Nutritional Status and Recurrent Major Cardiovascular Events Following Acute Myocardial Infarction-A Follow-Up Study in a Primary Percutaneous Coronary Intervention Center.

BACKGROUND: Acute myocardial infarction is often accompanied by malnutrition, which is associated with an imbalance between catabolic and anabolic processes. This ultimately leads to cardiac cachexia, which worsens the patient's prognosis. We aimed to assess the correlation between nutritional status, assessed using the controlling nutritional status (CONUT) score, and the rate of major cardiovascular adverse events (MACE). METHODS: The present investigation was a non-randomized, prospective, observational study in which 108 patients with acute myocardial infarction were included. Nutritional status was assessed using the CONUT score. Based on the CONUT score, the patients were divided as follows: Group 1-normal or mild nutritional status (CONUT < 3 points, n = 76), and Group 2-moderate to severe nutritional deficiency (CONUT ≥ 3 points, n = 32). Demographic, echocardiographic, and laboratory parameters were obtained for all patients, as well as the MACE rate at 1 and 3 months of follow-up. RESULTS: The MACE occurred more frequently in patients with impaired nutritional status at both 1-month follow-up (46.9% versus 9.2%; p < 0.0001) and 3-month follow-up (68.8% versus 10.5%; p < 0.0001). In terms of cardiovascular events, patients with poor nutritional status, with a CONUT score ≥ 3, presented more frequent non-fatal myocardial infarction, stroke, revascularization procedure, and ventricular arrhythmia. Also, the number of cardiovascular deaths was higher in the undernourished group. CONCLUSIONS: This study found that patients with poor nutritional status experienced inflammatory status, frailty, and cardiovascular events more often than those with normal nutritional status at 1-month and 3-month follow-up after an acute myocardial infarction.

CT-Assessment of Epicardial Fat Identifies Increased Inflammation at the Level of the Left Coronary Circulation in Patients with Atrial Fibrillation.

Background: Atrial fibrillation (AF) can often be triggered by an inflammatory substrate. Perivascular inflammation may be assessed nowadays using coronary computed tomography angiography (CCTA) imaging. The new pericoronary fat attenuation index (FAI HU) and the FAI Score have prognostic value for predicting future cardiovascular events. Our purpose was to investigate the correlation between pericoronary fat inflammation and the presence of AF among patients with coronary artery disease. Patients and methods: Eighty-one patients (mean age 64.75 ± 7.84 years) who underwent 128-slice CCTA were included in this study and divided into two groups: group 1 comprised thirty-six patients with documented AF and group 2 comprised forty-five patients without a known history of AF. Results: There were no significant differences in the absolute value of fat attenuation between the study groups (p > 0.05). However, the mean FAI Score was significantly higher in patients with AF (15.53 ± 10.29 vs. 11.09 ± 6.70, p < 0.05). Regional analysis of coronary inflammation indicated a higher level of this process, especially at the level of the left anterior descending artery (13.17 ± 7.91 in group 1 vs. 8.80 ± 4.75 in group 2, p = 0.008). Conclusions: Patients with AF present a higher level of perivascular inflammation, especially in the region of the left coronary circulation, and this seems to be associated with a higher risk of AF development.

Coronary Artery Calcium Score Predicts Major Adverse Cardiovascular Events in Stable Chest Pain.

Background Coronary artery calcium (CAC) has prognostic value for major adverse cardiovascular events (MACE) in asymptomatic individuals, whereas its role in symptomatic patients is less clear. Purpose To assess the prognostic value of CAC scoring for MACE in participants with stable chest pain initially referred for invasive coronary angiography (ICA). Materials and Methods This prespecified subgroup analysis from the Diagnostic Imaging Strategies for Patients With Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) trial, conducted between October 2015 and April 2019 across 26 centers in 16 countries, focused on adult patients with stable chest pain referred for ICA. Participants were randomly assigned to undergo either ICA or coronary CT. CAC scores from noncontrast CT scans were categorized into low, intermediate, and high groups based on scores of 0, 1-399, and 400 or higher, respectively. The end point of the study was the occurrence of MACE (myocardial infarction, stroke, and cardiovascular death) over a median 3.5-year follow-up, analyzed using Cox proportional hazard regression tests. Results The study involved 1749 participants (mean age, 60 years ± 10 [SD]; 992 female). The prevalence of obstructive coronary artery disease (CAD) at CT angiography rose from 4.1% (95% CI: 2.8, 5.8) in the CAC score 0 group to 76.1% (95% CI: 70.3, 81.2) in the CAC score 400 or higher group. Revascularization rates increased from 1.7% to 46.2% across the same groups (P < .001). The CAC score 0 group had a lower MACE risk (0.5%; HR, 0.08 [95% CI: 0.02, 0.30]; P < .001), as did the 1-399 CAC score group (1.9%; HR, 0.27 [95% CI: 0.13, 0.59]; P = .001), compared with the 400 or higher CAC score group (6.8%). No significant difference in MACE between sexes was observed (P = .68). Conclusion In participants with stable chest pain initially referred for ICA, a CAC score of 0 showed very low risk of MACE, and higher CAC scores showed increasing risk of obstructive CAD, revascularization, and MACE at follow-up. Clinical trial registration no. NCT02400229 © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Hanneman and Gulsin in this issue.

Assessing the Impact of Long-Term High-Dose Statin Treatment on Pericoronary Inflammation and Plaque Distribution-A Comprehensive Coronary CTA Follow-Up Study.

Computed tomography angiography (CTA) has validated the use of pericoronary adipose tissue (PCAT) attenuation as a credible indicator of coronary inflammation, playing a crucial role in coronary artery disease (CAD). This study aimed to evaluate the long-term effects of high-dose statins on PCAT attenuation at coronary lesion sites and changes in plaque distribution. Our prospective observational study included 52 patients (mean age 60.43) with chest pain, a low-to-intermediate likelihood of CAD, who had documented atheromatous plaque through CTA, performed approximately 1 year and 3 years after inclusion. We utilized the advanced features of the CaRi-Heart® and syngo.via Frontier® systems to assess coronary plaques and changes in PCAT attenuation. The investigation of changes in plaque morphology revealed significant alterations. Notably, in mixed plaques, calcified portions increased (p < 0.0001), while non-calcified plaque volume (NCPV) decreased (p = 0.0209). PCAT attenuation generally decreased after one year and remained low, indicating reduced inflammation in the following arteries: left anterior descending artery (LAD) (p = 0.0142), left circumflex artery (LCX) (p = 0.0513), and right coronary artery (RCA) (p = 0.1249). The CaRi-Heart® risk also decreased significantly (p = 0.0041). Linear regression analysis demonstrated a correlation between increased PCAT attenuation and higher volumes of NCPV (p < 0.0001, r = 0.3032) and lipid-rich plaque volume (p < 0.0001, r = 0.3281). Our study provides evidence that high-dose statin therapy significantly reduces CAD risk factors, inflammation, and plaque vulnerability, as evidenced by the notable decrease in PCAT attenuation, a critical indicator of plaque progression.

Age and Computed Tomography and Invasive Coronary Angiography in Stable Chest Pain: A Prespecified Secondary Analysis of the DISCHARGE Randomized Clinical Trial.

Importance: The effectiveness and safety of computed tomography (CT) and invasive coronary angiography (ICA) in different age groups is unknown. Objective: To determine the association of age with outcomes of CT and ICA in patients with stable chest pain. Design, Setting, and Participants: The assessor-blinded Diagnostic Imaging Strategies for Patients With Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) randomized clinical trial was conducted between October 2015 and April 2019 in 26 European centers. Patients referred for ICA with stable chest pain and an intermediate probability of obstructive coronary artery disease were analyzed in an intention-to-treat analysis. Data were analyzed from July 2022 to January 2023. Interventions: Patients were randomly assigned to a CT-first strategy or a direct-to-ICA strategy. Main Outcomes and Measures: MACE (ie, cardiovascular death, nonfatal myocardial infarction, or stroke) and major procedure-related complications. The primary prespecified outcome of this secondary analysis of age was major adverse cardiovascular events (MACE) at a median follow-up of 3.5 years. Results: Among 3561 patients (mean [SD] age, 60.1 [10.1] years; 2002 female [56.2%]), 2360 (66.3%) were younger than 65 years, 982 (27.6%) were between ages 65 to 75 years, and 219 (6.1%) were older than 75 years. The primary outcome was MACE at a median (IQR) follow-up of 3.5 (2.9-4.2) years for 3523 patients (99%). Modeling age as a continuous variable, age, and randomization group were not associated with MACE (hazard ratio, 1.02; 95% CI, 0.98-1.07; P for interaction = .31). Age and randomization group were associated with major procedure-related complications (odds ratio, 1.15; 95% CI, 1.05-1.27; P for interaction = .005), which were lower in younger patients. Conclusions and Relevance: Age did not modify the effect of randomization group on the primary outcome of MACE but did modify the effect on major procedure-related complications. Results suggest that CT was associated with a lower risk of major procedure-related complications in younger patients. Trial Registration: ClinicalTrials.gov Identifier: NCT02400229.

Impact of smoking in patients with suspected coronary artery disease in the randomised DISCHARGE trial.

OBJECTIVES: To investigate if the effect of cardiac computed tomography (CT) vs. invasive coronary angiography (ICA) on cardiovascular events differs based on smoking status. MATERIALS AND METHODS: This pre-specified subgroup analysis of the pragmatic, prospective, multicentre, randomised DISCHARGE trial (NCT02400229) involved 3561 patients with suspected coronary artery disease (CAD). The primary endpoint was major adverse cardiovascular events (MACE: cardiovascular death, non-fatal myocardial infarction, or stroke). Secondary endpoints included an expanded MACE composite (MACE, transient ischaemic attack, or major procedure-related complications). RESULTS: Of 3445 randomised patients with smoking data (mean age 59.1 years + / - 9.7, 1151 men), at 3.5-year follow-up, the effect of CT vs. ICA on MACE was consistent across smoking groups (p for interaction = 0.98). The percutaneous coronary intervention rate was significantly lower with a CT-first strategy in smokers and former smokers (p = 0.01 for both). A CT-first strategy reduced the hazard of major procedure-related complications (HR: 0.21, 95% CI: 0.03, 0.81; p = 0.045) across smoking groups. In current smokers, the expanded MACE composite was lower in the CT- compared to the ICA-first strategy (2.3% (8) vs 6.0% (18), HR: 0.38; 95% CI: 0.17, 0.88). The rate of non-obstructive CAD was significantly higher in all three smoking groups in the CT-first strategy. CONCLUSION: For patients with stable chest pain referred for ICA, the clinical outcomes of CT were consistent across smoking status. The CT-first approach led to a higher detection rate of non-obstructive CAD and fewer major procedure-related complications in smokers. CLINICAL RELEVANCE STATEMENT: This pre-specified sub-analysis of the DISCHARGE trial confirms that a CT-first strategy in patients with stable chest pain referred for invasive coronary angiography with an intermediate pre-test probability of coronary artery disease is as effective as and safer than invasive coronary angiography, irrespective of smoking status. TRIAL REGISTRATION: ClinicalTrials.gov NCT02400229. KEY POINTS: • No randomised studies have assessed smoking status on CT effectiveness in symptomatic patients referred for invasive coronary angiography. • A CT-first strategy results in comparable adverse events, fewer complications, and increased coronary artery disease detection, irrespective of smoking status. • A CT-first strategy is safe and effective for stable chest pain patients with intermediate pre-test probability for CAD, including never smokers.

Computed Tomography Versus Invasive Coronary Angiography in Patients With Diabetes and Suspected Coronary Artery Disease.

OBJECTIVE: To compare cardiac computed tomography (CT) with invasive coronary angiography (ICA) as the initial strategy in patients with diabetes and stable chest pain. RESEARCH DESIGN AND METHODS: This prespecified analysis of the multicenter DISCHARGE trial in 16 European countries was performed in patients with stable chest pain and intermediate pretest probability of coronary artery disease. The primary end point was a major adverse cardiac event (MACE) (cardiovascular death, nonfatal myocardial infarction, or stroke), and the secondary end point was expanded MACE (including transient ischemic attacks and major procedure-related complications). RESULTS: Follow-up at a median of 3.5 years was available in 3,541 patients of whom 557 (CT group n = 263 vs. ICA group n = 294) had diabetes and 2,984 (CT group n = 1,536 vs. ICA group n = 1,448) did not. No statistically significant diabetes interaction was found for MACE (P = 0.45), expanded MACE (P = 0.35), or major procedure-related complications (P = 0.49). In both patients with and without diabetes, the rate of MACE did not differ between CT and ICA groups. In patients with diabetes, the expanded MACE end point occurred less frequently in the CT group than in the ICA group (3.8% [10 of 263] vs. 8.2% [24 of 294], hazard ratio [HR] 0.45 [95% CI 0.22-0.95]), as did the major procedure-related complication rate (0.4% [1 of 263] vs. 2.7% [8 of 294], HR 0.30 [95% CI 0.13 - 0.63]). CONCLUSIONS: In patients with diabetes referred for ICA for the investigation of stable chest pain, a CT-first strategy compared with an ICA-first strategy showed no difference in MACE and may potentially be associated with a lower rate of expanded MACE and major procedure-related complications.

Association of Atrial Fibrillation Recurrence with Right Coronary Atherosclerosis and Increased Left Arterial Epicardial Fat Following Catheter Ablation-Results of a Multimodality Study.

BACKGROUND: Identification of predictors for atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI) can lead to better long-term results. Our aim was to investigate the association between novel CT imaging markers reflecting the severity of coronary atherosclerosis and the risk of recurrence following PVI. METHODS: This study included 80 patients with paroxysmal/persistent AF who underwent PVI. The patients were divided into two groups: Group 1-23 patients with recurrence and Group 2-57 patients without recurrence. RESULTS: Patients with recurrence presented with a more enlarged left atrial diameter and reduced left ventricle EF, as assessed by echocardiography. Elevated calcium scores and right coronary artery (RCA) stenosis were correlated with a higher risk of AF recurrence (25.38 ± 4.1% vs. 9.76 ± 2.32%, p = 0.001). Patients with AF recurrence presented a higher left atrial volume index (LAVI) (61.38 ± 11.12 mm3/m2 vs. 46.34 ± 12.27 mm3/m2, p < 0.0001). The bi-atrial volume index (BAVI) was similarly higher in the AF recurrence group (98.23 ± 14.44 mm3/m2 vs. 76.48 ± 17.61 mm3/m2, p < 0.0001). Increased EAT volumes located around the LA (EAT-LA) were correlated with recurrence (25.55 ± 6.37 vs. 15.54 ± 8.44, p < 0.0001). CONCLUSIONS: RCA stenosis, together with atrial volumes and EAT-AS evaluated by CCTA, is associated with the risk of AF recurrence following PVI.

Ups and downs of conducting a national representative survey on hypertension during pandemic time: main results of SEPHAR IV.

OBJECTIVES: This national representative survey sought to assess hypertension's prevalence, awareness, treatment and control in Romania. METHODS: A representative sample (by age, sex and residence) of 1477 Romanian adults (51.19 ±â€Š16.61 years, range 18-80 years, 59.9% women) was multimodally evaluated during two study visits. Hypertension was defined as SBP at least 140 mmHg and/or DBP at least 90 mmHg or previously diagnosed hypertension, regardless of BP. Awareness was defined by knowledge of previous hypertension diagnosis or of current use of antihypertensive treatment. Treatment was defined by antihypertensive medication taken at least 2 weeks prior to enrolment. Control was defined as SBP less than 140 mmHg and DBP less than 90 mmHg at both visits in treated hypertensive patients. RESULTS: Hypertension prevalence was 46% ( n  = 680) consisting of 81.02% ( n  = 551) known hypertensive patients and 18.98% ( n  = 129) newly diagnosed hypertensive patients. Awareness, treatment and control of hypertension were: 81% ( n  = 551), 83.8% ( n  = 462) and 39.2% ( n  = 181). CONCLUSION: Despite numerous pandemic-related obstacles in conducting a national survey, SEPHAR IV updates hypertension epidemiological data of a high-cardiovascular-risk Eastern-European population. This study confirms previous predictions of hypertension prevalence, treatment and control, which remain unfavourable because of unsatisfactory control of promoting factors.

Elevated FAI Index of Pericoronary Inflammation on Coronary CT Identifies Increased Risk of Coronary Plaque Vulnerability after COVID-19 Infection.

Inflammation is a key factor in the development of atherosclerosis, a disease characterized by the buildup of plaque in the arteries. COVID-19 infection is known to cause systemic inflammation, but its impact on local plaque vulnerability is unclear. Our study aimed to investigate the impact of COVID-19 infection on coronary artery disease (CAD) in patients who underwent computed tomography angiography (CCTA) for chest pain in the early stages after infection, using an AI-powered solution called CaRi-Heart®. The study included 158 patients (mean age was 61.63 ± 10.14 years) with angina and low to intermediate clinical likelihood of CAD, with 75 having a previous COVID-19 infection and 83 without infection. The results showed that patients who had a previous COVID-19 infection had higher levels of pericoronary inflammation than those who did not have a COVID-19 infection, suggesting that COVID-19 may increase the risk of coronary plaque destabilization. This study highlights the potential long-term impact of COVID-19 on cardiovascular health, and the importance of monitoring and managing cardiovascular risk factors in patients recovering from COVID-19 infection. The AI-powered CaRi-Heart® technology may offer a non-invasive way to detect coronary artery inflammation and plaque instability in patients with COVID-19.

The Association between Apolipoprotein B, Cardiovascular Risk Factors and Subclinical Atherosclerosis-Findings from the SEPHAR National Registry on Hypertension in Romania.

The present study aimed to investigate the association between apolipoprotein B (Apo B) and classical features associated with clinical or subclinical atherosclerosis. A total of 811 adult patients from the general Romanian population, included in the national SEPHAR registry on hypertension, were divided into two groups based on Apo B value (low versus high Apo B with a cut-off established at 130 mg/dL) and subsequently into four subgroups according to the cut-offs recommended by the 2021 ESC Guidelines on Cardiovascular Disease Prevention. In all patients, lipid profile, uric acid, full blood count and presence of significant carotid plaques were assessed. Apo B levels were positively correlated with proatherogenic lipids (total cholesterol, triglycerides and LDL-cholesterol, p < 0.0001) and negatively correlated with HDL cholesterol (all p < 0.05). In comparison with patients with low Apo B levels, those with elevated Apo B levels more frequently presented significant carotid plaques (17% vs. 19% vs. 28% vs. 46%, p < 0.0001). Univariate regression analysis identified a strong association between the level of uric acid and increased value of Apo B in the four subgroups (uric acid 4.8 +/- 1.3 vs. 5 +/- 1.6 vs. 5.1 +/- 1.5 vs. 5.8 +/- 1.6, r = 0.2, p < 0.0001). The results of this nationwide registry on hypertension in Romania indicate that high Apo B may be considered as a risk factor for CVD, promoting atherosclerosis and associated with increased expression of classical markers of clinical or subclinical CVD.

Social and Metabolic Determinants of Prevalent Hypertension in Men and Women: A Cluster Analysis from a Population-Based Study.

Essential hypertension (HTN) has a complex spectrum of pathophysiological determinants and current guidelines provide limited information on high-risk groups that should be targeted for its primary prevention. The objective of our research was to identify clusters of social and metabolic factors associated with prevalent HTN in men and women from a population-based survey in Romania. Of the 1477 participants in the main study, 798 with complete data were analyzed here. Using two-step cluster analysis, one high-risk cluster in women and two high and intermediate risk for prevalent HTN in men were identified. Older age, rural area, lower education, and higher burden of metabolic factors characterized clusters with higher risk, while intermediate risk in men was characterized by a more metabolically healthy phenotype in younger individuals. In logistic regression, men in Cluster 1 vs. those in Cluster 3 had an odds ratio (OR) of 9.6 (95%CI: 4.6; 20.0), p < 0.001 for prevalent HTN, while OR for Cluster 2 vs. Cluster 3 was 3.2 (95%CI: 1.4; 7.4), p = 0.005. In women, the OR for HTN was 10.2 (95%CI: 5.7; 18.5) if assigned to Cluster 2 vs. Cluster 1, p < 0.001. These results pointed out the subgroups and communities that the primary prevention of HTN should be prioritized in.

Prevalence and Predictors of Renal Disease in a National Representative Sample of the Romanian Adult Population: Data from the SEPHAR IV Survey.

Background: The prevalence of chronic kidney disease (CKD) correlates with the prevalence of hypertension (HT). We studied the prevalence and predictors of CKD in a representative sample of the Romanian adult population. Methods: A sample of 1470 subjects were enrolled in the SEPHAR IV (Study for the Evaluation of Prevalence of Hypertension and Cardiovascular Risk) survey. All subjects were evaluated for blood pressure (BP) and extensive evaluations of target organ damage, blood, and urine samples were undertaken. Results: A total of 883 subjects were included in the statistical analysis. Those experiencing CKD with an eGFR < 60 mL/min/1.73 m2 were older at 71.94 ± 7.4 years (n = 19, 2.15%) compared with those without renal impairment at 50.3 ± 16.21 years (n = 864, 97.85%), p < 0.0001. The prevalence of CKD among hypertensives (379 from 883) was 4.49% (17/379), while 17 out of 19 subjects with CKD had HT (89.47%). After adjusting for age, sex, and diabetic status, only serum uric acid (SUR) > 6.9 mg/dL (OR: 6.61; 95% CI: 2.063, 10.83; p = 0.004) was an independent risk factor and a predictor of CKD. Conclusions: The prevalence of CKD in hypertensive Romanian adults was more than ten times higher than in the normotensive population. Levels of SUR > 6.9 mg/dL were predictors of CKD.

What Patients Find on the Internet When Looking for Information About Percutaneous Coronary Intervention: Multilanguage Cross-sectional Assessment.

BACKGROUND: The internet provides general users with wide access to medical information. However, regulating and controlling the quality and reliability of the considerable volume of available data is challenging, thus generating concerns about the consequences of inaccurate health care-related documentation. Several tools have been proposed to increase the transparency and overall trustworthiness of medical information present on the web. OBJECTIVE: We aimed to analyze and compare the quality and reliability of information about percutaneous coronary intervention on English, German, Hungarian, Romanian, and Russian language websites. METHODS: Following a rigorous protocol, 125 websites were selected, 25 for each language sub-sample. The websites were assessed concerning their general characteristics, compliance with a set of eEurope 2002 credibility criteria, and quality of the informational content (namely completeness and accuracy), based on a topic-specific benchmark. Completeness and accuracy were graded independently by 2 evaluators. Scores were reported on a scale from 0 to 10. The 5 language subsamples were compared regarding credibility, completeness, and accuracy. Correlations between credibility scores on the one hand, and completeness and accuracy scores, on the other hand, were tested within each language subsample. RESULTS: The websites' compliance with credibility criteria was average at best with scores between 3.0 and 6.0. In terms of completeness and accuracy, the website subsets qualified as poor or average, with scores ranging from 2.4 to 4.6 and 3.6 to 5.3, respectively. English language websites scored significantly higher in all 3 aspects, followed by German and Hungarian language websites. Only German language websites showed a significant correlation between credibility and information quality. CONCLUSIONS: The quality of websites in English, German, Hungarian, Romanian, and Russian languages about percutaneous coronary intervention was rather inadequate and may raise concerns regarding their impact on informed decision-making. Using credibility criteria as indicators of information quality may not be warranted, as credibility scores were only exceptionally correlated with content quality. The study brings valuable descriptive data on the quality of web-based information regarding percutaneous coronary intervention in multiple languages and raises awareness about the need for responsible use of health-related web resources.

Comparative effectiveness of initial computed tomography and invasive coronary angiography in women and men with stable chest pain and suspected coronary artery disease: multicentre randomised trial.

OBJECTIVE: To assess the comparative effectiveness of computed tomography and invasive coronary angiography in women and men with stable chest pain suspected to be caused by coronary artery disease. DESIGN: Prospective, multicentre, randomised pragmatic trial. SETTING: Hospitals at 26 sites in 16 European countries. PARTICIPANTS: 2002 (56.2%) women and 1559 (43.8%) men (total of 3561 patients) with suspected coronary artery disease referred for invasive coronary angiography on the basis of stable chest pain and a pre-test probability of obstructive coronary artery disease of 10-60%. INTERVENTION: Both women and men were randomised 1:1 (with stratification by gender and centre) to a strategy of either computed tomography or invasive coronary angiography as the initial diagnostic test (1019 and 983 women, and 789 and 770 men, respectively), and an intention-to-treat analysis was performed. Randomised allocation could not be blinded, but outcomes were assessed by investigators blinded to randomisation group. MAIN OUTCOME MEASURES: The primary endpoint was major adverse cardiovascular events (MACE; cardiovascular death, non-fatal myocardial infarction, or non-fatal stroke). Key secondary endpoints were an expanded MACE composite (cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, transient ischaemic attack, or major procedure related complication) and major procedure related complications. RESULTS: Follow-up at a median of 3.5 years was available in 98.9% (1979/2002) of women and in 99.0% (1544/1559) of men. No statistically significant gender interaction was found for MACE (P=0.29), the expanded MACE composite (P=0.45), or major procedure related complications (P=0.11). In both genders, the rate of MACE did not differ between the computed tomography and invasive coronary angiography groups. In men, the expanded MACE composite endpoint occurred less frequently in the computed tomography group than in the invasive coronary angiography group (22 (2.8%) v 41 (5.3%); hazard ratio 0.52, 95% confidence interval 0.31 to 0.87). In women, the risk of having a major procedure related complication was lower in the computed tomography group than in the invasive coronary angiography group (3 (0.3%) v 21 (2.1%); hazard ratio 0.14, 0.04 to 0.46). CONCLUSION: This study found no evidence for a difference between women and men in the benefit of using computed tomography rather than invasive coronary angiography as the initial diagnostic test for the management of stable chest pain in patients with an intermediate pre-test probability of coronary artery disease. An initial computed tomography scan was associated with fewer major procedure related complications in women and a lower frequency of the expanded MACE composite in men. TRIAL REGISTRATION: NCT02400229ClinicalTrials.gov NCT02400229.

Acute-Phase Inflammatory Reaction Predicts CMR Myocardial Scar Pattern and 2-Year Mortality in STEMI Patients Undergoing Primary PCI.

(1) Background: The inflammatory response following MI plays an important role in the healing, scar formation, and left ventricle (LV) remodeling. Cardiac magnetic resonance (CMR) imaging can accurately quantify the extent of myocardial scarring. The study aimed to investigate: (a) the relationship between acute inflammatory response and the CMR parameters of the scarring extent, and (b) the predictive power of inflammatory biomarkers and myocardial scarring for 2-year mortality. (2) Methods: The study included 202 STEMI patients, who underwent pPCI. Serum hs-CRP, IL-6, P-selectin, E-selectin, I-CAM, and V-CAM levels were determined at admission, and hs-CRP on the fifth day. Patients underwent LGE-CMR after 1 month, for LV volumes, ejection fraction (EF), infarct size (IS), and transmurality. Subjects were divided into tertiles according to the IS, and 2-year all-cause mortality was determined. (3) Results: IL-6 was associated with IS (r = 0.324, p = 0.01), increased transmurality index (r = 0.3, p = 0.01), and lower LVEF (r = −0.3, p = 0.02). Admission hs-CRP levels were not associated with IS, transmurality, or mortality, while hs-CRP at day 5 was a significant predictor for IS (AUC = 0.635, p = 0.05) as well as IL-6 levels (AUC = 0.685, p < 0.001). Mortality was significantly higher in the upper IS tertiles (6% vs. 8.7% vs. 24.52%, p = 0.005). IS was a significant predictor of 2-year mortality (AUC = 0.673, p = 0.002), with a cut-off value of 28.81 g, as well as high transmurality (AUC = 0.641, p = 0.013), with a cut off value of 18.38 g. (4) Conclusions: The serum levels of IL-6 and day-5 hs-CRP predict IS and transmurality, and day-5 hs-CRP levels are independent predictors of 2-year mortality in STEMI patients treated with pPCI. The CMR pattern of myocardial scarring after 1 month, as expressed by the magnitude of IS and transmurality, is a significant predictor for 2-year mortality after revascularized STEMI.

CT or Invasive Coronary Angiography in Stable Chest Pain.

BACKGROUND: In the diagnosis of obstructive coronary artery disease (CAD), computed tomography (CT) is an accurate, noninvasive alternative to invasive coronary angiography (ICA). However, the comparative effectiveness of CT and ICA in the management of CAD to reduce the frequency of major adverse cardiovascular events is uncertain. METHODS: We conducted a pragmatic, randomized trial comparing CT with ICA as initial diagnostic imaging strategies for guiding the treatment of patients with stable chest pain who had an intermediate pretest probability of obstructive CAD and were referred for ICA at one of 26 European centers. The primary outcome was major adverse cardiovascular events (cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke) over 3.5 years. Key secondary outcomes were procedure-related complications and angina pectoris. RESULTS: Among 3561 patients (56.2% of whom were women), follow-up was complete for 3523 (98.9%). Major adverse cardiovascular events occurred in 38 of 1808 patients (2.1%) in the CT group and in 52 of 1753 (3.0%) in the ICA group (hazard ratio, 0.70; 95% confidence interval [CI], 0.46 to 1.07; P = 0.10). Major procedure-related complications occurred in 9 patients (0.5%) in the CT group and in 33 (1.9%) in the ICA group (hazard ratio, 0.26; 95% CI, 0.13 to 0.55). Angina during the final 4 weeks of follow-up was reported in 8.8% of the patients in the CT group and in 7.5% of those in the ICA group (odds ratio, 1.17; 95% CI, 0.92 to 1.48). CONCLUSIONS: Among patients referred for ICA because of stable chest pain and intermediate pretest probability of CAD, the risk of major adverse cardiovascular events was similar in the CT group and the ICA group. The frequency of major procedure-related complications was lower with an initial CT strategy. (Funded by the European Union Seventh Framework Program and others; DISCHARGE ClinicalTrials.gov number, NCT02400229.).

Impact of COVID-19 Pandemic on STEMI Networks in Central Romania.

The COVID-19 pandemic has had a major impact on cardiovascular emergencies. The aim of this study was to investigate the impact of the COVID-19 pandemic on a regional network for management of ST-segment elevation acute myocardial infarction (STEMI). METHODS: We report a single center's experience of patients hospitalized for ACS in a high-volume hub of a STEMI network during the lockdown (in the first pandemic trimester), compared with the same time interval of the previous year and including all consecutive patients referred for an AMI during the second trimester of 2020 (from April to June) or during the same time interval of the previous year, 2019. RESULTS: The absolute number of hospital admissions for AMI decreased by 22.3%, while the non-AMI hospitalizations decreased by 77.14% in Q2-2020 compared to Q2-2019 (210 vs. 48, p < 0.0001). As a consequence, the percentage of AMI cases from the total number of hospital admission increased from 38% to 68% (p < 0.0001), AMI becoming the dominant pathology. In the STEMI group there was a significant reduction of 55% in the absolute number of late STEMI presentations. Functionality of the STEMI network at the hub level did not present a significant alteration with only a minor increase in the door-to-balloon time, from 34 min to 41 min. However, at the level of the network we recorded a lower number of critical cases transferred to the interventional center, with a dramatic reduction of 56.1% in the number of critical STEMI cases arriving in the acute cardiac care unit (17.0% vs. 7.3%, p-0.04 for KILLIP class III, and 21.17% vs. 11.11%, p = 0.08 for resuscitated out of hospital cardiac arrest). CONCLUSIONS: The COVID-19 outbreak did not have a major impact on the interventional center's functionality, but it limited the capacity of the regional STEMI network to bring the critical patient with complicated STEMI to the cathlab in time during the first months of the lockdown. Even a very well-functioning STEMI network like the one in Central Romania had difficulties bringing the most critical STEMI cases to the cathlab in time.

Is There a Link between COVID-19 Infection, Periodontal Disease and Acute Myocardial Infarction?

Both periodontal disease and atherosclerosis are chronic disorders with an inflammatory substrate that leads to alteration of the host's immune response. In PD, inflammation is responsible for bone tissue destruction, while in atherosclerosis, it leads to atheromatous plaque formation. These modifications result from the action of pro-inflammatory cytokines that are secreted both locally at gingival or coronary sites, and systemically. Recently, it was observed that in patients with PD or with cardiovascular disease, COVID-19 infection is prone to be more severe. While the association between PD, inflammation and cardiovascular disease is well-known, the impact of COVID-19-related inflammation on the systemic complications of these conditions has not been established yet. The purpose of this review is to bring light upon the latest advances in understanding the link between periodontal-cardiovascular diseases and COVID-19 infection.