Use of Janus kinase inhibitors before and after European Medicines Agency safety recommendations: a retrospective study.

Background: Safety recommendations for Janus kinase inhibitors (JAKi) issued by the European Medical Agency (EMA) in 2023 could potentially influence treatment patterns for rheumatoid arthritis (RA) drugs, but little is known about the impact of these recommendations in routine clinical care. Methods: We retrospectively analyzed the German RHADAR rheumatology database for adult patients with RA and documentation of a new therapy with a JAKi, tumor necrosis factor inhibitor (TNFi), or interleukin-6 receptor inhibitor (IL-6Ri). Data were grouped into half-yearly intervals from quarter (Q)2/2020 to Q3/2023. The period from Q4/2022 to Q1/2023 immediately followed the initial EMA endorsement of Pharmacovigilance Risk Assessment Committee (PRAC) recommendations and Q2/2023-Q3/2023 immediately followed the direct healthcare provider communication (DHPC) containing the new safety JAKi recommendations. Results: Between April 1, 2020 and September 23, 2023, 3008 newly initiated therapies for TNFi (1499 [49.8%]), JAKi (1126 [37.4%]), and IL-6Ri (383 [12.7%]) were documented by the treating physicians. JAKi were increasingly used in the first two half-year periods (from 29.7% of these therapies in Q2/2020-Q3/2020 to 46.7% in Q2/2021-Q3/2021; odds ratio [OR] 2.08; p<0.001). The proportion of initiated JAKi therapies decreased significantly after the PRAC recommendations (32.9%; OR vs peak 0.56; p=0.001) and the DHPC letter (26.1%; OR vs peak 0.40; p<0.001). JAKi were more likely to be used as >3rd-line therapy in later time periods. Conclusions: This exploratory study suggests that EMA safety recommendations for JAKi influenced treatment patterns of RA patients who received JAKi in Germany. Additional studies will be needed to confirm these findings.

Getting to the HEART of Major Adverse Cardiac Events.

How to cite this article: Samavedam S. Getting to the HEART of Major Adverse Cardiac Events. Indian J Crit Care Med 2024;28(8):724-725.

Long-Term Outcomes of Percutaneous Coronary Intervention in Patients with Prior Coronary Artery Bypass Graft - A Retrospective Experience.

OBJECTIVE: To evaluate the long-term clinical outcomes of percutaneous coronary intervention (PCI) in patients who had previously undergone coronary artery bypass grafting (CABG). METHOD: A total of 219 patients who had a history of CABG and underwent PCI at tertiary care centre were retrospectively enrolled in this study. Clinical endpoints such as major adverse cardiac events (MACE; cardiac death, non-fatal myocardial infarction [MI], and target vessel revascularization), any death, cardiac death, MI, target vessel revascularization (TVR), and target lesion revascularisation (TLR) were reported at long-term follow-up. RESULTS: About 66.6% patients were treated on the native vessel, and 24.2% on grafts vessel. In all, 360 stents [83.3% drug-eluting stent (DES) and 16.6% bare metal stent (BMS)] were implanted. Diabetes mellitus (p=0.03), LVEF<55% for PCI (p=0.04), stent type [BMS (p<0.001) and DES (p<0.001)] and chronic kidney disease [(CKD) p<0.01] were appeared to be the significant predictors of mortality. Age at CABG>50 years (p=0.04), stent type [BMS (p=0.03) and DES (p<0.01)] and CKD (p<0.01) as independent predictors for MACE. Higher event rate was reported in graft-vessel PCI group as compared to native-vessel PCI group: ISR (p<0.01), TLR (p=0.01), mortality (p=0.04), MACE (p<0.01) and MI (p=0.05). Mortality (p<0.001), MACE (p<0.001) and MI (p<0.001) were significantly lower in DES vs. BMS groups. CONCLUSION: Native-vessel PCI was associated with better clinical outcomes than graft-vessel PCI that also with the use of DES as the first choice in patients with a history of CABG.

Predischarge Peak Atrial Longitudinal Strain and Plasma N-terminal Pro-hormone Brain Natriuretic Peptide as a Predictor of Short-term Rehospitalization and Cardiovascular Mortality in Patients with Acute Heart Failure.

Context: The postacute heart failure (AHF) rehospitalization rate is attributed to persistent hemodynamic congestion despite clinical improvement. Peak atrial longitudinal strain (PALS), utilizing speckle tracking echocardiography technology, shows potential in post-AHF prognosis. Meanwhile, N-terminal pro-hormone brain natriuretic peptide (NT-proBNP) remains a known biomarker of intracardiac congestion. Aims: This study aimed to determine the relationship between predischarge PALS and NT-proBNP as predictors of major adverse cardiac event (MACE) in patients after AHF hospitalization. Settings and Design: This study is a prospective cohort study, conducted in Prof. Dr. I G.N.G Ngoerah Hospital, Bali, Indonesia. Subjects and Methods: The study included hospitalized AHF patients, collecting demographic data, comorbidities, therapies, and echocardiographic measures before discharge. Predischarge PALS and NT-proBNP were taken within 24 h before discharge. The main outcome was MACE, defined as rehospitalization and cardiovascular mortality within 90 days. Statistical Analysis Used: Comparative statistical analyses was done using independent t-test for continuous variables (Mann-Whitney U test for variables with abnormal distribution) and Chi-squared tests. Receiver operating characteristic (ROC) used in determining optimal threshold values of predischarge PALS and NT-proBNP as a predictor of MACE. Kaplan-Meier curves were employed to gauge event-free survival differences between these cohorts. Then, independent Cox regression was used to identify the predictors of MACE. Results: The study enrolled 67 patients with varying ejection fraction (EF) (16 - heart failure with preserved ejection fraction, 10 - heart failure with mildly reduced ejection fraction, and 41 - heart failure with reduced ejection fraction; mean age: 56.88 ± 14.57 years). Over the 90-day follow-up, 21 patients (31.3%) encountered MACE. Both PALS (area under the curve [AUC] 0.816) and NT-proBNP (AUC 0.856) before discharge served as predictors of MACE. There was no significant AUC difference between ROC curves (area difference: 0.039, P = 0.553). The regression model highlighted that PALS and NT-proBNP level before discharge acted as independent predictors of MACE, irrespective of EF, average E/e', or estimated predischarge pulmonary capillary wedge pressure. Conclusions: Predischarge PALS is comparable to NT-proBNP levels as independent predictors of short-term MACE after AHF hospitalization.

Estimating the risk of major adverse cardiac events following radiotherapy for left breast cancer using a modified generalized Lyman normal-tissue complication probability model.

BACKGROUND: We introduced an adapted Lyman normal-tissue complication probability (NTCP) model, incorporating clinical risk factors and censored time-to-event data, to estimate the risk of major adverse cardiac events (MACE) following left breast cancer radiotherapy (RT). MATERIALS AND METHODS: Clinical characteristics and MACE data of 1100 women with left-side breast cancer receiving postoperative RT from 2005 to 2017 were retrospectively collected. A modified generalized Lyman NTCP model based on the individual left ventricle (LV) equivalent uniform dose (EUD), accounting for clinical risk factors and censored data, was developed using maximum likelihood estimation. Subgroup analysis was performed for low-comorbidity and high-comorbidity groups. RESULTS: Over a median follow-up 7.8 years, 64 patients experienced MACE, with higher mean LV dose in affected individuals (4.1 Gy vs. 2.9 Gy). The full model accounting for clinical factors identified D50 = 43.3 Gy, m = 0.59, and n = 0.78 as the best-fit parameters. The threshold dose causing a 50 % probability of MACE was lower in the high-comorbidity group (D50 = 30 Gy) compared to the low-comorbidity group (D50 = 45 Gy). Predictions indicated that restricting LV EUD below 5 Gy yielded a 10-year relative MACE risk less than 1.3 and 1.5 for high-comorbidity and low-comorbidity groups, respectively. CONCLUSION: Patients with comorbidities are more susceptible to cardiac events following breast RT. The proposed modified generalized Lyman model considers nondosimetric risk factors and addresses incomplete follow-up for late complications, offering comprehensive and individualized MACE risk estimates post-RT.

Pericoronary adipose tissue for predicting long-term outcomes.

AIMS: Pericoronary adipose tissue (PCAT) attenuation obtained by coronary computed tomography angiography (CCTA) has been associated with coronary inflammation and outcomes. Whether PCAT attenuation is predictive of major adverse cardiac events (MACE) during long-term follow-up is unknown. METHODS AND RESULTS: Symptomatic patients with coronary artery disease (CAD) who underwent CCTA were included, and clinical outcomes were evaluated. PCAT was measured at all lesions for all three major coronary arteries using semi-automated software. A comparison between patients with and without MACE was made on both a per-lesion and a per-patient level. The predictive value of PCAT attenuation for MACE was assessed in Cox regression models. In 483 patients (63.3 ± 8.5 years, 54.9% men), 1561 lesions were analysed over a median follow-up duration of 9.5 years. The mean PCAT attenuation was not significantly different between patients with and without MACE. At a per-patient level, the adjusted hazard ratio (HR) and 95% confidence interval (CI) for MACE were 0.970 (95% CI: 0.933-1.008, P = 0.121) when the average of all lesions per patient was analysed, 0.992 (95% CI: 0.961-1.024, P = 0.622) when only the most obstructive lesion was evaluated, and 0.981 (95% CI: 0.946-1.016, P = 0.285) when only the lesion with the highest PCAT attenuation per individual was evaluated. Adjusted HRs for vessel-specific PCAT attenuation in the right coronary artery, left anterior descending artery, and left circumflex artery were 0.957 (95% CI: 0.830-1.104, P = 0.548), 0.989 (95% CI: 0.954-1.025, P = 0.550), and 0.739 (95% CI: 0.293-1.865, P = 0.522), respectively, in predicting long-term MACE. CONCLUSION: In patients referred to CCTA for clinically suspected CAD, PCAT attenuation did not predict MACE during long-term follow-up.

A machine learning algorithm for stratification of risk of cardiovascular disease in metabolic dysfunction-associated steatotic liver disease.

BACKGROUND: Steatotic liver disease (SLD) is associated with adverse cardiac events. Metabolic dysfunction-associated steatotic liver disease (MASLD) has emerged as a condition characterized by the abnormal accumulation of hepatic lipids that is closely linked to five metabolic disorders: overweight or obesity, impaired glucose regulation, hypertension, hypertriglyceridemia, and low high-density lipoprotein-cholesterol. This retrospective study aimed to stratify the risk of cardiac events in patients with MASLD. METHODS: Patients diagnosed with MASLD through ultrasonography were evaluated. We implemented a machine learning-based approach using a survival classification and regression tree (CART) model to stratify patients based on age, and the number of risk scores was investigated as a predictor of adverse outcomes in the derivation cohort. The primary outcomes were major adverse cardiac events (MACE) including cardiac death, nonfatal myocardial infarction, and revascularization due to coronary artery disease. RESULTS: Among 2,962 patients (median age, 62 years; men, 53.5 %), the distribution of risk factors was as follows: one (10.8 %), two (28.5 %), three (33.0 %), four (19.9 %), and five (7.8 %). Over a median follow-up period of 6.8 years, 170 (5.7 %) patients experienced MACE. In the derivation cohort of 2,073 patients, the CART model identified age ≥60 years old and risk factors ≥4 as significant predictors of MACE. These findings were corroborated in a validation cohort of 889 patients. Patients meeting both criteria exhibited the highest risk of MACE (log-rank test, p < 0.001). CONCLUSIONS: Patients aged ≥60 years old with risk factors ≥4 indicates at high risk of MACE in patients with MASLD. This risk stratification system provides a practical tool for identifying high-risk individuals in the MASLD population.

Cardiac arrest and cardiogenic shock complicating ST-segment elevation myocardial infarction in China: A retrospective multicenter study.

Background: Data on the effect of cardiac arrest (CA), cardiogenic shock (CS), and their combination on the prognosis of Chinese patients with ST-segment elevation myocardial infarction (STEMI) are limited. The present study sought to evaluate the clinical outcomes of STEMI complicated by CA and CS, and to identify the risk factors for CA or CS. Methods: This study included 7468 consecutive patients with STEMI in China. The patients were divided into 4 groups (CA + CS, CA only, CS only, and No CA or CS). The endpoints were 30-day all-cause death and major adverse cardiovascular events. A Cox proportional hazards regression analysis was performed. Results: CA, CS, and their combination were noted in 332 (4.4 %), 377 (5.0 %), and 117 (1.6 %) among all patients. During the 30-day follow-up, 817 (10.9 %) all-cause deaths and 964 (12.9 %) major adverse cardiovascular events occurred, and the incidence of all-cause mortality (3.6 %, 62.3 %, 74.1 %, 83.3 %) and major adverse cardiovascular events (5.4 %, 67.1 %, 75.0 %, and 87.2 %) significantly increased in the No CA or CS, CS only, CA only, and CA + CS groups, respectively. In the multivariate Cox regression models, compared with the No CA or CS group, the CA + CS, CA, and CS-only groups were associated with an increased risk of all-cause death and major adverse cardiovascular events. Patients with CA + CS had the highest risk of all-cause death (hazard ratio [HR], 25.259 [95 % confidence interval (CI) 19.221-33.195]) and major adverse cardiovascular events (HR 19.098, 95%CI 14.797-24.648). Conclusions: CA, CS, and their combination were observed in approximately 11 % of Chinese patients with STEMI, and were associated with increased risk for 30-day mortality and major adverse cardiovascular events in Chinese patients with STEMI.

Performance of the EDACS-ADP incorporating highsensitivity troponin assay: Do components of major adverse cardiac events matter?

BACKGROUND: The accelerated diagnostic protocol (ADP) using the Emergency Department Assessment of Chest pain Score (EDACS-ADP), a tool to identify patients at low risk of a major adverse cardiac event (MACE) among patients presenting with chest pain to the emergency department, was developed using a contemporary troponin assay. This study was performed to validate and compare the performance of the EDACS-ADP incorporating high-sensitivity cardiac troponin I between patients who had a 30-day MACE with and without unstable angina (MACE I and II, respectively). METHODS: A single-center prospective observational study of adult patients presenting with chest pain suggestive of acute coronary syndrome was performed. The performance of EDACS-ADP in predicting MACE was assessed by calculating the sensitivity and negative predictive value. RESULTS: Of the 1,304 patients prospectively enrolled, 399 (30.6%; 95% confidence interval [95% CI]: 27.7%-33.8%) were considered low-risk using the EDACS-ADP. Among them, the rates of MACE I and II were 1.3% (5/399) and 1.0% (4/399), respectively. The EDACS-ADP showed sensitivities and negative predictive values of 98.8% (95% CI: 97.2%-99.6%) and 98.7% (95% CI: 97.0%-99.5%) for MACE I and 98.7% (95% CI: 96.8%-99.7%) and 99.0% (95% CI: 97.4%-99.6%) for MACE II, respectively. CONCLUSION: EDACS-ADP could help identify patients as safe for early discharge. However, when unstable angina was added to the outcome, the 30-day MACE rate among the designated low-risk patients remained above the level acceptable for early discharge without further evaluation.

Predictability of noninvasive liver fibrosis score for cardiac events in patients with nonalcoholic fatty liver disease.

BACKGROUND AND AIMS: Patients with nonalcoholic fatty liver disease (NAFLD) have a higher risk of cardiac events. However, although the severity of liver fibrosis is related to worsening prognosis in patients with NAFLD, it is unclear whether the noninvasive liver fibrosis score has a predictive value for cardiac events. METHODS AND RESULTS: We evaluated 4071 patients with NAFLD diagnosed using ultrasonography. Liver fibrosis was assessed and divided into three groups based on the Fibrosis-4 (FIB4) index and NAFLD fibrosis score (NFS). The primary outcome of this study was major adverse cardiac events (MACE), including cardiac death, nonfatal myocardial infarction, and revascularization due to coronary artery disease. The median age of the evaluated patients was 61 (52-69) years, and 2201 (54.1%) were male. During the median follow-up period of 6.6 years, 179 (4.4%) patients experienced MACE. Kaplan-Meier survival analysis demonstrated that MACE increased progressively with the FIB4 index (log-rank, p < 0.001) and NFS (log-rank, p < 0.001). Multivariable analysis showed that the higher the FIB4 index, the higher the risk for MACE (low group as reference vs. intermediate group, hazard ratio [HR]: 1.860 [95% confidence interval (CI), 1.326-2.610; p < 0.001]; vs. high group, HR:3.325 [95% CI, 2.017-5.479; p < 0.001]), as well as NFS (low NFS group as reference vs. intermediate group, HR: 1.938 [95% CI, 1.391-2.699; p < 0.001]; vs. high group, HR: 3.492 [95% CI, 1.997-6.105; p < 0.001]). CONCLUSIONS: The FIB4 index and NFS are associated with the probability of MACE in patients with NAFLD. CLINICAL TRIALS: The study design was approved by the ethics review board of Ogaki Municipal Hospital (approval number: 20221124-12, registration date: November 28th, 2022). https://www.ogaki-mh.jp/chiken/kenkyu.html.

The value of neutrophil-to-lymphocyte ratio in predicting severity of coronary involvement and long-term outcome of percutaneous coronary intervention in patients with acute coronary syndrome: a systematic review and meta-analysis.

BACKGROUND: The value of counting inflammatory cells and especially their counting ratio in predicting adverse clinical outcomes in patients with acute coronary syndrome (ACS) undergoing revascularization has been shown, but the results of studies have been very diverse and paradoxical. The aim of the current study was to systematically review the studies that investigated the role of increased neutrophil-to-lymphocyte ratio (NLR) in predicting long-term clinical outcomes in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). METHODS: Data abstraction was independently performed by both un-blinded reviewers on deeply assessing Medline, Web of Knowledge, Google Scholar, Scopus, and Cochrane Central Register of Controlled Trials and using the relevant keywords. The risk of bias for each study was assessed using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions and the QUADAS-2 tool. Statistical analysis was performed using the Stata software. Overall, 14 articles published between 2010 and 2021 were eligible for the final analysis. RESULTS: A total of 20,846 ACS patients undergoing PCI were included. Higher values of NLR were associated with higher numbers of involved coronaries (RR: 1.175, 95%CI 1.021-1.353, P = 0.024). Increasing the value of NLR was associated with a 3.4 times increase in long-term death (RR: 3.424, 95%CI 2.325-5.025, P = 0.001). Similarly, higher values of NLR were significantly associated with a higher likelihood of long-term MACE (RR: 2.604, 95%CI 1.736-3.906, P = 0.001). CONCLUSIONS: NLR has a high value in predicting both the severity of coronary artery involvement and long-term adverse clinical outcomes following the PCI procedure.

Assessing risk of major adverse cardiac events among patients with chest pain and cocaine use using the HEART score.

INTRODUCTION: Chest pain (CP), a common presentation in the emergency department (ED) setting, is associated with significant morbidity and mortality if emergency clinicians miss the diagnosis of acute coronary syndrome (ACS). The HEART (History, Electrocardiogram, Age, Risk Factors, Troponin) score had been validated for risk-stratification patients who are at high risk for ACS and major adverse cardiac events (MACE). However, the use of cocaine as a risk factor of the HEART score was controversial. We hypothesized that patients with cocaine-positive (COP) would not be associated with higher risk of 30-day MACE than cocaine-negative (CON) patients. METHODS: This retrospective study included adult patients who presented to 13 EDs of a University's Medical System between August 7, 2017 to August 19, 2021. Patients who had CP and prospectively calculated HEART scores and urine toxicology tests as part of their clinical evaluation were eligible. Areas Under The Receiver Operating Curve (AUROC) were calculated for the performance of HEART score and 30-day MACE for each group. RESULTS: This study analyzed 46,210 patients' charts, 663 (1.4%) were COP patients. Mean age was statistically similar between groups but there were fewer females in the COP group (26.2% vs 53.2%, p < 0.001). Mean (+/- SD) HEART score was 3.7 (1.4) comparing to 3.1 (1.8, p < 0.001) between COP vs CON groups, respectively. Although more COP patients (54%) had moderate HEART scores (4-6) vs. CON group (35.2%, p < 0.001), rates of 30-day MACE were 1.1% for both groups. HEART score's AUROC was 0.72 for COP and 0.78 for CON groups. AUROC for the Risk Factor among COP patients, which includes cocaine, was poor (0.54). CONCLUSION: This study, which utilized prospective calculated HEART scores, demonstrated that overall performance of the HEART score was reasonable. Specifically, our analysis showed that the rate of 30-day MACE was not affected by cocaine use as a risk factor. We would recommend clinicians to consider the HEART score for this patient group.

Standardized risk-stratified cardiac assessment and early posttransplant cardiovascular complications in kidney transplant recipients.

Introduction: Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in kidney transplant recipient (KTR). There is a dearth of standardized guidelines on optimal cardiovascular evaluation of transplant candidates. Methods: This single-center cohort study aims to determine the effectiveness of our standardized risk-stratified pretransplant cardiovascular screening protocol, which includes coronary angiography (CAG), in identifying advanced CVD, the proper pretransplant management of which could lead to a reduction in the incidence of major cardiac events (MACE) in the early posttransplant period. Results: Out of the total 776 KTR transplanted between 2017 and 2019, CAG was performed on 541 patients (69.7%), of whom 22.4% were found to have obstructive coronary artery disease (CAD). Asymptomatic obstructive CAD was observed in 70.2% of cases. In 73.6% of cases, CAG findings resulted in myocardial revascularization. MACE occurred in 5.6% (N = 44) of the 23 KTR with pretransplant CVD and 21 without pretransplant CVD. KTR with posttransplant MACE occurrence had significantly worse kidney graft function at the first year posttransplant (p = 0.00048) and worse patient survival rates (p = 0.0063) during the 3-year follow-up period compared with KTR without MACE. After adjustment, the independent significant factors for MACE were arrhythmia (HR 2.511, p = 0.02, 95% CI 1.158-5.444), pretransplant history of acute myocardial infarction (HR 0.201, p = 0.046, 95% CI 0.042-0.970), and pretransplant myocardial revascularization (HR 0.225, p = 0.045, 95% CI 0.052-0.939). Conclusion: Asymptomatic CVD is largely prevalent in KTR. Posttransplant MACE has a negative effect on grafts and patient outcomes. Further research is needed to assess the benefits of pretransplant myocardial revascularization in asymptomatic kidney transplant candidates.

Circulating osteoprotegerin levels and cardiovascular outcomes in patients with pre-dialysis chronic kidney disease: results from the KNOW-CKD study.

While the relationship between circulating osteoprotegerin (OPG) and cardiovascular events is well-established in the general population, its association with cardiovascular risks in chronic kidney disease (CKD) patients remains less robust. This study hypothesized that elevated circulating OPG levels might be associated with an increased risk of major adverse cardiac events (MACE) in CKD patients, a total of 2,109 patients with CKD stages 1 through pre-dialysis 5 from the KNOW-CKD cohort were categorized into quartiles based on serum OPG levels. The primary outcome of the study was 3-point MACE, defined as a composite of nonfatal myocardial infarction, nonfatal stroke, or cardiac death. The median follow-up duration was 7.9 years. The cumulative incidence of 3-point MACE significantly varied across serum OPG levels in Kaplan-Meier curve analysis (P < 0.001, log-rank test), with the highest incidence observed in the 4th quartile. Cox regression analysis indicated that, relative to the 1st quartile, the risk of 3-point MACE was significantly higher in the 3rd (adjusted hazard ratio 2.901, 95% confidence interval 1.009 to 8.341) and the 4th quartiles (adjusted hazard ratio 4.347, 95% confidence interval 1.410 to 13.395). In conclusion, elevated circulating OPG levels are associated with adverse cardiovascular outcomes in pre-dialysis CKD patients.

Progression of Frailty and Cardiovascular Outcomes Among Medicare Beneficiaries.

Background: Frailty is associated with adverse cardiovascular outcomes independent of age and comorbidities, yet the independent influence of frailty progression remains uncertain. Methods: Medicare Fee-for-service beneficiaries ≥ 65 years at cohort inception with continuous enrollment from 2003-2015 were included. Frailty trajectory was measured by annualized change in a validated claims-based frailty index (CFI) over a 5-year period. Linear mixed effects models, adjusting for baseline frailty, were used to estimate CFI change over a 5-year period. Survival analysis was used to evaluate associations of frailty progression and future health outcomes (major adverse cardiovascular and cerebrovascular events [MACCE], all-cause death, heart failure, myocardial infarction, ischemic stroke, and days alive at home [DAH] within the following calendar year). Results: 26.4 million unique beneficiaries were included (mean age 75.4 ± 7.0 years, 57% female, 13% non-White). In total, 20% had frailty progression, 66% had no change in frailty, and 14% frailty regression over median follow-up of 2.4 years. Compared to those without a change in CFI, when adjusting for baseline frailty, those with frailty progression had significantly greater risk of incident MACCE (hazard ratio [HR] 2.30, 95% confidence interval [CI] 2.30-2.31), all-cause mortality (HR 1.59, 95% CI 1.58-1.59), acute myocardial infarction (HR 1.78, 95% CI 1.77-1.79), heart failure (HR 2.78, 95% CI 2.77-2.79), and stroke (HR 1.78, 95% CI 1.77-1.79). There was also a graded increase in risk of each outcome with more rapid progression and significantly fewer DAH with the most rapid vs. the slowest progression group (270.4 ± 112.3 vs. 308.6 ± 93.0 days, rate ratio 0.88, 95% CI 0.87-0.88, p < 0.001). Conclusions: In this large, nationwide sample of Medicare beneficiaries, frailty progression, independent of baseline frailty, was associated with fewer DAH and a graded risk of MACCE, all-cause mortality, myocardial infarction, heart failure, and stroke compared to those without progression.

What's New in Preoperative Cardiac Testing.

More than 300 million surgeries are performed annually worldwide. Patients are progressively aging and often have multiple comorbidities that put them at increased cardiovascular risk in the perioperative period. The United States published latest guidelines regarding preoperative cardiac evaluation and risk stratification for patients undergoing non-cardiac surgery in 2014. There are multiple risk stratification tools available that can help guide management. Furthermore, newer laboratory tests, such as preoperative NT-proBNP and high-sensitivity troponin assays, may aid in preventing and diagnosing perioperative myocardial injury.

Impact of Isolated Coronary Microvascular Disease Diagnosed Using Various Measurement Modalities on Prognosis: An Updated Systematic Review and Meta-Analysis.

INTRODUCTION: The main aim of this study was to investigate the impact of isolated coronary microvascular disease (CMD) as diagnosed via various modalities on prognosis. METHODS: A systematic literature review of PubMed, Embase, and Cochrane Library databases was conducted to identify relevant studies published up to March 2023. Included studies were required to measure coronary microvascular function and report outcomes in patients without obstructive coronary artery disease (CAD) or any other cardiac pathological characteristics. The primary endpoint was all-cause mortality, and the secondary endpoint was a major adverse cardiac event (MACE). Pooled effects were calculated using random effects models. RESULTS: A total of 27 studies comprising 18,204 subjects were included in the meta-analysis. Indices of coronary microvascular function measurement included coronary angiography-derived index of microcirculatory resistance (caIMR), hyperemic microcirculatory resistance (HMR), coronary flow reserve (CFR), and so on. Patients with isolated CMD exhibited a significantly higher risk of mortality (OR: 2.97, 95% CI, 1.91-4.60, p < 0.0001; HR: 3.38, 95% CI, 1.77-6.47, p = 0.0002) and MACE (OR: 5.82, 95% CI, 3.65-9.29, p < 0.00001; HR: 4.01, 95% CI, 2.59-6.20, p < 0.00001) compared to those without CMD. Subgroup analysis by measurement modality demonstrated consistent and robust pooled effect estimates in various subgroups. CONCLUSION: CMD is significantly associated with an elevated risk of mortality and MACE in patients without obstructive CAD or any other identifiable cardiac pathologies. The utilization of various measurement techniques may have potential advantages in the management of isolated CMD.

Prior electrocardiograms not useful for machine learning predictions of major adverse cardiac events in emergency department chest pain patients.

At the emergency department (ED), it is important to quickly and accurately determine which patients are likely to have a major adverse cardiac event (MACE). Machine learning (ML) models can be used to aid physicians in detecting MACE, and improving the performance of such models is an active area of research. In this study, we sought to determine if ML models can be improved by including a prior electrocardiogram (ECG) from each patient. To that end, we trained several models to predict MACE within 30 days, both with and without prior ECGs, using data collected from 19,499 consecutive patients with chest pain, from five EDs in southern Sweden, between the years 2017 and 2018. Our results indicate no improvement in AUC from prior ECGs. This was consistent across models, both with and without additional clinical input variables, for different patient subgroups, and for different subsets of the outcome. While contradicting current best practices for manual ECG analysis, the results are positive in the sense that ML models with fewer inputs are more easily and widely applicable in practice.