Daily Cardiology Research Analysis

BACKGROUND: Coronary artery calcium (CAC) is highly predictive of cardiovascular events. Although millions of chest computed tomography (CT) scans are performed annually in the United States, CAC is not routinely quantified from scans done for noncardiac purposes. METHODS: We developed a deep learning algorithm, AI-CAC, using 446 expert segmentations to automatically quantify CAC on noncontrast, nongated CT scans. Our study differs from prior works by utilizing imaging data from 98 medical centers across the Veterans Affairs national health care system, capturing extensive heterogeneity in imaging protocols, scanners, and patients. AI-CAC performance on nongated scans was compared against clinical standard electrocardiogram (ECG)-gated CAC scoring in 795 patients with paired gated scans within 1 year of their nongated scan. In addition, the model was tested on 8052 low-dose CTs (LDCTs) to simulate opportunistic CAC screening. RESULTS: Nongated AI-CAC differentiated zero versus nonzero and less than 100 versus 100 or greater Agatston scores with accuracies of 89.4% (F1 0.93) and 87.3% (F1 0.89), respectively. Nongated AI-CAC was predictive of 10-year all-cause mortality (CAC 0 vs. >400 group: 25.4% vs. 60.2%, Cox hazard ratio 3.49; P<0.005), and composite first-time stroke, myocardial infarction, or death (CAC 0 vs. >400 group: 33.5% vs. 63.8%, Cox hazard ratio 3.00; P<0.005). In the LDCT dataset, 3091 out of 8052 (38.4%) individuals had AI-CAC scores >400. Four cardiologists qualitatively reviewed a random sample of the >400 AI-CAC LDCT patients and verified that 527 of the 531 (99.2%) would benefit from lipid-lowering therapy. CONCLUSIONS: This nongated CT CAC algorithm was developed across a national health care system and shows strong performance in evaluation against paired gated CT scans. The model code and weights are available at https://github.com/Raffi-Hagopian/AI-CAC/. (Funded by the Veterans Affairs health care system.).

BACKGROUND AND AIMS: The beneficial effect of pre-treatment with unfractionated heparin (UFH) at first medical contact (FMC) before primary percutaneous coronary intervention (PPCI) in all-comers with ST-elevation myocardial infarction (STEMI) remains uncertain. METHODS: HELP-PCI was an investigator-initiated, randomized controlled trial conducted at 36 clinical centres in China. Patients with STEMI presenting ≤12 h after symptom onset undergoing PPCI were randomly assigned (1:1) to intravenous administration with UFH (100 U/kg) at FMC or in the Cath Lab through a catheter sheath. The primary endpoint was Thrombolysis in Myocardial Infarction flow grade (TFG)-3 of infarct-related artery (IRA) at diagnostic angiography before PPCI. The secondary outcome was complete epicardial and myocardial reperfusion after PPCI and major adverse cardiac and cerebrovascular events (MACCE; defined as the composite of all-cause death, cardiac death, heart failure hospitalizations, re-infarction, stent thrombosis, unplanned revascularization, and stroke) at 12 months. Safety outcome was 30-day Bleeding Academic Research Consortium (BARC) type ≥2 bleeding. RESULTS: A total of 999 patients with STEMI undergoing PPCI were randomly assigned to receive either UFH administration at FMC (n = 505) or in the Cath Lab (n = 494). Pre-treated population at FMC showed a higher frequency of TFG-3 of IRA compared with the Cath Lab group (23.6% vs 17.6%; odds ratio, 1.44; 95% confidence interval, 1.06-1.97; P = .02). There were no significant differences in secondary endpoints or in the safety endpoint, including 12-month MACCE, complete epicardial and myocardial reperfusion, and major bleeding. CONCLUSIONS: Pre-treatment with loading-dose UFH at FMC was associated with an improvement of spontaneous reperfusion of IRA without increasing the risk of major bleeding.

KEY POINTS: Among patients undergoing dialysis with acute coronary syndrome, women received less treatment with coronary artery bypass graft or percutaneous coronary intervention than men. Women, as compared with men, had a lower risk of all-cause death with percutaneous coronary intervention and no difference in all-cause death with coronary artery bypass graft. BACKGROUND: Coronary artery disease is the leading cause of mortality among both men and women with ESKD in the United States. A critical knowledge gap exists on sex differences in revascularization strategies and outcomes in dialysis patients. METHODS: We evaluated 59,951 patients who initiated dialysis between January 1, 2005, and December 31, 2018, and had a primary diagnosis of acute coronary syndrome (ACS) using the United States Renal Data System database. We examined the association of sex with initial cardiac revascularization (defined as coronary artery bypass graft [CABG], percutaneous coronary intervention [PCI], or both on the same day) within 30 days of the first new ACS event after dialysis initiation and examined the association of sex and initial cardiac revascularization with the outcome of all-cause death. RESULTS: Women comprised 44.3% of the cohort. Among patients with first new ACS event after dialysis initiation, 34.6% received PCI, 14.7% received CABG, and 6.1% received both CABG and PCI. After the first new ACS event after dialysis initiation, women had a 42% lower likelihood of receiving CABG only (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.55 to 0.61), 14% lower likelihood of receiving PCI only (OR, 0.86; 95% CI, 0.83 to 0.90), and 41% lower likelihood of receiving CABG and PCI (OR, 0.59; 95% CI, 0.55 to 0.64) compared with men. Women had a slightly lower risk of all-cause death during the follow-up without treatment (Hazard ratios, 0.91; 95% CI, 0.88 to 0.94) or after receiving PCI (Hazard ratios, 0.96; 95% CI, 0.93 to 0.99), but no difference in all-cause death after receiving CABG, or after receiving both CABG and PCI compared with men. CONCLUSION: Among patients undergoing dialysis with ACS, women received less treatment with CABG or PCI than men. Women had a lower risk of all-cause death with PCI and no difference in all-cause death with CABG compared with men.