Search

Vericiguat reduced the risk of cardiovascular death (CVD) or hospitalization for heart failure (HF) in patients with worsening HF and reduced left ventricular ejection fraction (LVEF).

Graphical Abstract

The effect of vericiguat on sequential N-terminal pro–B-type natriuretic peptide (NT-proBNP) levels and influence of this relationship on clinical outcomes is unknown.

Background: Baseline Q waves may provide additional value compared with time from the onset of symptoms in predicting outcomes for patients with ST-segment elevation. We evaluated whether baseline Q waves superseded time from symptom onset as a prognostic marker of one-year mortality in patients with ST-segment elevation acute coronary syndrome. Our study was derived from data from patients undergoing primary percutaneous coronary intervention within 24 hours in the PLATelet inhibition and patient Outcomes trial Methods: Q waves on the baseline electrocardiogram were evaluated by a blinded core laboratory. We assessed the associations between baseline Q waves and time from symptom onset to percutaneous coronary intervention with peak biomarkers, ST-segment resolution on the discharge electrocardiogram, and one-year all-cause and vascular mortality. Results: Of 4341 patients with ST-segment elevation, 46% had baseline Q waves. Compared to those without Q waves, those with baseline Q waves were older, more frequently male, had higher heart rates, more advanced Killip class and had a longer time between the onset of symptoms and percutaneous coronary intervention. They also had higher one-year all-cause mortality than patients without baseline Q waves (baseline Q waves: 4.9%; no baseline Q waves: 2.8%; hazard ratio [HR] 1.78, 95% confidence interval [CI] 1.29-2.45, p < 0.001). Complete ST-segment resolution was greatest and all-cause mortality lowest among those with symptom onset three hours or less before percutaneous coronary intervention and no baseline Q waves. After multivariable adjustment, baseline Q waves, but not time from symptom onset, were associated with a significant increase in all-cause mortality (adjusted HR 1.42, 95% CI 1.10-2.01, p = 0.046) and vascular mortality (adjusted HR 1.58, 95% CI 1.09-2.28, p = 0.02). Interpretation: The presence of baseline Q waves provides useful additional prognostic insight into the clinical outcome of patients with ST-segment elevation. Clinical Trials.gov registration no. NCT00391872, The clinical outcome of patients with ST-segment elevation myocardial infarction (STEMI) is directly related to the extent of myocardial necrosis. (1) Because the extent of necrosis is strongly influenced by [...]

ObjectivesRemote ischaemic conditioning (RIC) has been tested as a possible strategy for mitigating reperfusion injury in ST elevation myocardial infarction (STEMI) with primary percutaneous coronary intervention (PPCI). However, surrogate outcomes have shown inconsistent effects with lack of clinical correlation.MethodsWe performed a registry-based randomised study of patients with STEMI allocated to RIC (4 cycles of blood pressure cuff inflation to 200 mm Hg for 5 min of ischaemia followed by 5 min of reperfusion) or standard of care (SOC) during PPCI. We examined the associations of RIC on core laboratory measurements of myocardial perfusion, infarct size (IS), left ventricular (LV) performance and clinical outcomes.ResultsA total of 252 patients were enrolled. The median age was 61 (IQR: 55–70) years and 72.8% were male. Sum ST segment deviation resolution ≥50% was similar between RIC and SOC (65.2% vs 55.7%, p=0.269). In those with 3-day cardiovascular MRI (n=88), no difference in median (25th, 75th percentiles) IS (14.9% (4.5%, 23.1%) vs 16.1% (3.3%, 22.0%), p=0.980), LV dimensions (LV end-diastolic volume index: 78.7 (71.1, 91.2) mL/m2vs 79.9 (71.2, 88.8) mL/m2, p=0.630; LV end-systolic volume index: 48.8 (35.7, 51.4) mL/m2vs 37.9 (31.8, 47.5) mL/m2, p=0.551) or ejection fraction (50.0% (41.0%–55.0%) vs 50.0% (43.0%–56.0%), p=0.554) was demonstrated. Similar results were observed with 90-day cardiovascular MRI. At 1 year, the clinical composite of death, congestive heart failure, cardiogenic shock and recurrent myocardial infarction was similar in RIC and SOC (21.7% vs 13.3%, p=0.110).ConclusionsIn a contemporary registry-based randomised study of patients with STEMI undergoing PPCI, adjunctive therapy with RIC did not improve myocardial perfusion, reduce IS or alter LV performance. Consequently, there was no difference in clinical outcomes within 1 year.Trial registration numberNCT03930589.

Aims: The STREAM study randomly assigned ST-elevation myocardial infarction (STEMI) patients to receive a pharmacoinvasive versus primary percutaneous coronary intervention reperfusion strategy. We assessed whether there was an association between outcomes based on randomisation at a community hospital versus a prehospital location.Methods/results: Community hospital patients (358/1866 (19.2%)) were compared to prehospital patients and their outcomes categorised into pharmacoinvasive according to their treatment assignment. Compared to prehospital patients, community hospital patients had more diabetes (17.8% vs. 11.5%, P=0.001), higher Killip Class >1 (9.4% vs. 5.0%, P=0.002) and thrombolysis in myocardial infarction risk scores ⩾5 (18.2% vs. 12.4%, P=0.005). The 30-day primary endpoint (death, shock, congestive heart failure and re-infarction) for community hospital patients was 14.9% versus 13.2% for prehospital patients (P=0.403). Community hospital pharmacoinvasive patients tended to receive less rescue (35.1% vs. 42.8%, P=0.062); when deployed their rescue was delayed 43 minutes. Community hospital patients undergoing primary percutaneous coronary intervention experienced a delay of 31 minutes versus prehospital patients. Pharmacoinvasive patients receiving scheduled angiography from a community hospital and prehospital patients had comparable times to angiography (17.7 vs. 18.7 hours) and low event rates (6.2% vs. 8.0%). Although the interaction between randomisation location and treatment received on the primary endpoint was not significant (Pinteraction=0.065) those pharmacoinvasive patients requiring rescue from community hospitals had worse outcomes than prehospital rescue patients (odds ratio 2.28, 95% confidence interval 1.16–4.49).Conclusion: Within STREAM, STEMI patients randomly assigned at community hospitals had a higher baseline risk but similar outcomes compared to those studied prehospital patients irrespective of successful pharmacoinvasive therapy or primary percutaneous coronary intervention. However, worse outcomes in the pharmacoinvasive patients requiring rescue in community hospitals emphasises their need for immediate transfer to a percutaneous coronary intervention-capable hospital.

Background:Both patient age and sex influence heart failure (HF) treatment and outcomes. Given women are generally older in HF trials, we examined the associations of age and sex with clinical characteristics, background HF therapy, and response to vericiguat in VICTORIA. VICTORIA enrolled 5050 patients with HF with reduced ejection fraction (HFrEF) and recent worsening HF, was broadly inclusive without an upper age limit, and included 28% women (n=1208), and 31% (1568 ) were ≥75 years old with event rates exceeding most HF trials.Methods:Clinical characteristics were compared across age groups (<65, 65 to <75, ≥75 and <75, ≥75 years) and sex (Table).Results:More women (37%) than men (29%) were age ≥75 years. Compared with younger patients, those ≥75 had higher EF and class III/IV symptoms, more comorbidities, higher NT-proBNP and lower eGFR, indicative of more advanced disease; however, this age group had the lowest use of triple therapy. Within each age group, women had higher EF and lower burden of some comorbidities (atrial fibrillation, hyperlipidemia, coronary artery disease) compared with men, but similar functional status and NT-proBNP. There were no sex differences in the use of triple therapy by age group; however, women ≥75 years less often achieved target doses of triple therapy than men of similar age. Women were also less likely to receive HF devices across all ages. The incidence of the primary composite endpoint (cardiovascular death or HF hospitalization) increased across age groups and was higher in men than women. Compared with the pre-specified age subgroup analysis (i.e., <75, ≥75 years), the beneficial effect of vericiguat on the primary endpoint was not modified by age (continuous) and sex (3-way interaction; p=0.847).Conclusions:Women in VICTORIA were older than men, and while elderly women received less intense background HF therapy, their prognosis was nominally better than elderly men. Vericiguat’s benefit was independent of age and sex.

Background:Patients with chronic heart failure with reduced ejection fraction (HFrEF) and recent decompensation are at high risk of cardiovascular (CV) events including mortality; risk stratification remains challenging. To further assess risk in this population, we characterized their baseline 12-lead ECGs and their prognostic value in 4880 patients (24% female) from the VICTORIA study.Methods:Baseline ECG parameters were interpreted in a core laboratory blinded to centrally adjudicated clinical outcomes. There were 1799 primary composite events (time to first HF hospitalization (HFH) or CV death) and 1005 total all-cause deaths (21% sudden). The MAGGIC-adjusted association between baseline ECG parameters and outcomes are presented as hazard ratio (HR) and 95% confidence intervals (CIs).Results:Incidence rates of baseline ECG parameters and their association with all-cause death and the primary composite outcome are shown below. The median MAGGIC score was 24 (19, 28) points. Higher heart rate, greater QRS duration, and prolonged QTc were significantly associated with the primary composite and all-cause death (Table), as well as for CV death ([HR 1.04, 95% CI 1.02-1.07; p<0.001] [HR 1.02, 1.00-1.04; p=0.015] [HR 1.16, 1.00-1.34; p=0.049]), respectively. Sex-based interactions were evident for contiguous Q waves on all-cause death (male: HR 0.98, 0.82-1.17; female: HR 1.56, 1.15-2.12; interaction p=0.010) and CV death (male: HR 1.03, 0.85-1.25; female: HR 1.66, 1.17-2.34; interaction p=0.019). Additionally, contiguous Q-waves were associated with sudden death (HR 1.45, 1.05-2.00; p=0.022) and appeared to double the risk in females (male: HR 1.25, 0.87-1.79; female: HR 2.50, 1.23-5.06; interaction p= 0.087).Conclusion:Routine ECG parameters are associated with worse outcomes in high risk HFrEF patients—particularly in females with contiguous Q waves.

The aim of this study was to compare clinical outcomes, resource utilization, and health-related quality of life between Canadian and U.S. patients enrolled in ASCEND-HF (Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure). A further aim was to supplement the within-trial analysis with a contemporaneous population-based comparison of all patients hospitalized with primary diagnoses of heart failure (HF) in the 2 countries.

Introduction:There is limited data to inform policy mandating primary PCI (PPCI) volume benchmarks for cardiac catheterization labs in low- and middle-income countries.Hypothesis:Higher volume PPCI hospitals may have better outcomes compared to lower volume hospitals.Methods:All STEMI patients, >18 years with chest pain of <12 hours, undergoing PPCI were included in a state-wide registry. From June 2013 till March 2016, 5560 consecutive PPCI cases were recruited and followed up for 1 year. Hospitals were categorized based on the annual PPCI volumes into low, medium and high-volume (<100, 100-199 and ? 200, respectively) as well as into private or public.Results:Of the 42 recruiting hospitals, there were 24 (57.2%) low-, 8 (19%) intermediate- and 10 (23.8%) high-volume hospitals. There were 4 public hospitals all of which were high-volume. The median TIMI risk score was 3 (IQR, 2-5). Cardiac arrest prior to admission occurred in 4.2%, 2.1% and 2.9% of cases at low, medium and high-volume hospitals (p=0.02). Total ischemic time was longer at high (median [IQR] 4.16 [2.8-6.3] hours) compared to low (3.5 [2.4-5.5] hours) and medium-volume hospitals (3.8 [2.58-6.05] hours) (p=0.01). Radial access was used in 71.3% in medium compared to 61.5% in low and 63.2% in high-volume hospitals (p=0.01). High-volume hospitals had lower thrombus aspiration use (34.8%) compared to low (45.2%) and medium (37.5%) (p=0.01). The un-adjusted 1-year mortality rate was 6.5% in low, 3.4% in medium and 8.6% in high-volume hospitals, which was not attenuated by multivariate adjustment (low vs medium: HR [95% CI] 1.86 [1.21-2.87], high vs medium: HR [95% CI] 2.56 [1.88-3.49]).Conclusions:A parabolic relationship between hospital-level annual PPCI volumes and STEMI outcomes may be present in Kerala, India, with medium-volume hospitals having better outcomes compared to low and high-volume hospitals, although the influence of private versus public hospitals deserves investigation.

Supplemental Digital Content is available in the text.

Supplemental Digital Content is available in the text.