Stephan J. Achenbach

Description:Background: The absence of chest discomfort has been hypothesized to delay treatment and consequently result in worse outcomes in patients with non-ST-elevation myocardial infarction (NSTEMI). Methods: In 888 consecutive patients with type 1 NSTEMI, symptoms were systematically classified as chest discomfort defined as chest pain or pressure, dyspnea or other symptoms, e.g. epigastric pain. Patient characteristics predictive for the absence of chest discomfort and the impact of the symptom type on adverse in-hospital events (all-cause mortality, cardiogenic shock, and mechanical ventilation) were analyzed. Results: Chest discomfort was reported in 81.0%, dyspnea without chest discomfort in 12.2%, and only other symptoms in the remaining 6.9% of patients. In a multivariable regression analysis, female sex (p = 0.035), diabetes mellitus (p = 0.003), the absence of any family history of coronary artery disease (CAD) (p = 0.002), anemia (p < 0.001), and atrial fibrillation or flutter at presentation (p = 0.017) were independent predictors for the absence of chest discomfort. The absence of chest discomfort was associated with a higher rate of in-hospital adverse events (10.6% for chest discomfort vs. 29.6% for dyspnea and 27.9% for other symptoms, p < 0.001), which appeared partially mediated (p = 0.044) by longer times from diagnosis to invasive management (p < 0.001). Conclusions: In type 1 NSTEMI, the absence of chest discomfort is associated with a higher rate of adverse in-hospital events. Women, diabetics, patients without a family history of CAD, patients with anemia, and patients with atrial fibrillation are more likely to present without chest discomfort and special attention may be required to avoid delayed invasive management in these patients.

Description:Background: Multivessel coronary artery disease (CAD) is present in 30% to 70% of patients presenting with non-ST-segment elevation myocardial infarction (NSTEMI) depending on varying age and risk profiles. In contrast to the STEMI cohort, there is only limited scientific evidence derived from randomized controlled trials directing the general decision for or against complete revascularization in the NSTEMI population. The COMPLETE-NSTEMI trial aims to investigate whether multivessel percutaneous coronary intervention (PCI) is superior over culprit-lesion only PCI in patients with NSTEMI and multivessel CAD. Methods: COMPLETE-NSTEMI is a prospective, randomized, controlled, multicenter, parallel group, open-label trial. It will enroll 3390 NSTEMI patients with multivessel CAD at 65 to 70 sites in Germany and Austria. Patients will be randomized 1:1 to either complete revascularization with PCI or culprit lesion-only PCI. Methods: The primary efficacy endpoint is a composite of cardiovascular death or rehospitalization for nonfatal myocardial infarction during follow-up. The trial is event-driven and will be stopped as soon as 578 primary endpoint events and a minimal follow-up duration of 12 months for each patient are reached. Results: The first patient was enrolled at October 27, 2023. By April 2025, 51 sites have been activated and >500 patients have been randomized. Completion of recruitment is expected for the first half of 2027. The final results of the primary endpoint are expected in 2028. Conclusions: COMPLETE NSTEMI will be the first dedicated trial to answer the question about the optimal revascularization strategy in patients with NSTEMI and multivessel CAD. Background: CLINICALTRIALS.GOV: NCT05786131.

Description:Background: High-degree atrioventricular block with the need for permanent pacemaker (PPM) implantation represents a frequent complication after transcatheter aortic valve implantation (TAVI). Extension of indication for TAVI toward subjects with lower surgical risk requires reduction of the likelihood for the need for PPM implantation. The aim of the current analysis was to identify predictors of the need for PPM implantation after TAVI. Results: In a cohort of 1500 consecutive patients without a PPM undergoing transfemoral TAVI, clinical and procedural characteristics as well as parameters derived from cardiac computed tomography, such as membranous septal length and calcium volumes of the aortic valve cusps and the left ventricular outflow tract were assessed. Median calcium volume of the aortic valve was 552 mm3 (interquartile range [IQR]: 340-811 mm3) in the group of subjects requiring a PPM, which was higher than in the group of subjects not requiring PPM implantation (455 mm3 [IQR: 245-723 mm3], Padj=0.001). The same was true for calcification of the noncoronary cusp (Padj=0.027), left coronary cusp (Padj=0.033), and right coronary cusp (Padj=0.006). In multivariable analysis, calcium volume of the noncoronary cusp (P=0.039; odds ratio [OR], 1.089 per 100 mm3), preexisting complete right bundle-branch block (P<0.001; OR, 9.402), and implantation of a self-expandable prosthesis (P<0.001; OR, 1.856) were significantly associated with PPM implantation after TAVI. Conclusions: The current analysis offers a detailed examination of predictors for the need for PPM implantation after TAVI. Our results may contribute to improved risk stratification on the need for PPM implantation after TAVI.

Description:Background: Multivessel coronary artery disease (CAD) is present in 30% to 70% of patients presenting with non-ST-segment elevation myocardial infarction (NSTEMI) depending on varying age and risk profiles. In contrast to the STEMI cohort, there is only limited scientific evidence derived from randomized controlled trials directing the general decision for or against complete revascularization in the NSTEMI population. The COMPLETE-NSTEMI trial aims to investigate whether multivessel percutaneous coronary intervention (PCI) is superior over culprit-lesion only PCI in patients with NSTEMI and multivessel CAD. Methods: COMPLETE-NSTEMI is a prospective, randomized, controlled, multicenter, parallel group, open-label trial. It will enroll 3390 NSTEMI patients with multivessel CAD at 65 to 70 sites in Germany and Austria. Patients will be randomized 1:1 to either complete revascularization with PCI or culprit lesion-only PCI. Methods: The primary efficacy endpoint is a composite of cardiovascular death or rehospitalization for nonfatal myocardial infarction during follow-up. The trial is event-driven and will be stopped as soon as 578 primary endpoint events and a minimal follow-up duration of 12 months for each patient are reached. Results: The first patient was enrolled at October 27, 2023. By April 2025, 51 sites have been activated and >500 patients have been randomized. Completion of recruitment is expected for the first half of 2027. The final results of the primary endpoint are expected in 2028. Conclusions: COMPLETE NSTEMI will be the first dedicated trial to answer the question about the optimal revascularization strategy in patients with NSTEMI and multivessel CAD. Background: CLINICALTRIALS.GOV: NCT05786131.

Description:Objective: The burden of coronary atherosclerosis differs between men and women. Beyond traditional cardiovascular risk factors, inflammatory biomarkers can influence plaque progression. We analyzed the influence of sex on coronary atherosclerosis and inflammatory cytokines. Results: Coronary CT angiography was performed in 301 patients and the extent of coronary atherosclerosis was assessed using semi-automated software. We analyzed total (TPV), non-calcified (NCPV), calcified (CPV) and low-density plaque volume in mm3. Serum was analyzed for various cytokines. Out of 301 patients, 94 (31 %) were female and 207 (69 %) were male. Significant differences were seen between women and men respectively for age, BMI and smoking status (all p < 0.05). All plaque types showed significantly higher volumes in men as compared to women (all p < 0.05). In men, significantly lower serum levels for IL-2 (3.2vs.4.3; p = 0.01) and interferon-gamma (3.2vs.8.8; p < 0.001) but higher levels for MCP-1 (224vs.155; p < 0.001) were seen. In regression analysis, interferon-gamma - but not IL-2 or MCP-1 - showed significant inverse association with male sex (OR 0.32; 95 %CI: 0.16-0.67; p = 0.002). Of note, interferon-gamma levels significantly differed according to high and low TPV in men (16.8vs.9.9; p < 0.001) but not in women (14.5vs. 8.9; p = 0.65). Conclusions: In our cohort of individuals with suspected CAD undergoing coronary CTA, serum levels of interferon-gamma were significantly higher in women, in spite of a lower coronary plaque burden. Higher interferon-gamma levels were associated with higher plaque burden among men, but not in women, which suggests an influence of sex on the role of interferon-gamma in atherogenesis and atherosclerosis progression.