Citations

AbstractBackgroundThe clinical relevance of cardiac troponin (cTn) elevation in takotsubo syndrome (TTS) remains uncertain. The present study sought to investigate the role of cardiac troponin (cTn) elevations in mortality prediction of patients with Takotsubo syndrome (TTS).MethodsPatients enrolled in the International Takotsubo (InterTAK) Registry from January 2011 to February 2020 with available data on peak cTn levels were included in the analysis. Peak cTn levels during the index hospitalization were used to define clinically relevant myocardial injury. The threshold at which clinically relevant myocardial injury drives mortality at 1 year was identified using restricted cubic spline analysis.ResultsOut of 2′938 patients, 222 (7.6%) patients died during 1‐year follow‐up. A more than 28.8‐fold increase of cTn above the upper reference limit was identified as threshold for clinically relevant myocardial injury. The presence of clinically relevant myocardial injury was significantly associated with an increased risk of mortality at 5 years (adjusted HR 1.58, 95% CI 1.18–2.12, p =.002). Clinically relevant myocardial injury was related to an increased 5‐year mortality risk in patients with apical TTS (adjusted HR 1.57, 95% CI 1.21–2.03, p =.001), in presence of physical stressors (adjusted HR 1.60, 95% CI 1.22–2.11, p =.001), and in absence of emotional stressors (adjusted HR 1.49, 95% CI, 1.17–1.89, p =.001).ConclusionThis study for the first time determined a troponin threshold for the identification of TTS patients at excess risk of mortality. These findings advance risk stratification in TTS and assist in identifying patients in need for close monitoring and follow‐up.

Abstract Background Physical or emotional stress is the most common cause of Takotsubo cardiomyopathy (TS). The exact mechanism of TS remains unclear, and some possible mechanism include myocardial edema and inflammation, coronary vasospasm, microcirculatory dysfunction, catecholamine surge, and sympathetic overdrive. Recently, and consistent with the availability of coronary spasm provocative studies, data suggests that coronary artery vasospasm (CAVS) plays an essential role in the pathogenesis of TS. However, whether CAVS is a consequence or a primary cause of TS is still unclear. The clinical implications of concomitant TS and CAVS have not been studied. Purpose Describe differences in baseline characteristics, comorbidities, cardiovascular risk factors, in-hospital mortality, and outcomes of patients with TS and documented CAVS. Methods The US National Inpatient Database was queried from 2011 to 2019 for relevant ICD-9 and -10 diagnostic and procedural codes. We identified patients admitted with TS who had a coronary angiogram. We then excluded those who underwent coronary percutaneous coronary intervention (PCI), coronary artery bypass graft (CAGB) or had a diagnosis of myocarditis. We compared baseline characteristics and in-hospital outcomes of patients with TS with vs. without documented CAVS. Results We identified 136,732 patients admitted with TS, of which 1,112 (0.8%) had CAVS. We found that those patients with TS and CAVS were younger and less likely to have hypertension, diabetes, atrial fibrillation, hyperlipidemia, coronary artery disease, peripheral artery disease, chronic kidney disease, chronic obstructive pulmonary disease, a prior cancer diagnosis, and smoking history than those without CAVS. Conversely, they were more likely to be obese, have substance abuse disorder, a history of polycystic ovary syndrome, post-traumatic stress disorder, anxiety, history of migraines, and have had a prior myocardial infarction (MI). Regarding in-hospital outcomes, we did not find a significant difference in mortality between groups. Those with TS and CAVS were more likely to have a cardiac arrest, 2nd-degree AV block, ventricular fibrillation, ventricular tachycardia, and more likely to require ICD placement compared to those patients without CAVS. Conclusions Patients with TS and coronary vasospasm were younger, had fewer cardiovascular risk factors but were more likely to have had a prior MI than those without CAVS. We report no significant difference in mortality between groups. However, those with TS and CAVS were more likely to have hospitalizations complicated by cardiac arrest and significant arrhythmias like ventricular fibrillation, ventricular tachycardia, and 2nd-degree AV Block, which led to a higher need for ICD implantation. This large US nationwide retrospective study can provide hypotheses generating ideas for more extensive prospective studies to determine the frequency and role of CAVS in patients with TS.

Background Coronary microvascular dysfunction (CMD) represents an early functional characteristic of coronary vascular aging. Klotho (α‐klotho) is a circulating protein inversely linked to physiological aging. We examined low klotho as a potential marker for vascular aging in patients with CMD and no coronary artery disease. Methods and Results Patients undergoing nonurgent angiogram for chest pain who had no coronary artery disease underwent invasive coronary microvascular and endothelial function testing. CMD was defined by ≤50% increase in coronary blood flow (percentage change in coronary blood flow) in response to intracoronary acetylcholine or coronary flow reserve ≤2. Fresh arterial whole blood was used to analyze circulating endothelial progenitor cells with flow cytometry. Stored arterial plasma was used for klotho analysis by ELISA. Participants with CMD (n=62) were compared with those without CMD (n=36). Those with CMD were age 55±10 years (versus 51±11 years; P =0.07) and 73% women (versus 81%; P =0.38). Traditional risk factors for coronary artery disease were similar between groups. Patients with CMD had less klotho (0.88±1.50 versus 1.75±2.38 ng/mL; P =0.03), and the odds of low klotho in CMD were significant in a logistic regression model after adjusting for traditional cardiovascular risk factors (odds ratio [OR], 0.80 [95% CI, 0.636–0.996]; P =0.05). Higher klotho was associated with higher numbers of endothelial progenitor cells with vascular regenerative potential (CD34 + and CD34 + CD133 + KDR + ). Among a subgroup of patients with atherosclerotic cardiovascular disease risk <5% (n=58), CMD remained associated with lower klotho (OR, 0.80 [95% CI, 0.636–0.996]; P =0.047). Conclusions Klotho may be a biomarker for CMD and may be a therapeutic target for groups of patients without significant traditional cardiovascular risk.

Introduction: Racial, regional, and income disparities have been shown to impact cardiovascular outcomes in postmenopausal women with SARS-CoV-2. Addressing these disparities can improve healthcare equity and outcomes for this vulnerable population. Methods: A retrospective cohort study utilized data from the National Inpatient Sample (NIS)-2020 to examine female patients aged over 55 years who were admitted to hospitals in 2020. The study focused on primary endpoints, specifically major cardiac and cerebrovascular events (MACCE) including all-cause mortality, AMI, cardiac arrest, and stroke. Multivariable logistic regression was used to evaluate the association between demographic factors and cardiovascular outcomes, after controlling for confounding variables. Results: Of the total 547,225 postmenopausal women hospitalized with SARS-CoV-2, 19.8% had MACCE. Racial disparities were significant, as Native American, Hispanic, Asian and African American women exhibited higher rates of MACCE compared to Caucasian women, with odds ratios (OR) of 1.63 (95% CI: 1.33-1.98, p<0.001), 1.25 (95% CI: 1.18-1.32, p<0.001), 1.17 (95% CI: 1.07-1.28, p<0.001), and 1.11 (95% CI: 1.06-1.17, p<0.001), respectively. Regional variations were also observed, with the Northeast region demonstrating a higher prevalence of cardiovascular complications compared to the West (OR: 1.22, 95% CI: 1.14-1.32, p<0.001). Additionally, income level played a significant role, as women from the first- and second-income quartiles had higher MACCE rates compared to those in the fourth quartile (OR: 1.19, 95% CI: 1.12-1.26, p<0.001; OR: 1.09, 95% CI: 1.03-1.15, p<0.001). Conclusions: This study reveals significant racial, regional, and income disparities in cardiovascular outcomes among postmenopausal women with SARS-CoV-2. Targeted interventions and further research are necessary to improve healthcare equity and outcomes in vulnerable populations.

Background: Anemia in Type 2 Myocardial Infarction (T2MI) related hospitalizations has been linked to higher one year mortality along with other causes of hemodynamic stress. We conducted the first ever meta analysis to evaluate the overall global prevalence of Anemia among patients with T2MI with differences by subgroups. Methods: PUBMED, SCOPUS and Google Scholar Databases were systematically reviewed to find studies through January 2023 ascertaining prevalence of Anemia in T2MI. Binary Random Effects models were used to estimate the pooled prevalence and subgroup analysis of anemia in T2MI. Heterogeneity was assessed using I 2 statistics. Leave-One-Out sensitivity analysis was also performed. Results: A total of 16 cohorts with 28,629 patients, hospitalized with T2MI (Mean Age 74; SD13) revealed a 23.3% [95% CI 17.8% - 28.8%, I 2 -98.61%, P<0.001] pooled prevalence of Anemia and a Mean Hb level of 121; SD - 25 in g/L. The prevalence of Anemia was higher among T2MI cohorts with younger Mean Age [Mean <70 vs >70 Years; 24.6% (95% CI 14.1% - 34.1%) vs 21.4% (95% CI 15.6 - 27.2%)]; smaller sample size [ n<500 vs n>500; 26.6% (95% CI 18.4% - 34.8%) vs 18.6% (95%CI 10.4% - 26.8%)]; prospective studies [Prospective vs Retrospective; 26.1% (95%CI 17.4% - 34.7%) vs 18.7% (95%CI 12.7% - 24.7%)] and single center studies [Single Center vs Multi Center; 24.9% (95%CI 17.5% - 32.2%) vs 21.4% (95%CI 12.7% - 30.1%)]. The prevalence of Anemia in T2MI related hospitalizations was also higher in studies from Asia [36.2% (95%CI 24.6% - 47.7%)], Europe [21.9% (95% CI 14.1% - 29.7%)] and Multinational [21.1% (95%CI 11.9%-30.2%)] as compared to North America [16.4% (95%CI 8% - 24.8%)]. Conclusions: The pooled prevalence of Anemia in this worldwide meta analysis of T2MI hospitalized patients was 23.3% with wide variance among subgroups. Further studies should focus on scrutinizing the outcomes and devastating complications of Anemic patients with T2MI among various populations universally.

Ischemic symptoms may be explained by a multitude of coronary pathologies, including coronary artery tortuosity, atherosclerosis, fibromuscular dysplasia, vasculitis, coronary vasospasm, or microvascular disease. We present an unusual case of coronary kinking in a patient presenting with exertional jaw pain in the absence of atherosclerotic risk factors. Multimodality imaging, coronary imaging, and coronary physiology helped establish the diagnosis and guide management.

ABSTRACT Aims Takotsubo syndrome (TTS) is associated with a substantial rate of adverse events. We sought to design a machine learning (ML)-based model to predict the risk of in-hospital death and to perform a clustering of TTS patients to identify different risk profiles. Methods and results A ridge logistic regression-based ML model for predicting in-hospital death was developed on 3482 TTS patients from the International Takotsubo (InterTAK) Registry, randomly split in a train and an internal validation cohort (75% and 25% of the sample size, respectively) and evaluated in an external validation cohort (1037 patients). Thirty-one clinically relevant variables were included in the prediction model. Model performance represented the primary endpoint and was assessed according to area under the curve (AUC), sensitivity and specificity. As secondary endpoint, a K-medoids clustering algorithm was designed to stratify patients into phenotypic groups based on the 10 most relevant features emerging from the main model. The overall incidence of in-hospital death was 5.2%. The InterTAK-ML model showed an AUC of 0.89 (0.85–0.92), a sensitivity of 0.85 (0.78–0.95) and a specificity of 0.76 (0.74–0.79) in the internal validation cohort and an AUC of 0.82 (0.73–0.91), a sensitivity of 0.74 (0.61–0.87) and a specificity of 0.79 (0.77–0.81) in the external cohort for in-hospital death prediction. By exploiting the 10 variables showing the highest feature importance, TTS patients were clustered into six groups associated with different risks of in-hospital death (28.8% vs. 15.5% vs. 5.4% vs. 1.0.8% vs. 0.5%) which were consistent also in the external cohort. Conclusion A ML-based approach for the identification of TTS patients at risk of adverse short-term prognosis is feasible and effective. The InterTAK-ML model showed unprecedented discriminative capability for the prediction of in-hospital death.

BACKGROUND: The financial burden linked to the diagnosis and treatment of patients with chest pain on the health care system is considerable. Angina and nonobstructive coronary artery disease (ANOCA) is common, associated with adverse cardiovascular events, and may lead to repeat testing or hospitalizations. Diagnostic certainty can be achieved in patients with ANOCA using coronary reactivity testing (CRT); however, its financial effect on the patient has not been studied. Our goal was to assess the effect of CRT on health care–related cost in patients with ANOCA. METHODS: Patients with ANOCA who underwent diagnostic coronary angiography (CAG) and CRT (CRT group) were matched to controls who had similar presentation but only underwent a CAG without CRT (CAG group). Standardized inflation-adjusted costs were collected and compared between the 2 groups on an annual basis for 2 years post the index date (CRT or CAG). RESULTS: Two hundred seven CRT and 207 CAG patients were included in the study with an average age of 52.3±11.5 years and 76% females. The total cost was significantly higher in the CAG group as compared with the CRT group ($37 804 [$26 933–$48 674] versus $13 679 [$9447–$17 910]; P <0.001). When costs are itemized and divided based on the Berenson-Eggers Type of Service categorization, the largest cost difference occurred in imaging (any type, including CAG; P <0.001), procedures (eg, percutaneous coronary intervention/coronary artery bypass grafting/thrombectomy) ( P =0.001), and test (eg, blood tests, EKG; P <0.001). CONCLUSIONS: In this retrospective observational study, assessment of CRT in patients with ANOCA was associated with significantly reduced annual total costs and health care utilization. Therefore, the study may support the integration of CRT into clinical practice.