Daily Cardiology Research Analysis

BACKGROUND: Rapid triage of patients presenting with chest pain is essential for early diagnosis and safe disposition. The European Society of Cardiology (ESC) 0/1-hour hs-cTn algorithm has shown promising performance in Western cohorts, but evidence supporting its implementation in diverse Asian emergency department (ED) settings remains limited. Therefore, we evaluated the safety and clinical utility of the ESC 0/1-hour algorithm for chest pain triage across multiple Asian EDs. METHODS: This was a prospective, stepped-wedge, cluster-randomised trial conducted across 12 hospitals in five Asian countries, enrolling 3869 patients with suspected acute coronary syndrome without ST elevation (NSTE-ACS). Usual care involved troponin testing without standardised timing, whereas the 0/1-hour protocol followed ESC recommendations using high-sensitivity cardiac troponin T testing at baseline and 1 hour. The primary endpoint was 30-day major adverse cardiac events (MACE), including cardiovascular death, myocardial infarction (MI) and unplanned revascularisation. Non-inferiority was assessed using a one-sided 95% CI with a margin of 1.5%. RESULTS: Of 3869 patients (2059 usual care; 1810 0/1-hour care), MACE occurred in 1.7% of usual care patients and 1.4% in the 0/1-hour care (upper one-sided 95% CI -0.3%), confirming non-inferiority. ED discharge rates were significantly higher with the 0/1-hour algorithm (60% vs 35%, p<0.001). Among 941 patients classified as low risk group, MACE occurred in only 3 patients, including one cardiovascular death and two unplanned revascularisations; no non-fatal MIs were reported. CONCLUSION: The ESC 0/1-hour algorithm is safe and effective for rapid triage of chest pain in Asian EDs. These findings provide external validation of the 0/1-hour algorithm and support broader global implementation. TRIAL REGISTRATION NUMBER: UMIN000042461.

BACKGROUND: Pre- and post-procedural high-sensitivity cardiac troponin T (hs-cTnT) detects periprocedural myocardial injury (PPMI) and predicts adverse outcomes following transcatheter aortic valve implantation (TAVI). Current diagnosis of PPMI relies on fixed cutoffs, lacking the integration of time- and dose-dependent effects of hs-cTnT. This limits the precision of risk stratification and subsequent patient management. AIMS: To investigate the non-linear and time-dependent effects of pre- and post-procedural hs-cTnT levels on outcomes after TAVI, these findings were compared to the dichotomized definition of PPMI proposed by the Valve Academic Research Consortium-3 (VARC-3). METHODS: Consecutive patients undergoing TAVI between 2011 and 2024 at two tertiary university hospitals with available hs-cTnT measurements were enrolled. The primary outcome was all-cause mortality at 1 year. Multivariable Cox proportional hazards models were fitted. To relax the proportional hazards assumption, allowing for hazard ratios (HRs) to vary over time and across hs-cTnT values, a Royston-Parmar model was fitted. RESULTS: Among 5158 patients, the HR for all-cause mortality at 1 year associated with VARC-3 defined PPMI was not statistically significant. Continuous variable analysis showed that both higher pre- and post-procedural hs-cTnT levels correlated with increased all-cause mortality risk at 1 year. Time-dependent models revealed the hazard to be greatest for higher hs-cTnT levels early post-procedurally and to decline over time. CONCLUSIONS: The dichotomized VARC-3 definition of PPMI showed no prognostic value. Modelling hs-cTnT as continuous and time-dependent revealed a dynamic risk trajectory after TAVI. Incorporating these non-linear and time-dependent effects into risk prediction models may improve clinical decision-making and personalize post-procedural surveillance.

AIMS: Emerging evidence suggests that ApoB outperforms LDL-C in predicting cardiovascular risk, especially in cases of discordance with the two. However, the specific type and composition of lipoprotein particles in this situation remain unclear. METHODS: 375,544 individuals were enrolled from the UK Biobank without baseline cardiovascular disease, not on lipid-lowering therapy, and with available lipid nuclear magnetic resonance (NMR) data. Based on whether the absolute difference in baseline percentile of LDL-C and ApoB level was over 10 units, participants were categorized into concordant, discordantly high ApoB, and discordantly low ApoB group. The primary endpoint was major adverse cardiovascular events (MACE). RESULTS: Cox regression analysis showed the risk of MACE was increased in the discordantly high ApoB group (HR, 1.11; 95% CI, 1.06-1.15) and reduced in the discordantly low ApoB group (HR, 0.87; 95% CI, 0.83-0.93). Similar trends were observed in the NMR data. Compared to the other two groups, the discordantly high ApoB group exhibited the highest concentrations of VLDL-C, VLDL-CE, and VLDL particles. However, the CE content per LDL, IDL, and VLDL particle was lower in this group. Mediation analysis showed that VLDL particles and triglycerides mediated 25.5% and 26.6% of the MACE risk, respectively, in the discordantly high ApoB group (both P < 0.001). CONCLUSION: ApoB is a more comprehensive marker of cardiovascular risk than LDL-C. The higher cardiovascular risk in discordantly high ApoB individuals was partly mediated by VLDL; however, no conclusive evidence indicated that VLDL provides additional prognostic value beyond triglyceride measurements alone. In a large prospective database, traditional lipid measurements were combined with nuclear magnetic resonance (NMR) spectroscopy data to further investigate variations in lipoprotein particle types and compositions among individuals with discordant ApoB and LDL-C levels. The results showed that cardiovascular risk was elevated in the discordantly high ApoB group and reduced in the discordantly low ApoB group, independent of absolute LDL-C or ApoB levels. The increased risk in those with discordantly high apoB was partially mediated by VLDL.