: 1 point, 5-9.9: 3 points, ≥ 10: 6 points), (4) Intubated & Ventilated (2 points), (5) Left Ventricular function (normal or mildly impaired: -1 point, moderately impaired: 1 point, severely impaired: 3 points) and (6) External / out of hospital cardiac arrest (1 point). We applied the BE-ALIVE score was applied to 205 consecutive patients at a different institution. RESULTS: Calibration was strong, with an observed to expected ratio of 1.01, a calibration slope of 1.26 and calibration in the large of -0.03. The Spiegelhalter's Z-statistic was -0.95 (p = 0.34). The AUC was 0.95 (0.92-0.98) in the external validation cohort versus 0.90 (0.85-0.95) during internal validation. Overall performance was excellent with a Brier score of 0.07 versus 0.06 during internal validation. The negative predictive value for 30-day mortality of a BE-ALIVE score < 4 was 98 %, with a positive predicted value of a score ≥ 10 of 95 %. CONCLUSIONS: The BE-ALIVE score remains a robust predictor of 30-day mortality in an external validation cohort.

Acute epigastric pain unveiling biventricular myocardial infarction: A case report.

Acute coronary syndromes are a clinical entity frequently encountered in practice and are responsible for significant morbidity and mortality, despite therapeutic advances. The initiation of early reperfusion therapy reduces mortality and morbidity and improves patients' prognosis, but this depends on how quickly patients receive their treatment. Although it is often easy to diagnose in the presence of typical symptoms, certain patients, such as diabetics, sometimes have atypical symptoms, resulting in a delay in management. In nearly 50% of cases, inferior wall ischaemia is accompanied by right ventricular myocardial infarction; the clinical outcomes range from no hemodynamic compromise to severe hypotension and cardiogenic shock. In this article, we present the case of a 54-year-old male patient with active smoking and poorly controlled type 2 diabetes as cardiovascular risk factors who initially consulted at the first hour for epigastric pain, for which he received symptomatic treatment. As the symptoms persisted, he was admitted to our department at the eighth hour, where he was diagnosed with a biventricular infarction.

A rapid non-invasive wearable device for assessing cardiac troponin.

BACKGROUND: Chest pain, a common emergency department 35 (ED) presentation, requires rapid evaluation. Optical technology-based non-invasive wearable devices (Infrasensor, RCE, Carlsbad, CA) rapidly and transcutaneously assesses cardiac Troponin I (cTnI). OBJECTIVES: To perform a pilot study describing the performance of the Infrasensor in cTnI defined cohorts. METHODS: This was a 10-hospital prospective observational study in healthy US subjects with a normal cTnI, and in patients with an elevated local cTnI. Healthy subjects were without disease, defined by a negative questionnaire and bloodwork, had a 3-minute Infrasensor measurement and blood samples for high-sensitivity cardiac troponin I (hs-cTnI), n-terminal pro-B-type natriuretic peptide (NTproBNP), creatinine, and glycosylated hemoglobin (HbA1c). Elevated cTnI's patients had the same Infrasensor and blood sample measurements. Using a cross validation technique, a cTnI based binary classification model that did, and did not, include age was trained with 80%, and validated on 20% (n=168; elevated hs-cTnI equally distributed across 5 folds) of the overall cohort. RESULTS: Of 840 patients, 727 (87.5%) were non-elevated cTnI controls and the remainder, n=113, had elevated cTnI. Median (25th, 75th percentiles) age was 61 (52, 71) and 48 (32, 57) years for the elevated and healthy control cohorts, respectively. Overall, 50.5% were female, with 29.2% and 52.7% in the elevated and non-elevated troponin cohorts respectively. Overall, the sensitivity, specificity, negative and positive predictive values of the Infrasensor for identifying an elevated cTnI were 0.9, 0.7, 0.98 and 0.48 respectively, with a C-statistic of 0.90 (0.89-0.99). CONCLUSIONS: The Infrasensor identifies elevated cTnI within 3 minutes of application.

Sex-specific Prediction of Cardiogenic Shock After Acute Coronary Syndromes: The SEX-SHOCK Score.

BACKGROUND: and aims: Cardiogenic shock (CS) remains the primary cause of in-hospital death after acute coronary syndromes (ACS), with its plateauing mortality rates approaching 50%. To test novel interventions, personalized risk prediction is essential. The ORBI (Observatoire Régional Breton sur l'Infarctus) score represents the first-of-its-kind risk score to predict in-hospital CS in ACS patients undergoing percutaneous coronary intervention (PCI). However, its sex-specific performance remains unknown, and refined risk prediction strategies are warranted. METHODS: This multinational study included a total of 53 537 ACS patients without CS on admission undergoing PCI. Following sex-specific evaluation of ORBI, regression and machine-learning models were used for variable selection and risk prediction. By combining best-performing models with highest-ranked predictors, SEX-SHOCK was developed, and internally and externally validated. RESULTS: The ORBI score showed lower discriminative performance for the prediction of CS in females than males in Swiss (AUC [95% CI]: 0.78 [0.76-0.81] vs. 0.81 [0.79-0.83]; p=0.048) and French ACS patients (0.77 [0.74-0.81] vs. 0.84 [0.81-0.86]; p=0.002). The newly developed SEX-SHOCK score, now incorporating ST-segment elevation, creatinine, C-reactive protein, and left ventricular ejection fraction, outperformed ORBI in both sexes (females: 0.81 [0.78-0.83]; males: 0.83 [0.82-0.85]; p<0.001), which prevailed following internal and external validation in RICO (females: 0.82 [0.79-0.85]; males: 0.88 [0.86-0.89]; p<0.001) and SPUM-ACS (females: 0.83 [0.77-0.90], p=0.004; males: 0.83 [0.80-0.87], p=0.001). CONCLUSIONS: The ORBI score showed modest sex-specific performance. The novel SEX-SHOCK score provides superior performance in females and males across the entire spectrum of ACS, thus providing a basis for future interventional trials and contemporary ACS management.

Transitions of Care Pharmacist Impact Following Hospitalization for Acute Myocardial Infarction.

Background: Patients admitted with acute myocardial infarction (AMI) are at high risk for morbidity and rehospitalizations. Pharmacists can play a vital role in secondary prevention by providing services such as medication reconciliation and patient education upon discharge. Objective: The purpose of this study was to evaluate the impact of a pharmacist-led transitions of care (TOC) service on readmissions in patients hospitalized with AMI. Methods: This single center, pre-post observational cohort study evaluated adults with AMI who received pharmacist TOC services compared with a historical cohort who did not. Patients were excluded if they underwent cardiac surgery during admission. The primary outcome was the difference in 90-day cardiovascular (CV)-related readmissions. Secondary outcomes included 30- and 90-day all-cause readmissions, 30-day CV-related readmissions, and patients discharged on defect-free guideline-directed medical therapy (GDMT) for AMI. Results: There were 252 patients in each cohort included. No difference was found in 90-day CV readmissions, with a rate of 10.7% in the pre-TOC group versus 9.9% in the post-TOC group (OR 0.937, 95% CI [0.493, 1.769]; P = 0.842). Patients discharged on defect-free GDMT significantly increased from 61.5% pre-TOC to 87.7% post-TOC (OR 5.424, 95% CI [3.204, 9.468]; P < 0.001). There were no significant differences found in other key secondary outcomes. Conclusion and relevance: This study did not find a significant difference in hospital readmissions after implementation of a pharmacist-led TOC service. However, the service was associated with a significant increase in patients discharged on defect-free GDMT. Further studies are needed to confirm the impact of increased GDMT on clinical outcomes.

Clinical profile and management of patients with acute myocardial infarction admitted to cardiac care units: The EYESHOT-2 registry.

BACKGROUND: The clinical governance of patients with acute myocardial infarction (AMI) has markedly changed in the last few years. We sought to assess the contemporary in-hospital management patterns of patients with AMI at a country level. METHODS: EYESHOT (EmploYEd antithrombotic therapies in patients with acute coronary Syndromes HOspitalized in iTalian cardiac care units)-2 was a nationwide, prospective registry aimed to evaluate the current management of patients admitted to intensive cardiac care units (CCUs) for an AMI in Italy. RESULTS: Over a 4-week period (February 1st-29th, 2024), 183 CCUs enrolled 2806 consecutive patients: 52.6 % with non-ST elevation myocardial infarction (NSTEMI) and 47.4 % with ST-elevation myocardial infarction (STEMI). The median time from hospital admission to angiography in NSTEMI was 22.3 h (IQR 10.9-46.1), while for STEMI was 1.1 h (IQR 0.5-2.2) with significant difference between hospitals with and without catheterization laboratories. In both NSTEMI and STEMI patients, percutaneous coronary intervention (PCI) was the preferred management strategy (73.3 % and 94.2 %, respectively). An optimal secondary prevention therapy, including dual antiplatelet therapy, inhibition of the renin-angiotensin system, a beta-blocker and a high-intensity statin was prescribed at discharge in more than 75 % of patients with AMI. In-hospital major bleedings occurred in 2.0 % and 2.3 % (p = 0.58), while death in 1.8 % and 2.8 % (p = 0.09) of NSTEMI and STEMI patients, respectively. CONCLUSIONS: The EYESHOT-2 registry shows the current management strategies and outcome of AMI patients admitted to Italian CCUs and provides insights to improve the clinical care of such patients. CLINICAL TRIAL REGISTRATION: URL: http://www. CLINICALTRIALS: gov. Unique identifier: NCT06316128.

Early detection of resistance to dual antiplatelet therapy in patients who have undergone percutaneous coronary intervention using the VerifyNow test and associated factors.

Resistance to dual antiplatelet therapy (DAPT), including aspirin and clopidogrel, in patients who have undergone percutaneous coronary intervention (PCI) leads to the inability to prevent thrombotic complications. The present study aimed to evaluate early resistance to aspirin and clopidogrel in patients following PCI using the VerifyNow test and associated factors. A total of 50 patients diagnosed with acute coronary syndromes (ACS) who underwent emergency PCI and received DAPT were recruited in the present study. The detection of resistance to aspirin and clopidogrel was performed using the VerifyNow system. Resistance to aspirin was determined with VerifyNow Aspirin >550 aspirin reaction units (ARU). Resistance to clopidogrel was determined with VerifyNow P2Y12 >208 P2Y12 reaction units (PRU). The resistance rate to aspirin was 14%, while the resistance rate to clopidogrel was higher, at 34%. There were 2 patients with resistance to aspirin and clopidogrel (4%). Univariable logistic regression analysis revealed that diabetes, the use of ß-blockers, and low levels of hemoglobin and hematocrit were associated with resistance to clopidogrel. Following multivariable logistic regression analysis, only the use of ß-blockers was truly associated with resistance to clopidogrel. On the whole, the results of the present study may also prove to be helpful in the selection of therapeutic drugs for patients undergoing PCI and who are diagnosed with ACS.

Trends and Outcomes of Acute Myocardial Infarction During the Early COVID-19 Pandemic in the United States: A National Inpatient Sample Study.

BACKGROUND AND OBJECTIVES: There are limited national data on the trends and outcomes of patients hospitalized with acute myocardial infarction (AMI) during the coronavirus disease 2019 (COVID-19) pandemic. We aimed to evaluate the impact of early COVID-19 pandemic on the trends and outcomes of AMI using the National Inpatient Sample (NIS) database. METHODS: The NIS database was queried from January 2019 to December 2020 to identify adult (age ≥18 years) AMI hospitalizations and were categorized into ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) based on International Classification of Diseases, Tenth Revision, Clinical Modification codes. In addition, the in-hospital mortality, revascularization, and resource utilization of AMI hospitalizations early in the COVID-19 pandemic (2020) were compared to those in the pre-pandemic period (2019) using multivariate logistic and linear regression analysis. RESULTS: Amongst 1,709,480 AMI hospitalizations, 209,450 STEMI and 677,355 NSTEMI occurred in 2019 while 196,230 STEMI and 626,445 NSTEMI hospitalizations occurred in 2020. Compared with those in 2019, the AMI hospitalizations in 2020 had higher odds of in-hospital mortality (adjusted odds ratio [aOR], 1.27; 95% confidence interval [CI], [1.23-1.32]; p<0.01) and lower odds of percutaneous coronary intervention (aOR, 0.95 [0.92-0.99]; p=0.02), and coronary artery bypass graft (aOR, 0.90 [0.85-0.97]; p<0.01). CONCLUSIONS: We found a significant decline in AMI hospitalizations and use of revascularization, with higher in-hospital mortality, during the early COVID-19 pandemic period (2020) compared with the pre-pandemic period (2019). Further research into the factors associated with increased mortality could help with preparedness in future pandemics.

Proenkephalin Improves Cardio-Renal Risk Prediction in Acute Coronary Syndromes: The KID-ACS Score.

BACKGROUND AND AIMS: Circulating proenkephalin (PENK) is a stable endogenous polypeptide with fast response to glomerular dysfunction and tubular damage. This study examined the predictive value of PENK for renal outcomes and mortality in patients with acute coronary syndromes (ACS). METHODS: Proenkephalin was measured in plasma in a prospective multicentre ACS cohort from Switzerland (n=4787) and in validation cohorts from the UK (n=1141), Czechia (n=927), and Germany (n=220). A biomarker-enhanced risk score (KID-ACS score) for simultaneous prediction of in-hospital acute kidney injury (AKI) and 30-day mortality was derived and externally validated. RESULTS: On multivariable adjustment for established risk factors, circulating PENK remained associated with in-hospital AKI (per log2 increase: adjusted odds ratio [OR] 1.53, 95% confidence interval [CI] 1.13-2.09, P=0.007) and 30-day mortality (adjusted hazard ratio [HR] 2.73, 95% CI 1.85-4.02, P<0.001). The KID-ACS score integrates PENK and showed an area under the receiver operating characteristic curve (AUC) of 0.72 (95% CI 0.68-0.76) for in-hospital AKI, and of 0.91 (95% CI 0.87-0.95) for 30-day mortality in the derivation cohort. Upon external validation, KID-ACS achieved similarly high performance for in-hospital AKI (Zurich: AUC 0.73, 95% CI 0.70-0.77; Czechia: AUC 0.75, 95% CI 0.68-0.81; Germany: AUC 0.71, 95% CI 0.55-0.87) and 30-day mortality (UK: AUC 0.87, 95% CI 0.83-0.91; Czechia: AUC 0.91, 95% CI 0.87-0.94; Germany: AUC 0.96, 95% CI 0.92-1.00) outperforming the CA-AKI score and the GRACE 2.0 score, respectively. CONCLUSIONS: Circulating PENK offers incremental value for predicting in-hospital AKI and mortality in ACS. The simple 6-item KID-ACS risk score integrates PENK and provides a novel tool for simultaneous assessment of renal and mortality risk in patients with ACS.