Remnant cholesterol and risk of myocardial infarction in patients with coronary artery disease undergoing revascularization.

BACKGROUND: Despite substantial reduction in low-density lipoprotein cholesterol (LDL-C), patients develop recurrent cardiovascular events. Remnant cholesterol (RC), the cholesterol content of triglyceride-rich lipoproteins, is a potential contributor to this residual risk. OBJECTIVES: To investigate the association between RC and risk for myocardial infarction (MI) in patients with coronary artery disease, and examine whether the predictive value of RC is retained beyond non-high-density lipoprotein cholesterol (non-HDL-C). METHODS: Data on 9451 patients undergoing coronary revascularization in a single center. RC was calculated as total cholesterol minus high-density lipoprotein cholesterol minus LDL-C (estimated using Martin-Hopkins equation). Cox-regression models were used to estimate the association between RC and risk for MI. Discordance analyses were performed to examine the correlation between RC and non-HDL-C (or LDL-C) in relation to MI risk. RESULTS: Mean age was 65±11 years; 67% presented with acute coronary syndrome. During median follow-up of 9.6 years, 1690 patients developed MI. After multivariable adjustment including lipid-lowering therapies and non-HDL-C, RC was associated with higher MI risk: hazard ratio (95% confidence interval): 1.36 (1.20-1.56) and 1.58 (1.35-1.85) in those with RC levels ≥75th (32.6 mg/dL) and ≥90th (41.8 mg/dL) percentile, compared to RC <50th percentile (25.5 mg/dL). When RC and non-HDL-C (or LDL-C) levels were discordant, the level of RC better reflected the risk for MI. CONCLUSIONS: Elevated RC is a risk factor for MI independent of lipid-lowering therapies and non-HDL-C, providing further support that RC may serve as a residual cardiovascular risk marker and potential treatment target in patients with coronary artery disease.

Value of addition of coronary artery calcium to risk scores in the prediction of major cardiovascular events in patients with type 2 diabetes.

BACKGROUND: The increased risk for cardiovascular events in diabetics is heterogeneous and contemporary clinical risk score calculators have limited predictive value. We therefore examined the additional value of coronary artery calcium score (CACS) in outcome prediction in type 2 diabetics without clinical coronary artery disease (CAD). METHODS: The study examined a population-based cohort of type 2 diabetics (n = 735) aged 55-74 years, recruited between 2006 and 2008. Patients had at least one additional risk factor and no history or symptoms of CAD. Risk assessment tools included Pooled Cohort Equations (PCE) and Multi-Ethnic Study of Atherosclerosis (MESA) 10-year risk score calculators and CACS. The occurrence of myocardial infarction (MI), stroke or cardiovascular death (MACE) was assessed over 10-years. RESULTS: Risk score calculators predicted MACE and MI and cardiovascular death individually but not stroke. Increasing levels of CACS predicted MACE and its components independently of clinical risk scores, glycated hemoglobin and other baseline variables: hazard ratio (95% confidence interval) 2.92 (1.06-7.86), 6.53 (2.47-17.29) and 8.3 (3.28-21) for CACS of 1-100, 101-300 and > 300 Agatston units respectively, compared to CACS = 0. Addition of CACS to PCE improved discrimination of MACE [AUC of PCE 0.615 (0.555-0.676) versus PCE + CACS 0.696 (0.642-0.749); p = 0.0024]. Coronary artery calcium was absent in 24% of the study population and was associated with very low event rates even in those with high estimated risk scores. CONCLUSIONS: CACS in asymptomatic type 2 diabetics provides additional prognostic information beyond that obtained from clinical risk scores alone leading to better discrimination between risk categories.

Causes of mortality in a department of cardiology over a 15-year period.

AIMS: Over the last four decades, in-hospital mortality from acute coronary syndromes (ACS) has declined. We characterized the patients who died in our cardiovascular intensive care unit (CICU) over a 15-year period. Based on these data, we described the changing patient population in the CICU. METHODS: This retrospective study compared characteristics of patients who died in our CICU in 2005-6, 2013-4 and 2019. During these 5 years, 13,931 patients were hospitalized; 251 (1.8%) died. The mean age of the patients who died was 76 years, 144 (57%) were men. ACS was the leading cause of admission (93 patients, 37%), and 145 (58%) patients had a history of heart failure prior to hospitalization. The leading cause of death was cardiogenic shock in 104 (41%) patients, septic shock in 48 (19%) patients, and combined cardiogenic and septic shock in 31 (12%). Patients hospitalized in the later years of the study were significantly older (67.7, 69.0 and 70.5 years, 2005-6, 2013-4 and 2019, respectively, p < 0.02) but their medical characteristics did not differ significantly between the years examined. CONCLUSIONS: The profile of the patients who died did not change significantly over the 15-year study period. Age of admitted patients was higher in later years of the study. The leading cause of admission was ACS and the leading causes of death were cardiogenic and septic shock. Based on our observations, additional skills should be added to the curriculum of cardiology, including the management of patients with multiorgan failure.