Clinical outcomes of complete revascularization using either angiography-guided or fractional flow reserve-guided drug-eluting stent implantation in non-culprit vessels in ST elevation myocardial infarction patients: insights from a study based on a systematic review and meta-analysis

Current guidelines recommend that percutaneous coronary intervention (PCI) should be restricted to the culprit vessel in ST elevation myocardial infarction (STEMI) patients with multi-vessel disease (MVD) and without cardiogenic shock. However, newer data suggests that performing complete revascularization (CR) in MVD patients may lead to better outcomes compared to intervention in the culprit vessel only. The aim of this meta-analysis is to examine the available data to determine if CR (using either angio- or fractional flow reserve guidance—FFR) following primary PCI in STEMI patients without cardiogenic shock impacts clinical outcomes. Meta-analysis was performed by conducting a literature search of PubMed from January 2004 to July 2017. Pooled estimates of outcomes, presented as odds ratios (OR) [95% confidence intervals], were generated using random-effect models. A total of 9 studies (3317 patients) were included. CR showed a significant MACE reduction (OR 0.49, 95% CI 0.36–0.66, p?<?0.001); All-cause mortality (OR 0.69, 95% CI 0.48–0.98, p?=?0.04) and repeat revascularization (OR 0.38, 95% CI 0.28–0.51, p?<?0.001) at?≥?12 months follow-up. The FFR-guiding CR group presented a MACE reduction (odds ratio 0.52, 95% CI 0.30–0.90, p?=?0.02) due to a decrease of repeat revascularization (OR 0.41, 95% CI 0.21–0.80, p?=?0.009). Overall, performing complete revascularization in STEMI patients showed a MACE reduction, all-cause death and repeat revascularization. Compared to culprit-only revascularization, treating multi-vessel disease in STEMI patients using FFR guidance is associated with decreased incidence of MACE, due to a decreased rate of revascularization.     

中性粒细胞与淋巴细胞比值联合GRACE评分对急性STEMI患者PCI术后发生院内主要不良心血管事件的预测价值

目的 探讨中性粒细胞与淋巴细胞比值(neutrophil to lymphocyte ratio, NLR)联合全球急性冠状动脉事件注册(global registry of acute coronary events,GRACE)评分对急性ST段抬高型心肌梗死(ST-segment elevation myocardial infarction,STEMI)患者接受直接经皮冠状动脉介入(percutaneous coronary intervention,PCI)术治疗后发生院内主要不良心血管事件(major adverse cardiovascular events,MACE)的预测价值。方法 纳入2018年9月1日-2019年12月31日就诊于河北省人民医院心血管内科行直接PCI治疗的急性STEMI患者275例。根据PCI术后是否发生院内MACE(包括全因死亡、心源性休克、院内再次血运重建、恶性心律失常及心脏骤停),分为MACE组(35例)和非MACE组(240例)。收集两组临床资料,分析STEMI患者PCI术后发生院内MACE的独立危险因素,并绘制受试者工作特征(receiver operating characteristic, ROC)曲线分析NLR、GRACE评分及二者联合对急性STEMI患者PCI术后发生院内MACE的预测价值。结果 MACE组年龄、GRACE评分、CRUSADE评分及NLR均高于非MACE组,估算的肾小球滤过率低于非MACE组(均P<0.05)。多因素Logistic回归分析提示,GRACE评分、NLR是急性STEMI患者PCI术后发生院内MACE的独立危险因素(均P<0.05)。ROC曲线提示,GRACE评分、NLR对急性STEMI患者PCI术后发生院内MACE有一定预测能力,但两者联合的曲线下面积更大,可更好地预测急性STEMI患者PCI术后是否发生院内MACE。结论 GRACE评分、NLR是急性STEMI患者PCI术后发生院内MACE的独立危险因素,两者联合对急性STEMI患者PCI术后发生院内MACE具有较好的预测价值。     

急性ST段抬高型心肌梗死患者的hs-CRP/ALB变化对预后的预测价值

目的探讨急性ST段抬高型心肌梗死(STEMI)患者的高敏C-反应蛋白(hs-CRP)/白蛋白(ALB)变化对预后的预测价值.方法选取2014年7月至2018年7月收治的80例急性STEMI患者,收集患者一般资料、高危因素、相关检查结果和实验室指标.所有患者均予以介入治疗并术后随访,截至2019年7月,记录主要心血管不良事件(MACE)发生情况.根据患者随访结果,将患者分为MACE组(16例)与非MACE组(64例),比较两组一般资料、高危因素和实验室指标.采用多因素Logistic回归分析明确MACE的危险因素.绘制hs-CRP/ALB预测MACE的受试者工作特征(ROC)曲线,分析hs-CRP/ALB对MACE的预测价值.并以最佳截断值将患者分为两组,绘制Kaplan-Meier生存曲线,比较两组生存情况.结果80例患者随访结束后,MACE发生率20%(16/80).MACE组与非MACE组性别、体质量指数、心率、收缩压、舒张压、高血压史、冠心病史、吸烟史、甘油三脂(TG)、总胆固醇(TC)、血白细胞计数(WBC)、B型利钠肽(BNP)、D-二聚体(DD)及ALB比较差异无统计学意义(P>0.05).MACE组年龄、糖尿病史占比、血清BNP、hs-CRP及hs-CRP/ALB高于非MACE组,左室射血分数(LVEF)低于非MACE组,差异有统计学意义(P<0.05).经Logistic多元回归分析,年龄、糖尿病、BNP、hs-CRP及hs-CRP/ALB是MACE的危险因素,LVEF是MACE的保护因素(P<0.05).hs-CRP/ALB预测急性STEMI患者介入术后MACE的ROC曲线下面积(AUC)0.918(95%CI0.855~0.978),hs-CRP的AUC 0.741(95%CI0.697~0.845),hs-CRP/ALB对MACE的预测价值更高.当hs-CRP/ALB=0.58时的预测价值最高,此时敏感度为87.5%,特异度为79.7%.根据ROC曲线分析结果,将患者分为hs-CRP/ALB≥0.58组(31例)与hs-CRP/ALB<0.58组(49例).截至2019年7月,hs-CRP/ALB<0.58组的生存率为95.92%(47/49),较hs-CRP/ALB≥0.58组的80.65%(25/31)相对更高,且生存时间更长,Kaplan-Meier生存曲线的差异有统计学意义(Log-rank P=0.039).结论年龄、糖尿病史、BNP、hs-CRP/ALB是急性SIEMI患者介入术后MACE的危险因素,LVEF是MACE的保护因素,且hs-CRP/ALB对急性STEMI患者介入术后的MACE有较大预测价值,不同hs-CRP/ALB值的患者生存情况也不同,hs-CRP/ALB<0.58的患者生存率更高,生存时间更长.     

Implication of coronary CT angiography combined with four-dimensional speckle tracking echocardiography for predicting major adverse cardiac events

Coronary computed tomography angiography (CCTA) can provide abundant information about the anatomy of the coronary artery. However, this modality is limited in evaluation of myocardial function. Four-dimensional speckle tracking echocardiography (4DSTE) is a novel and sensitive technique for quantitative evaluation of myocardial deformation. We estimated the value of these imaging modalities to predict the risk of MACE in 209 patients with suspected coronary artery disease(CAD) after a median follow-up of 727 days. Three models were established: (1) CCTA alone, (2) CCTA combined with 4DSTE, and (3) CCTA combined with 4DSTE and clinical risk factors. Forty-six (22.0%) patients developed MACE. The hazard ratio (HR) of CCTA classification to predict the risk of MACE was greater (HR?=?4.86) than for other parameters, including B-type natriuretic peptide (BNP) (HR?=?2.44) and left ventricular ejection fraction (LVEF) (HR?=?0.40). The area under the curve of models 2 and 3 to predict MACE was significantly greater than that of model 1 (0.92 and 0.93 vs. 0.84, respectively, p?<?0.001). We conclude that there is direct relationship between CCTA classification and MACE risk. CCTA combined with 4DSTE can improve the ability of CCTA to predict the risk of MACE. This approach provides cardiologists a noninvasive, objective, and efficient method to predict MACE.     

Myocardial tissue tagging with cardiovascular magnetic resonance

Aims

Patients with prior major cardiovascular or cerebrovascular events (MACE) are more likely to have future recurrent events independent of traditional cardiovascular disease risk factors. The purpose of this study was to determine if patients with traditional risk factors and prior MACE had increased cardiovascular magnetic resonance (CMR) plaque burden measures compared to patients with risk factors but no prior events.

Methods and Results

Black blood carotid and thoracic aorta images were obtained from 195 patients using a rapid extended coverage turbo spin echo sequence. CMR measures of plaque burden were obtained by tracing lumen and outer vessel wall contours. Patients with prior MACE had significantly higher MR plaque burden (wall thickness, wall area and normalized wall index) in carotids and thoracic aorta compared to those without prior MACE (Wall thickness carotids: 1.03 ± 0.03 vs. 0.93± 0.03, p = 0.001; SD wall thickness carotids: 0.137 ± 0.0008 vs. 0.102 ± 0.0004, p < 0.001; wall thickness aorta: 1.63 ± 0.10 vs. 1.50 ± 0.04, p = 0.009; SD wall thickness aorta: 0.186 ± 0.035 vs. 0.139 ± 0.012, p = 0.009 respectively). Plaque burden (wall thickness) and plaque eccentricity (standard deviation of wall thickness) of carotid arteries were associated with prior MACE after adjustment for age, sex, and traditional risk factors. Area under ROC curve (AUC) for discriminating prior MACE improved by adding plaque eccentricity to models incorporating age, sex, and traditional CVD risk factors as model inputs (AUC = 0.79, p = 0.05).

Conclusion

A greater plaque burden and plaque eccentricity is prevalent among patients with prior MACE.     

Zotarolimus-eluting vs. sirolimus-eluting coronary stents in patients with and without acute coronary syndromes: a SORT OUT III substudy

Eur J Clin Invest 2012; 42 (10): 1047-1054 ABSTRACT: Objectives: To compare clinical outcomes among patients with acute coronary syndrome treated with zotarolimus-eluting and sirolimus-eluting stents in the SORT OUT III trial. Background: Currently, only limited data allow direct comparison of clinical outcomes among patients with acute coronary syndrome treated with a second-generation drug-eluting stent (DES) eluting zotarolimus vs. a first-generation DES eluting sirolimus. Methods: Patients with acute coronary syndrome (n?=?1052) were randomized to treatment with zotarolimus-eluting (n?=?506) or sirolimus-eluting (n?=?546) stents and followed for 18?months. The primary composite endpoint, major adverse cardiac events (MACE), was defined as a composite of cardiac death, myocardial infarction or target vessel revascularization. Results: Zotarolimus-eluting stent treatment compared to sirolimus-eluting stent treatment was associated with increased rates of MACE (8·7% vs. 5·0%; hazard ratio (HR), 1·78; 95% confidence interval (CI), 1·10-2·88; P?=?0·02) and TVR (6·8% vs. 3·9%; HR, 1·77; 95% CI, 1·03-3·04; P?=?0·04), while all-cause death, cardiac death, myocardial infarction and definite stent thrombosis did not differ significantly. In the same trial, stable angina pectoris patients (n?=?1206) were randomized to zotarolimus-eluting (n?=?614) and sirolimus-eluting (n?=?592) stents with similar results. Conclusions: With and without acute coronary syndromes, patients treated with the sirolimus-eluting stent had better clinical outcomes than those treated with the zotarolimus-eluting stent.     

Analysis of 1 year virtual histology changes in coronary plaque located behind the struts of the everolimus eluting bioresorbable vascular scaffold

Serial intravascular ultrasound virtual histology (IVUS-VH) after implantation of metallic stents has been unable to show any changes in the composition of the scaffolded plaque overtime. The everolimus-eluting ABSORB scaffold potentially allows for the formation of new fibrotic tissue on the scaffolded coronary plaque during bioresorption. We examined the 12?month IVUS-VH changes in composition of the plaque behind the struts (PBS) following the implantation of the ABSORB scaffold. Using IVUS-VH and dedicated software, the composition of the PBS was analyzed in all patients from the ABSORB Cohort B2 trial, who were imaged with a commercially available IVUS-VH console (s5i system, Volcano Corporation, Rancho Cordova, CA, USA), immediately post-ABSORB implantation and at 12?month follow-up. Paired IVUS-VH data, recorded with s5i system, were available in 17 patients (18 lesions). The analysis demonstrated an increase in mean PBS area (2.39?±?1.85?mm(2) vs. 2.76?±?1.79?mm(2), P?=?0.078) and a reduction in the mean lumen area (6.37?±?0.90?mm(2) vs. 5.98?±?0.97?mm(2), P?=?0.006). Conversely, a significant decrease of 16 and 30% in necrotic core (NC) and dense calcium (DC) content, respectively, were evident (median % NC from 43.24 to 36.06%, P?=?0.016; median % DC from 20.28 to 11.36%, P?=?0.002). Serial IVUS-VH analyses of plaque located behind the ABSORB struts at 12-month demonstrated an increase in plaque area with a decrease in its NC and DC content. Larger studies are required to investigate the clinical impact of these findings.     

Temporal changes of coronary artery plaque located behind the struts of the everolimus eluting bioresorbable vascular scaffold

Implantation of a coronary stent results in a mechanical enlargement of the coronary lumen with stretching of the surrounding atherosclerotic plaque. Using intravascular ultrasound virtual-histology (IVUS-VH) we examined the temporal changes in composition of the plaque behind the struts (PBS) following the implantation of the everolimus eluting bioresorbable vascular scaffold (BVS). Using IVUS-VH and dedicated software, the composition of plaque was analyzed in all patients from the ABSORB B trial who were imaged with a commercially available IVUS-VH console (s5i system, Volcano Corporation, Rancho Cordova, CA, USA) post-treatment and at 6-month follow-up. This dedicated software enabled analysis of the PBS after subtraction of the VH signal generated by the struts. The presence of necrotic core (NC) in contact with the lumen was also evaluated at baseline and follow-up. IVUS-VH data, recorded with s5i system, were available at baseline and 6-month follow-up in 15 patients and demonstrated an increase in both the area of PBS (2.45?±?1.93?mm(2) vs. 3.19?±?2.48?mm(2), P?=?0.005) and the external elastic membrane area (13.76?±?4.07?mm(2) vs. 14.76?±?4.56?mm(2), P?=?0.006). Compared to baseline there was a significant progression in the NC (0.85?±?0.70?mm(2) vs. 1.21?±?0.92?mm(2), P?=?0.010) and fibrous tissue area (0.88?±?0.79?mm(2) vs. 1.15?±?1.05?mm(2), P?=?0.027) of the PBS. The NC in contact with the lumen in the treated segment did not increase with follow-up (7.33 vs. 6.36%, P?=?0.2). Serial IVUS-VH analysis of BVS-treated lesions at 6-month demonstrated a progression in the NC and fibrous tissue content of PBS.     

超敏C反应蛋白对急性ST段抬高心肌梗死患者心脏终点事件的预测价值

目的 评价入院早期血清超敏C反应蛋白(hs-CRP)水平对急性ST段抬高心肌梗死(STEMI)患者主要不良心脏事件(MAcE)的预测价值.MACE是心绞痛、再梗死、心力衰竭和心源性死亡.方法 哈尔滨医科大学2006年6月至2007年5月收治的急性SrEMI患者189例,于发病24 h内采空腹肘静脉血(行介人治疗者于术前采血),分别测hs-CRP、白细胞(WBC)、肌酸激酶及其同工酶(CK及CK-MB)、血脂及血糖,并做超声心动图.根据hs-CRP水平,将患者分为hs-CRP升高组(hs-CRP＞4 mg/L)和正常组(hs-CRP≤4mg/L).随访入选患者MACE.各种潜在危险因素单独或联合时与MACE和死亡的相关性用COX比例风险回归进行单、多变量分析.生存曲线采用kaplan-Meier法,并用时序检验和Breslow检验比较生存曲线.结果 两组平均随访(271.1±136.7)d.hs-CRP升高组MACE发生率明显高于正常组(75%vs.25%,P＜0.01),血WBC、CK及CK-MB显著高于正常组(P值分别为0.002,0.039和0.049).MACE组hs-CRP水平显著高于无MACE组(P＜0.01),死亡组hs-CRP显著高于MACE组(P＜0.01). hs-CRP升高组和正常组存活和无MACE患者的Kaplan-Meier曲线均有显著分离(时序检验P值分别为0.0042和0.0062).多因素分析显示,hs-CRP水平是MACE(艘=1.919,P＜0.05)和死亡(RR=3.067,P＜0.05)的独立风险预测因子.高hs-CRP的老年患者(年龄≥65岁)发生MACE(RR=2.547,P＜0.01)和死亡(RR=4.140,P＜0.01)的风险较高.结论 入院早期血清hs-CRP升高是急性STEMI患者随访期发生MACE和死亡的独立危险预测因子.对血清hs-CRP水平和年龄联合评价提供了一种筛选高危患者的方法.     

Cardiovascular magnetic resonance parameters of atherosclerotic plaque burden improve discrimination of prior major adverse cardiovascular events

Aims

Patients with prior major cardiovascular or cerebrovascular events (MACE) are more likely to have future recurrent events independent of traditional cardiovascular disease risk factors. The purpose of this study was to determine if patients with traditional risk factors and prior MACE had increased cardiovascular magnetic resonance (CMR) plaque burden measures compared to patients with risk factors but no prior events.

Methods and Results

Black blood carotid and thoracic aorta images were obtained from 195 patients using a rapid extended coverage turbo spin echo sequence. CMR measures of plaque burden were obtained by tracing lumen and outer vessel wall contours. Patients with prior MACE had significantly higher MR plaque burden (wall thickness, wall area and normalized wall index) in carotids and thoracic aorta compared to those without prior MACE (Wall thickness carotids: 1.03 ± 0.03 vs. 0.93± 0.03, p = 0.001; SD wall thickness carotids: 0.137 ± 0.0008 vs. 0.102 ± 0.0004, p < 0.001; wall thickness aorta: 1.63 ± 0.10 vs. 1.50 ± 0.04, p = 0.009; SD wall thickness aorta: 0.186 ± 0.035 vs. 0.139 ± 0.012, p = 0.009 respectively). Plaque burden (wall thickness) and plaque eccentricity (standard deviation of wall thickness) of carotid arteries were associated with prior MACE after adjustment for age, sex, and traditional risk factors. Area under ROC curve (AUC) for discriminating prior MACE improved by adding plaque eccentricity to models incorporating age, sex, and traditional CVD risk factors as model inputs (AUC = 0.79, p = 0.05).

Conclusion

A greater plaque burden and plaque eccentricity is prevalent among patients with prior MACE.     

可溶性ST2对急性ST段抬高型心肌梗死患者临床预后的预测价值

目的探讨可溶性ST2(sST2)水平对急性ST段抬高型心肌梗死(STEMI)患者6个月内发生心力衰竭或心源性死亡的预测价值。方法选择就诊于我院心内科并确诊为STEMI患者117例,入院时采用酶联免疫吸附法测定患者血浆sST2水平,随访并记录6个月内MACE(定义为新发心力衰竭或心源性死亡)发生情况。依据是否发生MACE分为MACE事件组与非MACE事件组,分析两组一般资料,并行COX多因素回归分析STEMI患者发生MACE的独立危险因素。结果117例STEMI患者随访6个月内,发生心力衰竭20例,心源性死亡2例。Spearman相关分析结果显示,基线sST2与基础心率、cTnT峰值、Killip分级、NT-proBNP呈正相关(r=0.253、0.335、0.401、0.467,P<0.05),与LVEF呈负相关(r=-0.201,P<0.05)。多因素COX回归分析提示基线sST2值是STEMI患者发生MACE事件的独立危险因素(HR=1.817,P=0.001);而LVEF、cTnT峰值也可独立预测患者MACE事件的发生(HR=0.818、1.328,P=0.003、0.001)。结论基线sST2水平与STEMI患者的临床预后有关,可独立预测患者6个月内MACE的发生风险。     

Myocardial salvage after primary percutaneous coronary intervention in patients with ST-elevation myocardial infarction presenting early versus late after symptom onset

Primary percutaneous coronary intervention (PCI) is the treatment of choice in patients with ST-elevation myocardial infarction (STEMI) presenting within 12 h of symptom onset. A benefit in the subacute stage is less clear. The aim of the present analysis was to compare myocardial salvage and infarct size between patients with early and late reperfusion after STEMI. We compared cardiac magnetic resonance (CMR) data from a randomized controlled trial (RCT) in STEMI patients presenting within 12 h (n?=?695) and a RCT of subacute STEMI patients presenting between 12 and 48 h (n?=?93) after symptom onset. CMR imaging was performed 3.9?±?6.3 days after myocardial infarction. Analyses were performed for an unmatched cohort comprising all patients (n?=?788) and a cohort matched for area at risk (n?=?186). In the overall cohort, area at risk was similar in both groups [37.1?±?16.1% of left ventricular mass (%LV) vs. 38.3?±?16.2%LV; p?=?0.50]. Compared to STEMI patients with early reperfusion, patients with late PCI demonstrated larger infarct size (18.0?±?12.5%LV vs. 28.9?±?16.9%LV; p?<?0.01) and higher extent of microvascular obstruction (1.5?±?2.9%LV vs. 2.7?±?4.1%LV; p?=?0.01). Myocardial salvage index was significantly smaller in patients with late reperfusion (52.1?±?25.9 vs. 27.4?±?26.0; p?<?0.01). Analysis of the matched cohorts confirmed the decreased myocardial salvage (p?<?0.01) and increased infarct size (p?<?0.01) in case of late reperfusion. Compared to patients with timely primary PCI, late reperfusion after STEMI results in decreased myocardial salvage and increased infarct size. However, salvageable myocardium was also found in subacute stages of STEMI.     

Morphology of coronary artery lesions assessed by virtual histology intravascular ultrasound tissue characterization and fractional flow reserve

Fractional flow reserve (FFR) is an index of the physiological significance of a coronary stenosis. Patients who have lesions with a FFR of >0.80, even optimally treated with medication, have however a MACE rate ranging from 8 to 21%. Coronary plaques at high risk of rupture and clinical events can be also identified by virtual histology intravascular ultrasound (IVUS-VH) as plaques with high amount of necrotic core (NC) abutting the lumen. Aim of this exploratory study was to investigate whether the geometry and composition of lesions with FFR????0.80 were different from their counterparts. Fifty-five consecutive patients in whom FFR was clinically indicated on a moderate angiographic lesion, received also an imaging investigation on the same lesion with IVUS-VH. Data on plaque geometry and composition was analyzed. Patients were subdivided in two groups according to the value of FFR (> or ??0.80). Lesions with a FFR????0.80 (n?=?17) showed a slightly larger plaque burden than those with FFR?>?0.80 (n?=?38) (54.6?±?0.7% vs. 51.7?±?0.7% P?=?0.1). In addition, they tend to have less content of necrotic core than their counterparts (14.2?±?8% vs. 19.2?±?10.2%, P?=?0.08). No difference was found in the distribution of NC-rich plaques (fibroatheroma and thin-capped fibroatheroma) between groups (82% in FFR????0.80 vs. 79% in FFR?>?0.80, P?=?0.5). Although FFR????0.80 lesions have larger plaque size, they do not differ in composition from the ones with FFR?>?0.80. Further exploration in a large prospective study is needed to study whether the lesions with FFR?>?0.80 that are NC rich are the ones associated with the presence of clinical events at follow-up.     

Sex-based influence on clinical outcomes after drug-eluting stent implantation in real-world patients: insight from the FOCUS registry

Objectives: To investigate the impact of sex on clinical outcomes after drug-eluting stent (DES) implantation in real-world patients.

Methods and results: A total number of 4720 patients (3365 males and 1355 females) undergoing the second-generation cobalt-chromium sirolimus-eluting stent (CoCr-SES) implantation from the FOCUS registry were included in this analysis. The cumulative incidences of major adverse cardiovascular event (MACE) (1.5% vs. 2.4%; p?=?.03), cardiovascular death (0.5% vs. 1.0%; p?=?.02) and target vessel revascularization (TVR) (0.3% vs. 0.8%; p?=?.01) within six months were significantly higher in females and the risks of MACE (adjusted hazard ratio [HR] 0.5 (0.3–0.9); p?=?.01) and TVR (adjusted HR 0.1(0.0–0.5); p?=?.001) remained significant in multivariate analysis. Reversely, the cumulative incidences of MACE (5.4% vs. 4.8%; p?=?.04) and any revascularization (5.1% vs. 3.3%; p?=?.01) were significantly higher in males beyond six months and the risks of all-cause death (adjusted HR 1.6 (1.1–2.5); p?=?.03) and cardiovascular death (adjusted HR 1.9 (1.1–3.6); p?=?.03) turned out to be significant in multivariate analysis. Notes: All cumulative incidences were presented as male vs. female; all HRs were calculated as male relative to female.

Conclusions: Females were associated with higher risk of early adverse events, while, males were associated with higher risk of late adverse events.

• Key messages

• Females undergoing PCI are typically older, have more cardiovascular risk factors, while, males in need of PCI are more frequently associated with complex lesions.

• The overall three-year cumulative incidences of adverse events are not significantly different between males and females but numerically higher in males.

• Females are associated with significantly higher risks of MACE and TVR within six months, while, males are associated with significantly higher risk of all-cause mortality and cardiac mortality beyond 6 months.

     

Presence of post-systolic shortening is an independent predictor of heart failure in patients following ST-segment elevation myocardial infarction

Following an ischemic event post systolic shortening (PSS) may occur. We investigated the association between PSS in patients with ST-segment elevation myocardial infarction (STEMI) following primary percutaneous coronary intervention (pPCI) and occurrence of cardiovascular events at follow-up. A total of 373 patients admitted with STEMI and treated with pPCI were prospectively included in the study cohort. All patients were examined by echocardiography a median of 2 days after admission (interquartile range, 1–3 days). PSS was measured by color tissue Doppler imaging (TDI) and speckle tracking echocardiography (STE) in six myocardial walls from all three apical projections. During a median follow-up period of 5.4 years (interquartile range, 4.1–6.0 years), 180 events occurred: 59 deaths, 70 heart failures (HF) and 51 new myocardial infarctions (MI). In multivariable analysis adjusting for: age, sex, peak troponin, left ventricle ejection fraction, TIMI flow grade, left ventricle mass index, hypertension and diabetes, presence of PSS by TDI in the culprit region was associated with a nearly twofold increased risk of HF (HR 1.90, 95% CI 1.02–3.53, P?=?0.043) and the risk of HF increased incrementally with increasing numbers of walls displaying PSS. The increased risk of HF was confirmed when assessing the post-systolic index by STE (HR 1.29 95% CI 1.09–1.53, P?=?0.003, per 1% increase). A regional analysis showed that PSS by TDI in the septal wall was the strongest predictor of HF (HR 1.77, 95% CI 1.08–2.92, P?=?0.024). Presence of PSS was not associated with increased risk of death or MI. In patients with STEMI treated with pPCI, the presence of PSS examined by TDI and STE provides prognostic information on development of HF. Presence of PSS in the septal wall is the strongest predictor of HF.     

中性粒细胞与淋巴细胞比值和血小板平均体积对急性冠脉综合征患者PCI术后近期及远期不良事件的预测价值

目的 探讨中性粒细胞与淋巴细胞比值（NLR）和血小板平均体积（MPV）对急性冠脉综合征（ACS）患者接受介入治疗（PCI）后短期及远期主要不良心血管事件（MACE）的预测价值。方法 选择GRAND研究和GRANDEXTENDED研究中接受PCI治疗的ACS患者2 225例，分别按照NLR和MPV的第75百分位数分为高NLR组（n=557）、低NLR组（n=1 668）和高MPV组（n=577）、低MPV组（n=1 635）。比较不同NLR或MPV水平患者无复流/慢血流、住院期间MACE和术后1年MACE的发生情况。采用多因素logistic回归分析评估不良事件发生的独立影响因素。采用ROC曲线分析NLR和（或）MPV对不良事件的预测价值。结果 高NLR组术中无复流/慢血流、住院期间MACE和术后1年MACE的发生率均高于低NLR组（11.7%vs 5.1%,13.5%vs 8.5%和35.0%vs 10.8%;P<0.05）；高MPV组术中无复流/慢血流、住院期间MACE事件和术后1年MACE的发生率均高于低MPV组（12.1%vs 4.8%,17.3%vs 7.0%和29.6%...     

Leptin predicts short-term major adverse cardiac events in patients with coronary artery disease

Introduction: Leptin is an adipose tissue-derived hormone associated with cardiovascular risk factors. We examined whether leptin predicts major adverse cardiac events (MACE) in coronary artery disease (CAD) patients.

Methods: Fasting plasma leptin levels were measured in 1327 male and 619 female CAD patients. The patients were followed up for two years. The primary endpoint (MACE) was the composite of a hospitalisation for congestive heart failure (CHF) or a cardiac death. The secondary endpoint was the composite of an acute coronary syndrome (ACS) or a stroke.

Results: In regression analysis including established risk variables, high leptin levels were associated with a significantly increased risk of MACE (HR 3.37; 95%CI 1.64–6.90; p?=?0.001) and ACS or stroke (HR 1.95; 95%CI 1.29–2.96; p?=?0.002). Adding leptin to the risk model for MACE increased the C-index from 0.78 (95%CI 0.71–0.85) to 0.81 (0.74–0.88) and improved classification (NRI 0.36; 95%CI 0.13–0.60; p?=?0.002) and discrimination of the patients (IDI 0.016; 95%CI 0.001–0.030; p?=?0.031).

Conclusions: High plasma leptin levels predict short-term occurrence of CHF or cardiac death and ACS or stroke in patients with CAD independently of established risk factors. The possible harmful effects of leptin should be thoroughly investigated.

• Key messages

• Leptin is a peptide hormone secreted mainly by adipose tissue. It has been associated with several cardiovascular risk factors.

• High leptin levels predict the short-term occurrence of congestive heart failure or cardiac death and ACS or stroke in patients with CAD independently of established risk factors.

• The possible detrimental effects of leptin on the cardiovascular system should be thoroughly investigated.

     

Characteristics of culprit lesion in patients with non-ST-elevation myocardial infarction and improvement of diagnostic utility using dual energy cardiac CT

Aims

The aim of the study was to identify the characteristics of the culprit lesions compared to non-culprit lesions in patients with non-ST-elevation-myocardial infarction using dual energy computed tomography (DECT).

Methods and results

In 29 patients, we identified 29 culprit lesions and 227 non-culprit lesions.

Quantitative values such as the effective atomic number (effective-Z) and Hounsfield Units (HU) values were measured. Furthermore, all the lesions were characterised using characteristics such as composition (non-calcified, predominantly-non-calcified, predominantly-calcified, or calcified), presence of spotty calcification, remodelling index, and napkin ring sign.

The mean effective-Z and HU values were significantly lower in culprit lesions than in non-culprit lesions (8.99?±?1.21 vs 9.79?±?1.52; p?=?0.0066 and 87.41?±?84.97 vs. 154.45?±?176.13; p?=?0.0447). The culprit lesions had a higher frequency of non-calcified plaques and predominantly non-calcified plaques, and were with a greater presence of napkin ring signs in comparison with non-culprit lesions. There were no differences in the presence of spotty calcification or remodelling index.

By adding effective-Z to plaque characteristics such as non-calcified, positive remodelling, spotty calcification, and napkin rings we observed a significant increased sensitivity of detecting culprit lesions (65.5% vs.44.8%), but no significant changes in area under curve (AUC).

Conclusion

The use of DECT adds new information of the plaque composition expressed by the effective-Z, which differs significantly in culprit lesions in comparison with non-culprit lesions. The use of the effective-Z improves the diagnostic sensitivity in detection of culprit lesions.

     

外周血 NLR联合 PLR对动脉粥样硬化性脑梗死诊断及预测斑块稳定性的价值研究

目的　探究外周血中性粒细胞与淋巴细胞比值（ NLR）联合血小板与淋巴细胞比值（ PLR）在诊断动脉粥样硬化性脑梗死（ ACI）与预测斑块稳定性的价值。方法　选取陕西省人民医院神经内二科 2020年 1月 ~2021年 1月住院治疗的 ACI患者 54例作为脑梗死组,另选取同期健康体检者 65例作为对照组。均进行颈动脉超声检查、外周血 NLR,PLR检测,比较两组外周血 NLR和 PLR水平。采用受试者工作（ ROC）曲线探究 NLR和 PLR诊断 ACI的价值,对比不同稳定性斑块患者外周血 NLR和 PLR水平,探究二者之间关系及与斑块稳定性的相关性。结果　脑梗死组外周血 NLR（3.16±0.17 vs 2.23±0.12）和 PLR（133.45±5.02 vs 111.04±7.56）水平高于对照组,差异均有统计学意义（t=4.723,     

冠状动脉CT血管成像预测冠状动脉斑块患者发生主要不良心脏事件的价值

目的 探讨冠状动脉CT血管成像（CCTA）预测冠状动脉斑块患者发生主要不良心脏事件（MACE）的价值。方法 对256例冠状动脉粥样硬化斑块患者行CCTA检查,于CCTA图像上定量评定冠状动脉管腔狭窄程度,并依据斑块成分进行分型。随访MACE发生情况,建立预测MACE的3个模型（模型1,冠状动脉狭窄程度分级;模型2,冠状动脉狭窄程度分级联合管壁斑块分型;模型3：冠状动脉狭窄程度分级联合管壁斑块分型和临床危险因素指标）,评估3个模型对MACE的预测效能。结果 256例病例中47例失访,最终随访209例患者。随访结束时,46例发生MACE。冠状动脉狭窄程度分级和斑块分型评估MACE发病风险的风险比分别为4.47、3.43,高于临床危险因素指标。模型2、模型3预测MACE的ROC曲线下面积明显大于模型1（P<0.05）,模型2和模型3预测MACE的ROC曲线下面积差异无统计学意义（P=0.076）。结论 CCTA可定量评估冠状动脉管腔狭窄程度并进行斑块分型,联合应用有助于提高MACE的预测效能。