Daily Cardiology Research Analysis
Three impactful cardiology studies stood out today: a 60,042-patient validation shows a multimarker calculator greatly improves 30-day mortality risk stratification in acute pulmonary embolism; a 10-year randomized follow-up (DANAMI-3-PRIMULTI) confirms FFR-guided complete revascularization in STEMI reduces repeat procedures but not myocardial infarction or death; and atrial biopsies during AF ablation revealed a 7% prevalence of early, often atrium-confined amyloidosis, highlighting a new diagn
Summary
Three impactful cardiology studies stood out today: a 60,042-patient validation shows a multimarker calculator greatly improves 30-day mortality risk stratification in acute pulmonary embolism; a 10-year randomized follow-up (DANAMI-3-PRIMULTI) confirms FFR-guided complete revascularization in STEMI reduces repeat procedures but not myocardial infarction or death; and atrial biopsies during AF ablation revealed a 7% prevalence of early, often atrium-confined amyloidosis, highlighting a new diagnostic window.
Research Themes
- Risk stratification and prognostication in acute pulmonary embolism
- Long-term strategy optimization for STEMI with multivessel disease
- Early detection of cardiac amyloidosis in atrial fibrillation care
Selected Articles
1. Acute pulmonary embolism: a multimarker calculator to predict short-term outcomes.
In 60,042 hemodynamically stable acute PE patients, a multimarker calculator using sPESI, natriuretic peptides, troponin, and DVT status markedly improved 30-day mortality prediction versus the ESC model (C-statistic 0.79 vs 0.56). Positive predictive value for mortality tripled at a >10% risk threshold. This tool enhances discrimination and calibration across subgroups.
Impact: Provides a validated, scalable risk tool that substantially improves short-term mortality prediction in acute PE, enabling better triage and resource allocation than current ESC stratification.
Clinical Implications: Adoption of the calculator can refine identification of intermediate-high risk PE, inform monitoring intensity, early reperfusion consideration, and discharge planning, potentially reducing mortality and unnecessary admissions.
Key Findings
- C-statistic for 30-day mortality improved from 0.56 (ESC model) to 0.79 with the multimarker calculator (P<0.001).
- Improved discrimination persisted in a 16,648-patient subgroup with RV data and troponin (0.78 vs 0.66) and after missing data imputation (0.79 vs 0.66).
- At a >10% estimated risk threshold, positive predictive value for mortality was 15.7% versus 5.0% for ESC (P<0.001).
Methodological Strengths
- Very large, contemporary registry cohort (n=60,042) with robust discrimination and calibration analyses.
- Direct head-to-head comparison with ESC model across subgroups and with sensitivity analyses including imputation.
Limitations
- Observational registry design limits causal inference and is susceptible to residual confounding.
- Model performance assessed for short-term (30-day) outcomes; impact on management decisions and clinical endpoints not tested prospectively.
Future Directions: Prospective impact studies to test whether calculator-guided care improves outcomes, and external validation across diverse health systems with integration into clinical pathways and EHR.
BACKGROUND AND AIMS: Risk stratification of patients with acute pulmonary embolism (PE) is critical to provide targeted interventions aimed at improving patients' outcomes. The objective of this study was to validate a multimarker prognostic calculator and compare its performance with that of the European Society of Cardiology (ESC) model. METHODS: The multimarker calculator estimates absolute risk of key outcomes for an individual patient based on the individual variables of the simplified Pulmonary Embolism Severity Index, natriuretic peptide levels, troponin levels, and concomitant lower limb deep vein thrombosis. Using data for haemodynamically stable patients with acute PE from the Registro Informatizado de la Enfermedad TromboEmbólica registry, the study compared the performance of the multimarker calculator and the ESC model using measures of discrimination and calibration. The primary outcome was 30-day all-cause mortality. RESULTS: A total of 60 042 stable patients with PE (mean age: 67 years, 51.8% female) were included. Compared with the ESC model, the multimarker calculator provided significant C-statistic improvement in the whole cohort (0.79 vs. 0.56; P < .001), in the group of 16 648 participants with available data for right ventricular function/size and troponin (0.78 vs. 0.66; P < .001), and after imputation of missing data (0.79 vs. 0.66; P < .001). At a calculator estimated risk of >10% to identify intermediate-high risk PE, the positive predictive value for mortality was 15.7% (vs. 5.0% for the ESC model; P < .001). CONCLUSIONS: In stable patients with acute PE, the use of a multimarker calculator substantially improved the risk stratification for mortality beyond that of the ESC model.
2. 10-Year Outcome of Complete or Infarct Artery-Only Revascularization in STEMI With Multivessel Disease: The DANAMI-3-PRIMULTI Study.
In 627 STEMI patients with multivessel disease randomized to FFR-guided complete revascularization versus culprit-only PCI, 10-year outcomes favored complete revascularization for the composite endpoint (HR 0.76), driven by fewer repeat revascularizations (OR 0.62) without reductions in recurrent MI or death.
Impact: Provides definitive long-term randomized evidence on complete revascularization strategy in STEMI, confirming sustained reduction in repeat procedures but no mortality or MI benefit.
Clinical Implications: Supports current practice of considering staged complete revascularization for symptom and event reduction (repeat procedures), while setting realistic expectations regarding mortality/MI outcomes in shared decision-making.
Key Findings
- Primary composite (death, MI, any revascularization) reduced with complete revascularization at 10 years (HR 0.76; 95% CI 0.60-0.94; P=0.014).
- Repeat revascularization significantly lower (OR 0.62; 95% CI 0.44-0.89).
- No difference in recurrent MI (OR 0.90; 95% CI 0.60-1.35) or all-cause mortality (24% vs 25%).
Methodological Strengths
- Randomized design with decade-long follow-up and analysis of repeated events.
- FFR guidance standardizes non-culprit lesion selection, enhancing internal validity.
Limitations
- Trial underpowered to detect modest differences in mortality or MI over 10 years.
- Evolving PCI techniques/devices over a decade may limit external generalizability.
Future Directions: Assess patient-centered outcomes and cost-effectiveness of staged complete revascularization; explore physiology/intracoronary imaging-guided algorithms to align revascularization with prognosis.
BACKGROUND: The long-term outcomes of complete revascularization in ST-segment elevation myocardial infarction (STEMI) and multivessel disease is unknown. OBJECTIVES: The purpose of this study was to investigate the 10-year clinical outcomes including repeated events of fractional flow reserve (FFR)-guided complete revascularization vs treatment of the infarct-related artery only in STEMI. METHODS: This 10-year follow-up study of DANAMI-3-PRIMULTI (Third DANish Study of Optimal Acute Treatment of Patients With STEMI-Complete Revascularization versus Infarct-Related Artery Only) included patients with STEMI and ≥1 angiographically significant non-infarct-related lesion, randomized to FFR-guided complete revascularization or infarct-related artery only after the index procedure. As the original trial, the primary outcome was a composite of all-cause mortality, recurrent myocardial infarction, or any revascularization. Repeated events of revascularization and myocardial infarction were analyzed. RESULTS: Of 627 included patients, 313 were randomized to infarct-related artery only and 314 to complete revascularization. After 10 years, complete revascularization reduced the risk of the primary outcome (HR: 0.76; 95% CI: 0.60-0.94; P = 0.014). In the infarct-related artery-only group, 78 (25%) died vs 74 (24%) in the complete revascularization group. Complete revascularization reduced any revascularization compared with infarct-related artery only (OR: 0.62; 95% CI: 0.44-0.89). There was no difference in recurrent myocardial infarction (OR: 0.90; 95% CI: 0.60-1.35). The mean cumulative number of events were 76 per 100 persons (95% CI: 66-88) in the infarct-related artery-only group vs 63 events per 100 persons (95% CI: 54-73) in the complete revascularization group (absolute reduction: 13%; 95% CI: -1% to 28%). CONCLUSIONS: FFR-guided complete revascularization reduced future and repeated events compared with infarct-related artery only after 10 years. The risk was mainly driven by revascularization, with no reduction in myocardial infarctions or death. (Primary PCI in Patients With ST-elevation Myocardial Infarction and Multivessel Disease: Treatment of Culprit Lesion Only or Complete Revascularization [PRIMULTI]; NCT01960933).
3. Atrial amyloidosis identified by biopsy in atrial fibrillation: prevalence and clinical presentation.
Among 578 AF ablation patients, atrial biopsy detected amyloid in 7% (mostly ATTR), with prevalence rising to 20–40% in older patients, those with LV hypertrophy, or left atrial low-voltage areas. Notably, half of tested abio-CA cases lacked RV involvement, supporting an atrium-confined early phenotype.
Impact: Reveals a substantial burden of early, potentially atrium-confined ATTR amyloidosis in AF ablation candidates, defining high-yield phenotypes for targeted screening and earlier diagnosis.
Clinical Implications: Consider atrial biopsy or intensified amyloid evaluation in older AF ablation candidates with LV hypertrophy or left atrial low-voltage areas; earlier recognition could influence rhythm strategy, anticoagulation, and disease-modifying therapy referral.
Key Findings
- Atrial amyloid was detected in 7% (40/578) of AF ablation patients; 25 were transthyretin (ATTR) type.
- Prevalence increased to 20–40% with advancing age, LV hypertrophy, and left atrial low-voltage areas.
- Among abio-CA patients with RV biopsy, 50% had no RV deposits, indicating confined atrial amyloidosis.
Methodological Strengths
- Large procedural biopsy cohort with standardized immunohistochemistry typing.
- Concurrent RV biopsies in a large subset enabled anatomical localization (atrial confinement) assessment.
Limitations
- Single-procedure, cross-sectional sampling in an AF ablation population limits generalizability and prognostic inference.
- No longitudinal outcomes to link biopsy findings with clinical progression or therapy response.
Future Directions: Prospective studies to evaluate outcomes and treatment impact of early/atrial-confined ATTR detected at ablation; noninvasive markers to preselect high-yield cases for biopsy.
BACKGROUND AND AIMS: This study aimed to assess the prevalence of cardiac amyloidosis (CA) in patients with non-valvular atrial fibrillation (AF) and to test the hypothesis that early-stage CA can be identified through atrial biopsy. METHODS: Atrial biopsy was performed on 578 patients during AF ablation, with right ventricular (RV) biopsy conducted in 385 patients. The amyloid type was assessed using immunohistochemistry. Patients were classified into groups of atrial biopsy-detected CA (abio-CA) and non-CA, with an additional 58 patients clinically diagnosed with CA comprising the clinical CA group. RESULTS: Amyloid deposits were identified in atrial samples from 40 patients (7%), including 25 amyloid transthyretin (ATTR) types. Prevalence increased to 20%-40% with advancing age, left ventricular (LV) hypertrophy, and the presence of low-voltage areas in the left atrium. The abio-CA group exhibited a thinner LV posterior wall (11.3 ± 2.2 vs 15.3 ± 4.6 mm, P < .001) compared with the clinical CA group. The abio-CA group displayed a thicker LV posterior wall (11.3 ± 2.2 vs 9.6 ± 1.4 mm, P < .001) and a higher frequency of low-voltage areas defined as <0.5 mV (45% vs 13%, P < .001) compared with the non-CA group. Right ventricular biopsy identified amyloid deposits in 13 patients (3%), comprising 11 ATTR and 2 light-chain types. Among the 26 patients in the abio-CA group who underwent RV biopsy, 13 had no amyloid deposits in RV samples, indicating confined atrial amyloidosis. CONCLUSIONS: Atrial biopsy revealed amyloid deposits in 7% of patients undergoing AF ablation, identifying early-stage CA.