Impact of Sex in the Incidence of Heart Failure in Patients with Chronic Coronary Syndrome.

PURPOSE OF REVIEW: This review examines the available evidence concerning the incidence of heart failure in patients with chronic coronary syndrome, with a focus on gender differences. RECENT FINDINGS: The incidence of heart failure in the context of chronic coronary syndrome presents conflicting data. Most of the available information stems from studies involving stable patients' post-acute coronary syndrome, revealing a wide range of incidence rates, from less than 3% to over 20%, observed over 5 years of follow-up. Regarding the gender differences in heart failure incidence, there is no consensus about whether women exhibit a higher incidence, particularly in the presence of evidence of obstructive coronary artery disease. However, in cases where obstructive coronary artery disease is absent, women may face a more unfavourable prognosis due to a higher prevalence of microvascular disease and heart failure with preserved ventricular function. The different profile of ischaemic heart disease in women difficult to establish differences in prognosis independently associated with female sex. Targeted investigations are essential to discern the incidence of heart failure in chronic coronary syndrome and explore potential gender-specific associations.

Impact of frailty and atrial fibrillation in elderly patients with acute coronary syndromes.

BACKGROUND: There is scarce information on the prognostic role of frailty and atrial fibrillation (AF) in elderly patients with acute coronary syndrome (ACS). METHODS: The aim was to analyse the management of elderly patients with frailty and AF who suffered an ACS using data of the prospective multicentre LONGEVO-SCA registry. We evaluated the predictive performance of FRAIL, Charlson scores and AF status for adverse events at 6-month follow-up. RESULTS: A total of 531 unselected patients with ACS and above 80 years old [mean age 84.4 (SD = 3.6) years; 322 (60.6%) male] were enrolled, of whom 128 (24.1%) with AF and 145 (27.3%) with frailty. Mutually exclusive number of patients were as follows: non-frail and sinus rhythm (SR) 304 (57.2%); frail and SR 99 (18.6%); non-frail and AF 82 (15.4%); and frail and AF 46 (8.7%). Frail and AF patients compared with non-frail and SR patients had higher risk of all-cause mortality [HR 2.61, (95% CI 1.28-5.31; P = .008)], readmissions [HR 2.28, (95%CI 1.37-3.80); P = .002)] and its composite [HR 2.28, (95% CI 1.44-3.60); P < .001)]. After multivariate adjustment, FRAIL score [HR 1.41, (95% CI 1.02-1.97); P = .040] and Charlson index [HR 1.32, (95% CI 1.09-1.59); P = .003] were significantly associated with mortality. AF status was not independently related with adverse events. CONCLUSIONS: Frailty but not AF status was independently associated with follow-up adverse events. Frailty status and high Charlson index were independent conditions associated with adverse events during the follow-up. The impact of functional status has a bigger prognostic role over AF status in elderly patients with ACS.

Baseline CHA2 DS2 -VASc score and prognosis in octogenarians with non-ST segment elevation acute coronary syndrome.

BACKGROUND: CHA2 DS2 -VASc Score is widely used to predict thromboembolic risk in patients with Atrial Fibrillation (AF). We sought to study if this score predicts outcomes in elderly patients with Non-ST segment Elevation Acute Coronary Syndromes (NSTEACS). METHODS: The multicenter LONGEVO-SCA prospective registry included 532 unselected patients with NSTEACS aged ≥80 years. Data to calculate CHA2 DS2 -VASc Score were available in 523 patients (98.3%). They were classified according to CHA2 DS2 -VASc Score: group 1 (score ≤ 4), and 2 (5-9). We studied outcomes in terms of mortality or readmission at 6 months follow-up. RESULTS: A total of 266 patients (51%) had a high CHA2 DS2 -VASc Score (group 2). They were more often women, with more cardiovascular risk factors, such as hypertension or diabetes mellitus, and history of previous stroke and cardiovascular disease and heart failure (all, P = .001). Geriatric syndromes (Barthel Index, Lawton Brody, cognitive impairment, and frailty) and Charlson Index were worse in this group (all, P = .001). They had poorer clinical status on admission, with worse Killip class and lower left ventricle ejection fraction (all, P = .001), and developed new-onset AF more often during admission (12.4% vs. 6.6%, P = .024). At six months follow-up, patients in group 2 had higher reinfarction, all-cause mortality, and mortality or readmission rates. A CHA2 DS2 -VASc Score > 4 was associated with mortality or readmission at 6 months (HR 2.07, P < .001). However, after adjusting for potential confounders, this last association was not significant (P = .175). CONCLUSIONS: A CHA2 DS2 -VASc Score > 4 is present in half of octogenarians with NSTEACS and is associated with poorer outcomes. However, it is not an independent predictor of events and should not replace recommended tools for risk prediction in this setting.

Statin Treatment and Prognosis of Elderly Patients Discharged after Non-ST Segment Elevation Acute Coronary Syndrome.

BACKGROUND: Statins are recommended for secondary prevention. Our aims were to describe the proportion of very elderly patients receiving statins after non-ST segment elevation acute coronary syndrome (NST-ACS) and to determine the prognostic implications of statins use. METHODS: This prospective registry was performed in 44 hospitals that included patients ≥80 years discharged after a NST-ACS from April 2016 to September 2016. RESULTS: We included 523 patients, the mean age was 84.2 ± 4.0 years and 200 patients (38.2%) were women. Previous statin treatment was recorded in 282 patients (53.4%), and 135 (32.5%) had LDL cholesterol levels >2.6 mmol/L. Mean LDL cholesterol levels during admission were 2.3 ± 0.9 mmol/L. Statins were prescribed at discharge to 474 patients (90.6%). Compared with patients discharged on statins, those that did not receive statins were more often frail (22 [47.8%] vs. 114 [24.4%], p < 0.01) and underwent an invasive approach less frequently (30 [61.2%] vs. 374 [78.9%], p = 0.01). During a 6-month follow-up, 50 patients died (9.5%). There was a nonsignificant trend to higher mortality in patients not treated with statins (6 [15%] vs. 44 [9.6%], p = 0.30), but statins were not independently associated with lower mortality (hazard ratio [HR] 0.79; 95% confidence interval [CI] 0.30-2.11, p = 0.65), nor with a reduction in the combined endpoint mortality/hospitalizations (HR 0.89; 95% CI 0.52-1.55, p = 0.69). CONCLUSIONS: Although most octogenarians presenting a NST-ACS are already on statins before the episode, their LDL cholesterol is frequently >2.6 mmol/L. Octogenarians who do not receive statins have a high-risk profile, with significant frailty and comorbidity.

Diabetes mellitus, frailty and prognosis in very elderly patients with acute coronary syndromes.

BACKGROUND: The magnitude of the association between diabetes (DM) and outcomes in elderly patients with acute coronary syndromes (ACS) is controversial. No study assessed the prognostic impact of DM according to frailty status in these patients. METHODS: The LONGEVO-SCA registry included unselected ACS patients aged ≥ 80 years. Frailty was assessed by the FRAIL scale. We evaluated the impact of previous known DM on the incidence of death or readmission at 6 months according to status frailty by the Cox regression method. RESULTS: A total of 532 patients were included. Mean age was 84.3 years, and 212 patients (39.8%) had previous DM diagnosis. Patients with DM had more comorbidities and higher prevalence of frailty (33% vs 21.9%, p = 0.002). The incidence of death or readmission at 6 months was higher in patients with DM (HR 1.52, 95% CI 1.12-2.05, p 0.007), but after adjusting for potential confounders this association was not significant. The association between DM and outcomes was not significant in robust patients, but it was especially significant in patients with frailty [HR 1.72 (1.05-2.81), p = 0.030, p value for interaction = 0.049]. CONCLUSIONS: About 40% of elderly patients with ACS had previous known DM diagnosis. The association between DM and outcomes was different according to frailty status.

Effect of lesion length on functional significance of intermediate long coronary lesions.

OBJECTIVE: To assess the relationship between lesion length and other angiographic parameters on the functional significance of long coronary lesions with moderate stenosis. BACKGROUND: Coronary revascularization is usually based on angiographic percent stenosis. Coronary stenosis length is not usually considered in daily clinical practice for revascularization decision-making. The relevance of lesion length might be greater in longer lesions with intermediate stenosis. METHODS: All coronary lesions >20 mm and of 40-70% percent stenosis assessed by intracoronary pressure wire between 2007 and 2009 were included. Interventionists performing digital quantification of lesion stenosis were blinded to the result of fractional flow reserve (FFR). Correlations between angiographic data and FFR were analyzed. RESULTS: One hundred and six lesions from 103 patients were included. Reference diameter: 2.9 ± 0.56 mm; maximal stenosis: 49.0 ± 8.7%; minimal luminal diameter (MinimalLD): 1.48 ± 0.4 mm; mean luminal diameter (MeanLD): 2.3 ± 0.5 mm; mean lesion length: 28.7 ± 10.6 mm. Lesions with FFR <0.75 accounted for 33% (n = 35). Weak correlations were obtained between FFR and MinimalLD (r = 0.36; P < 0.0005), MeanLD (r = 0.24; P = 0.014), maximal stenosis (r = 0.31; P = 0.001), and mean stenosis (r = 0.018; P = 0.85); strong correlations were observed between FFR and lesion length (r = 0.63; P < 0.0005), lesion length/MinimalLD (r = 0.67; P < 0.0005), and lesion length/MeanLD (0.72; P < 0.0005). The predictive values of lesion length, lesion length/MinimalLD, and lesion length/MeanLD for FFR <0.75 were 0.86, 0.91, and 0.92, respectively. CONCLUSIONS: In long lesions (>20 mm) with moderate angiographic stenosis, lesion length might be the strongest determinant of functional repercussion. Lesion length should be considered when judging the benefit of revascularization or perform functional functional measures that overcome the limitations of simple stenosis quantification.

Outcomes Prediction in Complex High-Risk Indicated Percutaneous Coronary Interventions in the Older Patients.

Complex high-risk indicated percutaneous coronary intervention (CHIP-PCI) is a poorly defined concept, which has not been validated in an older population before. This study aimed to evaluate the predictive value of the CHIP-PCI score in a large cohort of elderly patients and to identify potential further risk factors. This is a pooled analysis of 3 registries that included patients aged ≥75 years who underwent percutaneous coronary intervention from 2012 to 2019: the multicenter prospective EPIC05-Sierra 75 study, the multicenter retrospective PACO-PCI (EPIC-15) registry, and the single-center, prospective Elderly-HCD registry. A total of 2,725 patients with a mean age of 81 ± 4 years were included in the study; 269 patients (10%) met the primary end point of 1-year major adverse cardiac and cerebrovascular events (MACCEs), and 51 patients (2%) had in-hospital MACCEs. Of the 12 investigated original CHIP-PCI score variables, 5 were independent predictors: previous myocardial infarction, left ventricular ejection fraction <30%, chronic kidney disease, left main coronary artery percutaneous coronary intervention, and nonradial access. Furthermore, diabetes mellitus, anemia, and severe calcification showed to be significant predictors of MACCEs. The additional variables improved the discriminatory value of the CHIP-PCI score for 1-year MACCEs (modified CHIP-PCI score: area under the curve [AUC] 0.647 vs original CHIP-PCI score: AUC 0.598, p = 0.02) and in-hospital MACCEs (AUC 0.729 vs 0.657, p = 0.003, respectively). In conclusion, the CHIP-PCI score retains its prognostic value in older patients for in-hospital MACCEs; however, it is of limited value at 1-year follow-up. The modified CHIP-PCI score, including the 5 patient-related and 3 procedure-related factors, significantly improved its discriminatory potential.

Accuracy of the angiography-based quantitative flow ratio in intermediate left main coronary artery lesions and comparison with visual estimation.

BACKGROUND: Revascularization of left main coronary artery (LMCA) stenosis is mostly based on angiography. Indices based on angiography might increase accuracy of the decision, although they have been scarcely used in LMCA. The objective of this study is to study the diagnostic agreement of QFR (quantitative flow ratio) with wire-based fractional flow reserve (FFR) in LMCA lesions and to compare with visual severity assessment. METHODS: In a series of patients with invasive FFR assessment of intermediate LMCA stenoses we retrospectively compared the measured value of QFR with that of FFR and the estimate of significance from angiography. RESULTS: 107 QFR studies were included. The QFR intra-observer and inter-observer agreement was 87% and 82% respectively. The mean QFR-FFR difference was 0.047 ± 0.05 with a concordance of 90.7%, sensitivity 88.1%, specificity 92.3%, positive predictive value 88.1% and negative predictive value 92.3%. All these values were superior to those observed with the visual estimation which showed an intra- and inter-observer agreement of 73% and 72% respectively, besides 78% with the FFR value. The low diagnostic performance of the visual estimation and the acceptable performance of the QFR index measurement were observed in all subgroups analysed. CONCLUSIONS: QFR allows an acceptable estimate of the FFR obtained with intracoronary pressure guidewire in intermediate LMCA lesions, and clearly superior to the assessment based on angiography alone. The decision to revascularize patients with moderate LMCA lesions should not be based solely on the degree of angiographic stenosis.

Long-term prognostic value of quantitative-flow-ratio-concordant revascularization in stable coronary artery disease.

OBJECTIVES: Confirming the prognostic value of global QFR and evaluating the long-term prognosis of QFR-concordant therapy in stable coronary artery disease. BACKGROUND: Wire-based functional evaluation of coronary disease is linked to patient's prognosis. Quantitative Flow Ratio (QFR) is a newer index of computational physiology, linked to clinical outcomes and prognosis at 1 year follow-up. Long-term prognosis of QFR-concordant revascularization in stable coronary artery disease is however unknown hitherto. METHODS: Consecutive patients with stable coronary disease undergoing coronary angiography were included. Centralized and blinded QFR analysis of three coronary territories was performed. Three vessel QFR (3vQFR) was defined as the sum of the basal QFR of each coronary territory. QFR-concordant revascularization was met if all significant lesions (QFR ≤ 0.80) were revascularized and all non-significant lesions (QFR > 0.80) were not; otherwise, the case was defined as QFR-discordant revascularization. Patient-oriented composite end-point (POCE) of cardiac death, myocardial infarction and unscheduled revascularization was the primary endpoint. RESULTS: A total of 803 patients from six high-volume centers were included. Canadian Cardiovascular Society (CCS) class II angina was the most frequent (48.9%) clinical presentation. Median of follow-up was 68.8 months. 3vQFR was an independent predictor of POCE (HR 1.79 CI95% 1.01-3.18), with 2.75 as optimal cut-off value, irrespective of the therapy received. QFR-discordant revascularization (QFR+/Revascularization- or QFR-/Revascularization+) was an independent predictor of POCE in multivariate analysis (HR 1.65, CI 95% 1.03-2.64). CONCLUSION: Global burden of epicardial coronary atherosclerosis, as evaluated by 3vQFR, as well as QFR-discordant therapy are independent predictors of adverse clinical outcome at long-term follow-up in stable coronary artery disease.

Validation of Quantitative Flow Ratio-Derived Virtual Angioplasty with Post-Angioplasty Fractional Flow Reserve-The QIMERA-I Study.

Background: Quantitative flow ratio (QFR) virtual angioplasty with pre-PCI residual QFR showed better results compared with an angiographic approach to assess post-PCI functional results. However, correlation with pre-PCI residual QFR and post-PCI fractional flow reserve (FFR) is lacking. Methods: A multicenter prospective study including consecutive patients with angiographically 50-90% coronary lesions and positive QFR results. All patients were evaluated with QFR, hyperemic and non-hyperemic pressure ratios (NHPR) before and after the index PCI. Pre-PCI residual QFR (virtual angioplasty) was calculated and compared with post-PCI fractional flow reserve (FFR), QFR and NHPR. Results: A total of 84 patients with 92 treated coronary lesions were included, with a mean age of 65.5 ± 10.9 years and 59% of single vessel lesions being the left anterior descending artery in 69%. The mean vessel diameter was 2.82 ± 0.41 mm. Procedural success was achieved in all cases, with a mean number of implanted stents of 1.17 ± 0.46. The baseline QFR value was 0.69 ± 0.12 and baseline FFR and NHPR were 0.73 ± 0.08 and 0.82 ± 0.11, respectively. Mean post-PCI FFR increased to 0.87 ± 0.05 whereas residual QFR had been estimated as 0.95 ± 0.05, showing poor correlation with post-PCI FFR (0.163; 95% CI:0.078-0.386) and low diagnostic accuracy (30.9%, 95% CI:20-43%). Conclusions: In this analysis, the results of QFR-based virtual angioplasty did not seem to accurately correlate with post-PCI FFR.