Performance of ECG-Derived Digital Biomarker for Screening Coronary Occlusion in Resuscitated Out-of-Hospital Cardiac Arrest Patients: A Comparative Study between Artificial Intelligence and a Group of Experts.

Acute coronary syndrome is a significant part of cardiac etiology contributing to out-of-hospital cardiac arrest (OHCA), and immediate coronary angiography has been proposed to improve survival. This study evaluated the effectiveness of an AI algorithm in diagnosing near-total or total occlusion of coronary arteries in OHCA patients who regained spontaneous circulation. Conducted from 1 July 2019 to 30 June 2022 at a tertiary university hospital emergency department, it involved 82 OHCA patients, with 58 qualifying after exclusions. The AI used was the Quantitative ECG (QCG™) system, which provides a STEMI diagnostic score ranging from 0 to 100. The QCG score's diagnostic performance was compared to assessments by two emergency physicians and three cardiologists. Among the patients, coronary occlusion was identified in 24. The QCG score showed a significant difference between occlusion and non-occlusion groups, with the former scoring higher. The QCG biomarker had an area under the curve (AUC) of 0.770, outperforming the expert group's AUC of 0.676. It demonstrated 70.8% sensitivity and 79.4% specificity. These findings suggest that the AI-based ECG biomarker could predict coronary occlusion in resuscitated OHCA patients, and it was non-inferior to the consensus of the expert group.

Integrative Assessment of Cardiopulmonary Fitness Using Cardiopulmonary Exercise Test With Supine Bicycle Echocardiography in Patients Presenting Dyspnea.

BACKGROUND: Cardiopulmonary exercise test (CPET) with supine bicycle echocardiography (SBE) enables comprehensive physiologic assessment during exercise. We characterized cardiopulmonary fitness by integrating CPET-SBE parameters and evaluated its prognostic value in patients presenting with dyspnea. METHODS AND RESULTS: We retrospectively reviewed 473 consecutive patients who underwent CPET-SBE for dyspnea evaluation. A dimensionality reduction process was applied, transforming 24 clinical and CPET-SBE parameters into a 2-dimensional feature map, followed by patient clustering based on the data distribution. Clinical and exercise features were compared among the clusters in addition to the 5-year risk of clinical outcome (a composite of cardiovascular death and heart failure hospitalization). Maximum exercise effort (R >1) was achieved in 95% of cases. Through dimensionality reduction, 3 patient clusters were derived: Group 1 (n=157), 2 (n=104), and 3 (n=212). Median age and female proportion increased from Group 1 to 2, and 3, although resting echocardiography parameters showed no significant abnormalities among the groups. There was a worsening trend in the exercise response from Group 1 to 2 and 3, including left ventricular diastolic function, oxygen consumption, and ventilatory efficiency. During follow-up (median 6.0 [1.6-10.4] years), clinical outcome increased from Group 1 to 2 and 3 (5-year rate 3.7% versus 7.0% versus 13.0%, respectively; log-rank P=0.02), with higher risk in Group 2 (hazard ratio, 1.94 [95% CI, 0.52-7.22]) and Group 3 (3.92 [1.34-11.42]) compared with Group 1. CONCLUSIONS: Comprehensive evaluation using CPET-SBE can reveal distinct characteristics of cardiopulmonary fitness in patients presenting with dyspnea, potentially enhancing outcome prediction.

Age-dependent implications of left ventricular hypertrophy regression in patients with hypertension.

Left ventricular hypertrophy (LVH) is a significant risk factor for cardiovascular mortality and morbidity in patients with hypertension. However, the effect of age on LVH regression or persistence and its differential prognostic value remain unclear. Therefore, we investigated the clinical implications of LVH regression in 1847 patients with hypertension and echocardiography data (at baseline and during antihypertensive treatment at an interval of 6-18 months) according to age. LVH was defined as a left ventricular mass index (LVMI) > 115 g/m2 and >95 g/m2 in men and women, respectively. LVH prevalence at baseline was not different according to age (age < 65 years: 42.6%; age ≥65 years: 45.7%; p = 0.187), but LVH regression was more frequently observed in the younger group (36.4% vs. 27.5%; p = 0.008). Spline curves and multiple linear regression analysis showed a significant relationship between reductions in systolic blood pressure and LVMI in the younger group (ß = 0.425; p < 0.001), but not the elderly group (ß = 0.044; p = 0.308). LVH regression was associated with a lower risk of the study outcome (composite of cardiovascular death and hospitalization for heart failure) regardless of age. In conclusion, the association between the reduction in blood pressure and LVH regression was prominent in patients with age < 65 years, but not in those with age ≥65 years. However, an association between LVH regression and lower risk of cardiovascular death and hospitalization for heart failure was observed regardless of patient age, suggesting the prognostic value of the LVH regression not only in the younger patients but also in elderly patients.

Clinical and Vessel Characteristics Associated With Hard Outcomes After PCI and Their Combined Prognostic Implications.

Background Cardiac death or myocardial infarction still occurs in patients undergoing contemporary percutaneous coronary intervention (PCI). We aimed to identify adverse clinical and vessel characteristics related to hard outcomes after PCI and to investigate their individual and combined prognostic implications. Methods and Results From an individual patient data meta-analysis of 17 cohorts of patients who underwent post-PCI fractional flow reserve measurement after drug-eluting stent implantation, 2081 patients with available clinical and vessel characteristics were analyzed. The primary outcome was cardiac death or target-vessel myocardial infarction at 2 years. The mean age of patients was 64.2±10.2 years, and the mean angiographic percent diameter stenosis was 63.9%±14.3%. Among 11 clinical and 8 vessel features, 4 adverse clinical characteristics (age ≥65 years, diabetes, chronic kidney disease, and left ventricular ejection fraction <50%) and 2 adverse vessel characteristics (post-PCI fractional flow reserve ≤0.80 and total stent length ≥54 mm) were identified to independently predict the primary outcome (all P<0.05). The number of adverse vessel characteristics had additive predictability for the primary end point to that of adverse clinical characteristics (area under the curve 0.72 versus 0.78; P=0.03) and vice versa (area under the curve 0.68 versus 0.78; P=0.03). The cumulative event rate increased in the order of none, either, and both of adverse clinical characteristics ≥2 and adverse vessel characteristics ≥1 (0.3%, 2.4%, and 5.3%; P for trend <0.01). Conclusions In patients undergoing drug-eluting stent implantation, adverse clinical and vessel characteristics were associated with the risk of cardiac death or target-vessel myocardial infarction. Because these characteristics showed independent and additive prognostic value, their integrative assessment can optimize post-PCI risk stratification. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04684043. www.crd.york.ac.uk/prospero/. Unique Identifier: CRD42021234748.

Endocardial versus whole-myocardial tracking global longitudinal strain analysis in patients with hypertrophic cardiomyopathy: A preliminary comparative study.

BACKGROUND AND OBJECTIVES: We investigated whether the feasibility of left ventricular (LV) global longitudinal strain (GLS) in hypertrophic cardiomyopathy (HCM) varies according to the methodology (e.g. endocardial vs. whole myocardial tracking techniques). METHODS: We retrospectively analyzed 111 consecutive patients with HCM (median age, 58 years; male, 68.5%) who underwent both transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging (apical 29.7%, septal 33.3%, and diffuse or mixed 37.0%). TTE-whole myocardial and TTE-endocardial GLS were measured and compared in terms of association with late gadolinium enhancement (LGE) extent and discrimination performance for extensive LGE (>15% of the LV myocardium). RESULTS: Although TTE-whole myocardial and TTE-endocardial GLS were significantly correlated, absolute TTE-endocardial GLS values (19.3 [16.2-21.9] %) were higher than TTE-whole myocardial GLS values (13.3[10.9-15.6] %, p<0.001). Both TTE-derived GLS parameters were significantly correlated with the LGE extent and independently associated with extensive LGE (odds ratio [OR] 1.30, p = 0.022; and OR 1.24, p = 0.013, respectively). Discrimination performance for extensive LGE was comparable between TTE-whole myocardial and TTE-endocardial GLS (area under the curve [AUC], 0.747 and 0.754, respectively, pdifference = 0.610). However, among patients with higher LV mass index (>70 g/m2), only TTE-whole myocardial GLS correlated with LGE extent and was independently associated with extensive LGE (OR 1.35, p = 0.042), while TTE-endocardial GLS did not. Additionally, TTE-whole myocardial GLS had better discrimination performance for extensive LGE than TTE-endocardial GLS (AUC, 0.705 and 0.668, respectively, pdifference = 0.006). CONCLUSION: TTE-derived GLS using either the endocardial or whole myocardial tracking technique is feasible in patients with HCM. However, in those with severe hypertrophy, TTE-whole myocardial GLS is better than TTE-endocardial GLS.

Feasibility of Artificial Intelligence-Based Electrocardiography Analysis for the Prediction of Obstructive Coronary Artery Disease in Patients With Stable Angina: Validation Study.

BACKGROUND: Despite accumulating research on artificial intelligence-based electrocardiography (ECG) algorithms for predicting acute coronary syndrome (ACS), their application in stable angina is not well evaluated. OBJECTIVE: We evaluated the utility of an existing artificial intelligence-based quantitative electrocardiography (QCG) analyzer in stable angina and developed a new ECG biomarker more suitable for stable angina. METHODS: This single-center study comprised consecutive patients with stable angina. The independent and incremental value of QCG scores for coronary artery disease (CAD)-related conditions (ACS, myocardial injury, critical status, ST-elevation myocardial infarction, and left ventricular dysfunction) for predicting obstructive CAD confirmed by invasive angiography was examined. Additionally, ECG signals extracted by the QCG analyzer were used as input to develop a new QCG score. RESULTS: Among 723 patients with stable angina (median age 68 years; male: 470/723, 65%), 497 (69%) had obstructive CAD. QCG scores for ACS and myocardial injury were independently associated with obstructive CAD (odds ratio [OR] 1.09, 95% CI 1.03-1.17 and OR 1.08, 95% CI 1.02-1.16 per 10-point increase, respectively) but did not significantly improve prediction performance compared to clinical features. However, our new QCG score demonstrated better prediction performance for obstructive CAD (area under the receiver operating characteristic curve 0.802) than the original QCG scores, with incremental predictive value in combination with clinical features (area under the receiver operating characteristic curve 0.827 vs 0.730; P<.001). CONCLUSIONS: QCG scores developed for acute conditions show limited performance in identifying obstructive CAD in stable angina. However, improvement in the QCG analyzer, through training on comprehensive ECG signals in patients with stable angina, is feasible.

The Risk of Heart Failure Progression in Patients With Patent Foramen Ovale: Differential Risk Associated With Device Closure.

BACKGROUND: A patent foramen ovale (PFO) can unload left atrial pressure via an interatrial shunt. We investigated whether device closure of PFO is associated with a subsequent risk of heart failure (HF), particularly in patients with structural heart disease or atrial fibrillation (AF). METHODS: We enrolled 4,804 consecutive patients who underwent transesophageal echocardiography at tertiary medical centers in Korea between 2007 and 2019. The primary outcome was the 4-year risk of HF hospitalization. Underlying structural heart disease was determined by echocardiography. RESULTS: A PFO was observed in 981 (20.4%) patients, where 161 underwent device closure. During follow-up (median, 3.5 [1.4-6.4] years), the primary outcome was lower in patients with PFO than in those without (2.6% vs 4.0%; adjusted hazard ratio [aHR], 0.65; 95% CI, 0.45-0.94; P = .021). Among the patients with PFO, the primary outcome was higher in the device closure group than in the no-closure group (5.5% vs 1.2%; aHR, 5.59; 95% CI, 4.26-7.34; P < .001). A consistent result was found in patients with structural heart disease or AF (9.6% vs 3.9%; aHR, 2.55; 95% CI, 1.95-3.33; P < .001), demonstrating an increased risk of the primary outcome proportionate to the number of combined structural abnormalities. However, no significant association was observed between the primary outcome and PFO closure in those without structural heart disease or AF (1.7% vs 1.5%; aHR, 1.22; 95% CI, 0.99-1.50; P = .054). CONCLUSION: Patients with underlying structural heart disease or AF may be predisposed to symptomatic HF progression after PFO closure. Therefore, careful medical surveillance with optimal risk management is needed in these patients.

Prognostic Implications of Mechanical Phenotypes in Heart Failure Characterized by 3-Chamber Strain Echocardiography.

Background Heart failure (HF) involves dysfunction of the left ventricle (LV) as well as left atrium and right ventricle. We characterized mechanical phenotypes of HF using 3-chamber strain echocardiography and compared their clinical outcomes. Methods and Results We retrospectively analyzed 3574 patients (median age, 74 years; male 52.8%) with acute HF who underwent 3-chamber strain echocardiography. Patients were classified as with LV, left atrium, or right ventricle myopathy if their corresponding strain values (LV global longitudinal strain, left atrium reservoir strain, and right ventricle global longitudinal strain) were lower than median cutoffs, respectively. The mechanical phenotypes of individual patients were characterized according to the combined myopathy. The primary outcome was a composite end point of 5-year all-cause mortality and HF hospitalization. During follow-up (median, 25.8 months), the primary outcome occurred in 1877 (52.5%) patients. Three-chamber strain values were independent predictors for the primary outcome. An incremental trend was observed for the primary outcome, along with the increasing numbers of combined myopathy. Each mechanical phenotype exhibited an increased risk of the primary outcome, with the highest risk observed in patients with 3-chamber myopathy (hazard ratio, 1.67 [95% CI, 1.42-1.96]). The prognostic significance of the mechanical phenotypes was feasible across the conventional HF subtypes stratified by LV ejection fraction. In HF with preserved ejection fraction, the presence of left atrium and right ventricle myopathy significantly increased the primary outcome, regardless of combined left ventricle myopathy. Conclusions Assessment of 3-chamber strain in HF enables characterization of distinctive mechanical phenotypes, which provides an independent prognostic value that may support long-term risk stratification.

Risk of earlier atherosclerotic cardiovascular disease in women with low bone mineral density.

Low bone mineral density (BMD) is associated with higher risk of atherosclerotic cardiovascular disease (ASCVD) in women. We investigated whether the association between low BMD and ASCVD differs according to the age at ASCVD occurrence. We retrospectively analyzed 7932 women aged 50-65 years who underwent dual-energy X-ray absorptiometry. ASCVD was defined as a composite of ASCVD death, myocardial infarction, and ischemic stroke. When we classified participants into no event (n = 7803), early ASCVD (< 70 years) (n = 97), and late ASCVD (≥ 70 years) (n = 32) groups, age gradually increased across groups (median, 58, 60, and 63 years, respectively). However, the estimated BMD T-score at the age of 65 years was lowest in the early ASCVD group (median - 0.9, - 1.1, and - 0.5, respectively). Lower BMD was an independent predictor for early ASCVD (adjusted hazard ratio [95% confidence interval]: 1.34 [1.08-1.67] per 1-SD decrease in T-score), but not for late ASCVD (0.88 [0.60-1.30]). The inverse trend between early ASCVD risk and BMD T-score was consistent regardless of the number of accompanied clinical risk factors. Thus, low BMD is an independent predictor for early ASCVD in women. BMD evaluation can provide prognostic benefit for risk stratification for early ASCVD.

Prognostic Implications of Fractional Flow Reserve After Coronary Stenting: A Systematic Review and Meta-analysis.

Importance: Fractional flow reserve (FFR) after percutaneous coronary intervention (PCI) is generally considered to reflect residual disease. Yet the clinical relevance of post-PCI FFR after drug-eluting stent (DES) implantation remains unclear. Objective: To evaluate the clinical relevance of post-PCI FFR measurement after DES implantation. Data Sources: MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched for relevant published articles from inception to June 18, 2022. Study Selection: Published articles that reported post-PCI FFR after DES implantation and its association with clinical outcomes were included. Data Extraction and Synthesis: Patient-level data were collected from the corresponding authors of 17 cohorts using a standardized spreadsheet. Meta-estimates for primary and secondary outcomes were analyzed per patient and using mixed-effects Cox proportional hazard regression with registry identifiers included as a random effect. All processes followed the Preferred Reporting Items for Systematic Review and Meta-analysis of Individual Participant Data. Main Outcomes and Measures: The primary outcome was target vessel failure (TVF) at 2 years, a composite of cardiac death, target vessel myocardial infarction (TVMI), and target vessel revascularization (TVR). The secondary outcome was a composite of cardiac death or TVMI at 2 years. Results: Of 2268 articles identified, 29 studies met selection criteria. Of these, 28 articles from 17 cohorts provided data, including a total of 5277 patients with 5869 vessels who underwent FFR measurement after DES implantation. Mean (SD) age was 64.4 (10.1) years and 4141 patients (78.5%) were men. Median (IQR) post-PCI FFR was 0.89 (0.84-0.94) and 690 vessels (11.8%) had a post-PCI FFR of 0.80 or below. The cumulative incidence of TVF was 340 patients (7.2%), with cardiac death or TVMI occurring in 111 patients (2.4%) at 2 years. Lower post-PCI FFR significantly increased the risk of TVF (adjusted hazard ratio [HR] per 0.01 FFR decrease, 1.04; 95% CI, 1.02-1.05; P < .001). The risk of cardiac death or MI also increased inversely with post-PCI FFR (adjusted HR, 1.03; 95% CI, 1.00-1.07, P = .049). These associations were consistent regardless of age, sex, the presence of hypertension or diabetes, and clinical diagnosis. Conclusions and Relevance: Reduced FFR after DES implantation was common and associated with the risks of TVF and of cardiac death or TVMI. These results indicate the prognostic value of post-PCI physiologic assessment after DES implantation.

The Clinical Impact of ß-Blocker Therapy on Patients With Chronic Coronary Artery Disease After Percutaneous Coronary Intervention.

BACKGROUND AND OBJECTIVES: The outcome benefits of ß-blockers in chronic coronary artery disease (CAD) have not been fully assessed. We evaluated the prognostic impact of ß-blockers on patients with chronic CAD after percutaneous coronary intervention (PCI). METHODS: A total of 3,075 patients with chronic CAD were included from the Grand Drug-Eluting Stent registry. We analyzed ß-blocker prescriptions, including doses and types, in each patient at 3-month intervals from discharge. After propensity score matching, 1,170 pairs of patients (ß-blockers vs. no ß-blockers) were derived. Primary outcome was defined as a composite endpoint of all-cause death and myocardial infarction (MI). We further analyzed the outcome benefits of different doses (low-, medium-, and high-dose) and types (conventional or vasodilating) of ß-blockers. RESULTS: During a median (interquartile range) follow-up of 3.1 (3.0-3.1) years, 134 (5.7%) patients experienced primary outcome. Overall, ß-blockers demonstrated no significant benefit in primary outcome (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.63-1.24), all-cause death (HR, 0.87; 95% CI, 0.60-1.25), and MI (HR, 1.25; 95% CI, 0.49-3.15). In subgroup analysis, ß-blockers were associated with a lower risk of all-cause death in patients with previous MI and/or revascularization (HR, 0.38; 95% CI, 0.14-0.99) (p for interaction=0.045). No significant associations were found for the clinical outcomes with different doses and types of ß-blockers. CONCLUSIONS: Overall, ß-blocker therapy was not associated with better clinical outcomes in patients with chronic CAD undergoing PCI. Limited mortality benefit of ß-blockers may exist for patients with previous MI and/or revascularization. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03507205.

Angiographic complete revascularization versus incomplete revascularization in patients with diabetes mellitus.

BACKGROUND: Considering the nature of diabetes mellitus (DM) in coronary artery disease, it is unclear whether complete revascularization is beneficial or not in patients with DM. We investigated the clinical impact of angiographic complete revascularization in patients with DM. METHODS: A total of 5516 consecutive patients (2003 patients with DM) who underwent coronary stenting with 2nd generation drug-eluting stent were analyzed. Angiographic complete revascularization was defined as a residual SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery) score of 0. The patient-oriented composite outcome (POCO, including all-cause death, any myocardial infarction, and any revascularization) and target lesion failure (TLF) at three years were analyzed. RESULTS: Complete revascularization was associated with a reduced risk of POCO in DM population [adjusted hazard ratio (HR) 0.70, 95% confidence interval (CI) 0.52-0.93, p = 0.016], but not in non-DM population (adjusted HR 0.90, 95% CI 0.69-1.17, p = 0.423). The risk of TLF was comparable between the complete and incomplete revascularization groups in both DM (adjusted HR 0.75, 95% CI 0.49-1.16, p = 0.195) and non-DM populations (adjusted HR 1.11, 95% CI 0.75-1.63, p = 0.611). The independent predictors of POCO were incomplete revascularization, multivessel disease, left main disease and low ejection fraction in the DM population, and old age, peripheral vessel disease, and low ejection fraction in the non-DM population. CONCLUSIONS: The clinical benefit of angiographic complete revascularization is more prominent in patients with DM than those without DM after three years of follow-up. Relieving residual disease might be more critical in the DM population than the non-DM population. Trial registration The Grand Drug-Eluting Stent registry NCT03507205.

Predicting Long-Term Mortality in Patients With Acute Heart Failure by Using Machine Learning.

BACKGROUND: High mortality rates in patients with acute heart failure (AHF) necessitate proper risk stratification. However, risk-assessment tools for long-term mortality are largely lacking. We aimed to develop a machine-learning (ML)-based risk-prediction model for long-term all-cause mortality in patients admitted for AHF. METHODS AND RESULTS: The ML model, based on boosted a Cox regression algorithm (CoxBoost), was trained with 2704 consecutive patients hospitalized for AHF (median age 73 years, 55% male, and median left ventricular ejection fraction 38%). We selected 27 input variables, including 19 clinical features and 8 echocardiographic parameters, for model development. The best-performing model, along with pre-existing risk scores (BIOSTAT-CHF and AHEAD scores), was validated in an independent test cohort of 1608 patients. During the median 32 months (interquartile range 12-54 months) of the follow-up period, 1050 (38.8%) and 690 (42.9%) deaths occurred in the training and test cohorts, respectively. The area under the receiver operating characteristic curve (AUROC) of the ML model for all-cause mortality at 3 years was 0.761 (95% CI: 0.754-0.767) in the training cohort and 0.760 (95% CI: 0.752-0.768) in the test cohort. The discrimination performance of the ML model significantly outperformed those of the pre-existing risk scores (AUROC 0.714, 95% CI 0.706-0.722 by BIOSTAT-CHF; and 0.681, 95% CI 0.672-0.689 by AHEAD). Risk stratification based on the ML model identified patients at high mortality risk regardless of heart failure phenotypes. CONCLUSIONS: The ML-based mortality-prediction model can predict long-term mortality accurately, leading to optimal risk stratification of patients with AHF.

Comparison of early clinical outcomes between dual antiplatelet therapy and triple antithrombotic therapy in patients with atrial fibrillation undergoing percutaneous coronary intervention.

BACKGROUND AND OBJECTIVE: Most Asian patients with atrial fibrillation (AF) who undergo percutaneous coronary intervention (PCI) receive only dual antiplatelet therapy (DAPT) without oral anticoagulants (vitamin K antagonists [VKA] or non-VKA oral anticoagulants [NOAC]). However, it has not been fully investigated whether the DAPT results in better clinical outcomes in the early period after PCI than the standard triple therapy with VKA or NOAC. METHODS: We analyzed the claims records of 11,039 Korean AF population who had PCI between 2013 and 2018. Patients were categorized according to the post-PCI antithrombotic therapy as VKA-based triple therapy (VKA-TT), NOAC-based triple therapy (NOAC-TT), and DAPT groups. After baseline adjustment using inverse probability weighting, we compared the risks of ischemic endpoints (ischemic stroke, myocardial infarction, and all-cause mortality) and major bleeding at 3 months post-PCI. RESULTS: Ischemic stroke, MI, and all-cause mortality occurred in 105, 423, and 379 patients, respectively, and 138 patients experienced major bleeding. The DAPT group was associated with a lower risk of ischemic stroke and major bleeding (hazard ratio [HR] 0.55, 95% confidence interval [CI] 0.37-0.84) compared to the VKA-TT group, despite no significant differences in the risks of MI and all-cause mortality. In contrast, the DAPT group demonstrated no significant difference in the risks for ischemic endpoints compared to the NOAC-TT group. Additionally, the DAPT group had a numerically lower risk of major bleeding than the NOAC-TT group but this was not statistically significant (HR 0.69, 95% CI 0.45-1.07). CONCLUSIONS: An outcome benefit of DAPT was observed in the early period after PCI compared to the VKA-TT, but not against NOAC-TT users among the Asian AF population. Given the potential long-term benefits of NOACs, greater efforts should be made to increase compliance in clinical practice with proper combination therapy with NOAC after PCI.

Feasibility of the contraction-relaxation coupling index in outcome prediction for patients with acute heart failure.

AIMS: Contemporary heart failure (HF) classification based on left ventricular (LV) ejection fraction is limited for comprehensive assessment of LV function. We aimed to validate the feasibility of the contraction-relaxation coupling index (CRC) as a novel predictor for clinical outcomes in patients with acute HF. METHODS AND RESULTS: A total of 3266 consecutive patients (median age: 74 years, 53% male) with acute HF were included. CRC was defined as the ratio of end-diastolic elastance (LV end-diastolic pressure/stroke volume) to end-systolic elastance (LV end-systolic pressure/end-systolic volume). The risk for 1 year composite endpoint of all-cause mortality or hospitalization for HF (primary outcome) was compared after group categorization using CRC tertiles (Tertile 1: CRC ≤ 0.17, Tertile 2: 0.17 < CRC ≤ 0.40, and Tertile 3: 0.40 < CRC). The median CRC was 0.3 and the median LVEF was 42%. After adjustment for clinical and echocardiographic covariates, CRC was an independent predictor for the primary outcome (hazard ratio [HR]: 1.74, 95% confidence interval [CI]: 1.47-2.07 in Tertile 3 and HR: 1.21, 95% CI: 1.02-1.44 in Tertile 2 when compared with Tertile 1; HR: 1.23, 95% CI: 1.14-1.33 per one-standard deviation increment in CRC). The risk model with CRC showed better performance in outcome discrimination than the model with LVEF (c-statistic 0.701 vs. 0.699, P for difference <0.001). Patients with higher CRC demonstrated better effectiveness of neurohormonal blockade for the primary outcome compared with those with lower CRC (HR: 0.38, 95% CI: 0.29-0.50 in Tertile 3 and HR: 0.67, 95% CI: 0.52-0.89 in Tertile 1). CONCLUSIONS: CRC provides an independent value for outcome prediction in patients with acute HF. CRC would be a sensitive indicator for prognostic risk stratification and for predicting treatment response to the neurohormonal blockade.

Association Between Change in Metabolic Syndrome Status and Risk of Incident Atrial Fibrillation: A Nationwide Population-Based Study.

Backgroud There is a paucity of information on whether changes in metabolic syndrome (MetS) status affect the risk of new-onset atrial fibrillation (AF). We aimed to evaluate whether changes in MetS status and components of MetS affect AF risk using data from a nationwide observational cohort. Methods and Results A total of 7 565 531 adults without prevalent AF (mean age, 47±14 years) who underwent 2 serial health examinations by the Korean National Health Insurance Cooperation were identified. The patients were categorized into 4 groups according to the change in MetS status in serial evaluations, as follows: patients with persistent MetS (n=1 388 850), healthy patients newly diagnosed with MetS in the second evaluation (n=608 158), patients with MetS who were healthy in the second evaluation (n=798 555), and persistently healthy individuals (n=4 769 968). During a mean 7.9-year follow-up, incident AF was diagnosed in 139 305 (1.8%) patients. After multivariable adjustment, the AF risk was higher by 31% in the patients with persistent MetS , 26% in the patients with MetS who were healthy in the second evaluation, and 16% in the healthy patients newly diagnosed with MetS in the second evaluation compared with the persistently healthy individuals. Regardless of the MetS component type, the AF risk correlated with changes in the number of components. The risk of AF was strongly correlated with MetS status changes in the young and middle-age groups (20-39 years and 40-64 years, respectively) than in the elderly group (≥65 years). Conclusions Dynamic changes in MetS status and persistent MetS were associated with an increased risk of AF in a large-scale Asian population.

Prognostic value of lower bone mineral density in predicting adverse cardiovascular disease in Asian women.

OBJECTIVE: We investigated whether the evaluation of bone mineral density (BMD) provides independent and incremental prognostic value for predicting atherosclerotic cardiovascular disease (ASCVD) in women. METHODS: A total of 12 681 women aged 50-80 years (mean, 63.0±7.8 years) who underwent dual-energy X-ray absorptiometry were retrospectively analysed. We assessed the hazard ratio (HR) for ASCVD events (ASCVD death, non-fatal myocardial infarction and ischaemic stroke) according to the BMD or a clinical diagnosis of osteopenia or osteoporosis, with adjustment for clinical risk factors, including age, body mass index, hypertension, type 2 diabetes, hyperlipidaemia, current smoking and previous fracture. We also evaluated whether the addition of BMD or a clinical diagnosis of osteopenia or osteoporosis to clinical risk factors improved the prediction for ASCVD events. RESULTS: In total, 468 women (3.7%) experienced ASCVD events during follow-up (median, 9.2 years). Lower BMD at the lumbar spine, femur neck and total hip was independently associated with higher risk for ASCVD events (adjusted HR per 1-standard deviation decrease in BMD: 1.16, p<0.001; 1.29, p<0.001; 1.38, p<0.001; respectively). A clinical diagnosis of osteoporosis was also independently associated with higher risk for ASCVD events (adjusted HR: 1.79, p<0.001). The addition of BMD or a clinical diagnosis of osteopenia or osteoporosis to clinical risk factors demonstrated significant incremental value in discriminating ASCVD events (addition of total hip BMD, p for difference <0.001). CONCLUSION: The evaluation of BMD provides independent and incremental prognostic value for ASCVD in women and thus may improve risk stratification in women.

High-Risk Morphological and Physiological Coronary Disease Attributes as Outcome Markers After Medical Treatment and Revascularization.

OBJECTIVES: This study sought to evaluate the prognostic impact of plaque morphology and coronary physiology on outcomes after medical treatment or percutaneous coronary intervention (PCI). BACKGROUND: Although fractional flow reserve (FFR) is currently best practice, morphological characteristics of coronary artery disease also contribute to outcomes. METHODS: A total of 872 vessels in 538 patients were evaluated by invasive FFR and coronary computed tomography angiography. High-risk attributes (HRA) were defined as high-risk physiological attribute (invasive FFR ≤0.8) and high-risk morphological attributes including: 1) local plaque burden (minimum lumen area <4 mm2 and plaque burden ≥70%); 2) adverse plaque characteristics ≥2; and 3) global plaque burden (total plaque volume ≥306.5 mm3 and percent atheroma volume ≥32.2%). The primary outcome was the composite of revascularization, myocardial infarction, or cardiac death at 5 years. RESULTS: The mean FFR was 0.88 ± 0.08, and PCI was performed in 239 vessels. The primary outcome occurred in 54 vessels (6.2%). All high-risk morphological attributes were associated with the increased risk of adverse outcomes after adjustment for FFR ≤0.8 and demonstrated direct prognostic effect not mediated by FFR ≤0.8. The 5-year event risk proportionally increased as the number of HRA increased (p for trend <0.001) with lower risk in the PCI group than the medical treatment group in vessels with 1 or 2 HRA (9.7% vs. 14.7%), but not in vessels with either 0 or ≥3 HRA. Of the vessels with pre-procedural FFR ≤0.8, ischemia relief by PCI (pre-PCI FFR ≤0.8 and post-PCI FFR >0.8) significantly reduced vessel-oriented composite outcome risk compared with medical treatment alone in vessels with 0 or 1 high-risk morphological attributes (hazard ratio: 0.33; 95% confidence interval: 0.12 to 0.93; p = 0.035), but the risk reduction was attenuated in vessels with ≥2 high-risk morphological attributes. CONCLUSIONS: High-risk morphological attributes offered additive prognostic value to coronary physiology and may optimize selection of treatment strategies by adding to FFR-based risk predictions (CCTA-FFR Registry for Development of Comprehensive Risk Prediction Model; NCT04037163).

Longitudinal Patterns in Antithrombotic Therapy in Patients with Atrial Fibrillation after Percutaneous Coronary Intervention in the Non-Vitamin K Oral Anticoagulant Era: A Nationwide Population-Based Study.

We investigated whether longitudinal patterns in antithrombotic therapy have changed after the introduction of non-vitamin K oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) who underwent percutaneous coronary intervention (PCI). Using a claims database of the Korean AF population who underwent PCI between 2012 and 2016 (n = 18,691), we analyzed prescription records of oral anticoagulants (OACs) and antiplatelets at 3-month intervals over 2 years after PCI. The study population was stratified (pre-NOAC, transition, and NOAC era) using time-periods of NOAC introduction in Korea and an expansion of reimbursement for NOAC in AF as indicators. The overall rates of OAC were low at baseline (24.9%, 26.9%, and 35.2% in pre-NOAC, transition, and NOAC era, respectively), contrary to high rates of dual antiplatelet therapy (DAPT) (73.3%, 71.4%, and 63.6%). However, OAC prescription rates were increased at 1-year (18.5%, 22.5%, and 31.6%), and 2-year follow-up (17.8%, 24.2%, and 31.8%) from pre-NOAC to NOAC era. In NOAC era, 63.5% of baseline OAC prescriptions comprised NOAC, of which 96.4% included triple therapy with DAPT. Over 2 years, we observed increasing rates of double therapy with a single antiplatelet (18.3% and 20.0% at 1- and 2-year follow-up) and OAC monotherapy (2.7% and 8.9% at 1- and 2-year follow-up).