Occluded myocardial infarction (OMI) remains under-recognized in patients without ST-elevation, delaying revascularization despite a high risk of adverse outcomes. We fine-tuned and validated a foundation model for detecting OMI from standard 12-lead electrocardiograms (ECGs), recorded between 2016 and 2022. The study included 17 165 ECGs from 11 338 patients. Among these, 4 038 encounters proceeded to acute invasive coronary angiography, identified from the Norwegian Registry of Invasive Cardiology (NORIC), and 1 338 of these were diagnosed with OMI. OMI was defined as an acute culprit lesion with Thrombolysis In Myocardial Infarction (TIMI) flow grade 0–2 treated with percutaneous coronary intervention. A pretrained ECG foundation model was fine-tuned and evaluated on a held-out test set. The model achieved an area under the receiver operating characteristic (AUROC) curve of 0.93 and an area under the precision-recall curve (AUPRC) of 0.72 for detecting OMI cases. Performance was high for OMI with ST-elevation (AUROC 0.98) and moderate for OMI without ST-elevation (AUROC 0.84, AUPRC 0.20), reflecting the inherent difficulty of detecting non-ST-elevation occlusions. Among OMI cases with available door-to-procedure timestamps, the model identified 59 (53%) of those with delayed door-to-procedure time (>30 minutes), of which 32 (54%) were NSTEMIs. These findings highlight the potential of AI-enabled ECG interpretation to improve early recognition and timely management of high-risk OMIs.

Aims The non-invasive myocardial work index (MWI) has been validated in patients without aortic stenosis (AS). A thorough assessment of methodological limitations is warranted before this index can be applied to patients with AS.Methods and results We simultaneously measured left ventricular pressure (LVP) by using a micromanometer-tipped catheter and obtained echocardiograms in 20 patients with severe AS. We estimated LVP curves and calculated pressure-strain loops using three different models: (i) the model validated in patients without AS; (ii) the same model, but with pressure at the aortic valve opening (AVO) adjusted to diastolic cuff pressure; and (iii) a new model based on the invasive measurements from patients with AS. Valvular events were determined by echocardiography. Peak LVP was estimated as the sum of the mean aortic transvalvular gradient and systolic cuff pressure. In same-beat comparisons between invasive and estimated LVP curves, Model 1 significantly overestimated early systolic pressure by 61 +/- 5 mmHg at AVO compared with Models 2 and 3. However, the average correlation coefficients between estimated and invasive LVP traces were excellent for all models, and the overestimation had limited influence on MWI, with excellent correlation (r = 0.98, P < 0.001) and good agreement between the MWI calculated with estimated (all models) and invasive LVP.Conclusion This study confirms the validity of the non-invasive MWI in patients with AS. The accuracy of estimated LVP curves improved when matching AVO to the diastolic pressure in the original model, mirroring that of the AS-specific model. This may sequentially enhance the accuracy of regional MWI assessment. [GRAPHICS]

Aims Percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs) has a lower success rate and a higher complication rate compared to PCI of non-occluded coronary arteries. Co-operation and supervision by a more experienced operator (proctoring) are associated with improved success of CTO procedures. This study aims to assess the feasibility of remote proctoring using web-based communication and mixed reality technology in CTO procedures. Methods and results The PCI operator was equipped with a Microsoft HoloLens 2 head-mounted display enabling visual and verbal interaction including holographic annotations with a remote proctor. Ten CTO procedures were performed by a single PCI operator assisted by a remote proctor. Audio and video communication was successfully established in all procedures. All procedures were possible to perform with a Microsoft HoloLens 2 head-mounted display. The PCI operator experienced the remote proctoring as useful. Conclusion Remote proctoring of CTO procedures using mixed reality technology was feasible. The impact of the method regarding procedural and patient outcomes needs to be assessed in new studies.

This protocol describes how digital 12-lead ECGs recorded at Akershus University Hospital between 2016 and 2022 were linked to the Norwegian Registry of Invasive Cardiology, troponin-T measurements, and ICD-10 diagnosis codes, and used to fine-tune and evaluate an AI-based ECG model for detecting acute occluded myocardial infarction (OMI), including in patients without ST-elevation, where OMI is most often missed by current diagnostic criteria. This effort is part of a growing body of international research applying machine learning to ECG-based OMI detection, alongside comparable models reported by Herman et al. (2024), Al-Zaiti et al. (2023), and Gustafsson et al. (2026). Model performance and detailed diagnostic results are reported in the associated peer-reviewed publication; this protocol documents the underlying data linkage, cohort selection, and model development methodology so the study can be reproduced or adapted.

Background The optimal antithrombotic therapy after transcatheter aortic valve implantation (TAVI) is unknown. Bio-prosthetic valve dysfunction (BVD) is associated with adverse outcomes and may be prevented by anticoagulation therapy. A dedicated randomized trial comparing monotherapy NOAC to single antiplatelet therapy has not been performed previously. We hypothesize that therapy with any anti-factor Xa NOAC will reduce BVD compared to antiplatelet therapy, without compromising safety.Methods ACASA-TAVI is a multicenter, prospective, randomized, open-label, blinded endpoint, all-comers trial com-paring a monotherapy anti-factor Xa NOAC strategy ( intervention arm ) with a single antiplatelet therapy strategy (control arm ) after successful TAVI. Three-hundred and sixty patients without indication for oral anticoagulation will be randomized in a 1:1 ratio to either apixaban 5 mg twice per day, edoxaban 60 mg daily, or rivaroxaban 20 mg daily for 12 months followed by acetylsalicylic acid 75 mg daily indefinitely, or to acetylsalicylic acid 75 mg daily indefinitely. The 2 co-primary outcomes are (1) incidence of Hypo-Attenuated Leaflet Thickening ( HALT ) on 4-dimensional cardiac CT at 12 months, and (2) a Safety Composite of VARC-3 bleeding events, thromboembolic events (myocardial infarction and stroke), and death from any cause, at 12 months.Results The first 100 patients had a mean age of 74 +/- 3.6 years, 33% were female, the average body-mass index was 27.9 +/- 4.4 kg/m2, and 15% were smokers. A balloon-expanded valve was used in 82% and a self-expandable valve in 18%.Conclusions The trial is planned, initiated, funded, and conducted without industry involvement.Trial Registration ClinicalTrials.gov Identifier NCT05035277.

BACKGROUND Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is a frequent cause of hospital admission in older people, but clinical trials targeting this population are scarce. OBJECTIVES The After Eighty Study assessed the effect of an invasive vs a conservative treatment strategy in a very old population with NSTE-ACS. METHODS Between 2010 and 2014, the investigators randomized 457 patients with NSTE-ACS aged center dot 80 years (mean age 85 years) to an invasive strategy involving early coronary angiography with immediate evaluation for revasculari-zation and optimal medical therapy or to a conservative strategy (ie, optimal medical therapy). The primary endpoint was a composite of myocardial infarction, need for urgent revascularization, stroke, and death. The long-term outcomes are presented. RESULTS After a median follow up of 5.3 years, the invasive strategy was superior to the conservative strategy in the reduction of the primary endpoint (incidence rate ratio: 0.76; 95% CI: 0.63-0.93; P = 0.0057). The invasive strategy demonstrated a significant gain in event-free survival of 276 days (95% CI: 151-400 days; P = 0.0001) at 5 years and 337 days (95% CI: 123-550 days; P = 0.0001) at 10 years. These results were consistent across subgroups of patients with respect to major cardiovascular prognostic factors. CONCLUSIONS In patients aged center dot 80 years with NSTE-ACS, the invasive strategy was superior to the conservative strategy in the reduction of composite events and demonstrated a significant gain in event-free survival. (The After Eighty Study: a randomized controlled trial; NCT01255540) (J Am Coll Cardiol 2023;82:2021-2030) (c) 2023 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Background Using contemporary data from NORIC (Norwegian Registry of Invasive Cardiology) we investigated the predictive value of patient age and time from ECG diagnosis to sheath insertion (ECG‐2‐sheath) in primary percutaneous coronary intervention for ST‐segment–elevation myocardial infarction (STEMI). Methods and Results Data from 11 226 patients collected from all centers offering 24/7/365 primary percutaneous coronary intervention service were explored. For patients aged <80 years the mortality rates were 5.6% and 7.6% at 30 days and 1 year, respectively. For octogenarians the corresponding rates were 15.0% and 24.2%. The Cox hazard ratio was 2.02 (1.93–2.11, P value <0.0001) per 10 years of patient age. Time from ECG‐2‐sheath was significantly associated with mortality with a 3.6% increase per 30 minutes of time. Using achievement of time goal <90 minutes in patients aged >80 years and mortality at 30 days, mortality was 10.5% and 17.7% for <90 or ≥90 minutes, respectively. The number needed to prevent 1 death was 39 in the whole population and 14 in the elderly. Restricted mean survival gains during median 938 days of follow‐up in patients with ECG‐2‐sheath time <90 minutes were 24 and 76 days for patients aged <80 and ≥80 years, respectively. Conclusions Time from ECG‐diagnosis to sheath insertion is strongly correlated with mortality. This applies especially to octogenarians who derive the most in terms of absolute mortality reduction. Registration URL: https://helsedata.no/en/forvaltere/norwegian‐institute‐of‐public‐health/norwegian‐registry‐of‐invasive‐cardiology/.

We hereby present a case of thrombus formation in the noncoronary sinus of Valsalva following primary graft dysfunction. The case highlights that stagnant and nonpulsatile flow can form thrombi in the noncoronary sinus since this sinus does not have a natural distal runoff.

OBJECTIVES:We aimed to report the angiographic and procedural results of the After Eighty study (ClinicalTrials.gov, NCT01255540), and to identify independent predictors of revascularisation.METHODS:Patients of ≥80 years old with non-ST-elevation myocardial infarction and unstable angina pectoris were randomised to an invasive or conservative strategy. Angiographic and procedural results were recorded. Univariate and multivariate analyses were performed to explore variables predicting revascularisation.RESULTS:Among 229 patients in the invasive group, 220 underwent immediate coronary angiography (90% performed via the radial artery). Of these patients, 48% had three-vessel disease or left main stenosis, 18% two-vessel disease, 16% one-vessel disease, 17% minor coronary vessel wall changes and two patients had normal coronary arteries. Six patients (3%) underwent coronary artery bypass graft. Percutaneous coronary intervention (PCI) was performed in 107 patients (49%), with 57% treated with bare metal stents, 37% drug-eluting stents and 6% balloon angioplasty. On average, 1.7 lesions were treated and 2 stents delivered per patient. Complications included 1 major PCI-related bleeding (successfully treated), 2 minor access site-related bleedings, 3 side branch occlusions during PCI and 11 periprocedural myocardial infarctions (considered end points). Sex, bundle branch block and smoking were independent predictors of revascularisation.CONCLUSIONS:PCI was performed in approximately half of the patients, similar to findings in younger populations. Procedural success was high, with few complications.TRIAL REGISTRATION NUMBER:NCT01255540.

Assessment of global longitudinal strain (GLS) is superior to ejection fraction (EF) in the evaluation of left ventricular (LV) function in patients with stable coronary artery disease (CAD). However, the role of mechanical dispersion (MD) in this context remains unresolved. We aimed to evaluate the potential role of MD as a marker of LV dysfunction and long-term prognosis in stable CAD. EF, GLS and MD were assessed in 160 patients with stable CAD, 1 year after successful coronary revascularization. Serum levels of high-sensitivity cardiac troponin I (hs-cTnI) and amino-terminal pro B-type natriuretic peptide (NT-proBNP) were quantified as surrogate markers of LV dysfunction. The primary endpoint was defined as all-cause mortality, the secondary endpoint was defined as the composite of all-cause mortality and hospitalization for acute myocardial infarction or heart failure during follow-up. Whereas no associations between EF and the biochemical markers of LV function were found, both GLS and MD correlated positively with increasing levels of hs-cTnI (R = 0.315, P < 0.001 and R = 0.442, P < 0.001, respectively) and NT-proBNP (R = 0.195, P = 0.016 and R = 0.390, P < 0.001, respectively). Median MD was 46 ms (interquartile range [IQR] 37–53) and was successfully quantified in 96% of the patients. During a median follow-up of 8.4 (IQR 8.2–8.8) years, 14 deaths and 29 secondary events occurred. MD was significantly increased in non-survivors, and provided incremental prognostic value when added to EF and GLS. NT-proBNP was superior to the echocardiographic markers in predicting adverse outcomes. MD may be a promising marker of LV dysfunction and adverse prognosis in stable CAD.

Background:Percutaneous coronary intervention in complex bifurcation lesions is prone to suboptimal implantation results and is associated with increased risk of subsequent clinical events. Angiographic ambiguity is high during bifurcation stenting, but it is unknown if procedural guidance by intravascular optical coherence tomography (OCT) improves clinical outcome. Methods and Design:OCTOBER is a randomized, investigator-initiated, multicenter trial aimed to show superiority of OCT-guided stent implantation compared to standard angiographic-guided implantation in bifurcation lesions. The primary outcome measure is a 2-year composite end point of cardiac death, target lesion myocardial infarction, and ischemia-driven target lesion revascularization. The calculated sample size is 1,200 patients in total, and allocation is 1:1. Eligible patients have stable or unstable angina pectoris or stabilized non–ST elevation myocardial infarction, and a coronary bifurcation lesion with significant main vessel stenosis and more than 50 % stenosis in a side branch with a reference diameter ≥2.5mm. Treatment is performed by the provisional side branch stenting technique or 2-stent techniques, and the systematic OCT guiding protocol is aimed to evaluate (1) plaque preparation, (2) lesion length, (3) segmental reference sizes, (4) lesion coverage, (5) stent expansion, (6) malapposition, (7) wire positions, and (8) ostial results. Implications:A positive outcome of the OCTOBER trial may establish OCT as a routine tool for optimization of complex percutaneous coronary intervention, whereas a negative result would indicate that OCT remains a tool for ad hoc evaluation in selected cases.

BACKGROUND:High-sensitivity cardiac troponin (hs-cTn) T and I assays are established as crucial tools for the diagnosis of acute myocardial infarction (AMI), as they have been found superior to old troponin assays. However, eventual differences between the assays in prediction of significant coronary lesions and long-term prognosis in patients with acute coronary syndrome (ACS) have not been fully unraveled.METHODS:Serum concentrations of hs-cTnT (Roche), hs-cTnI (Abbott), and amino-terminal pro-B-type natriuretic peptide (NT-proBNP; Roche) in 390 non-ST-elevation (NSTE) ACS patients were evaluated in relation to significant coronary lesions on coronary angiography (defined as a stenosis >50% of the luminal diameter, with need for revascularization) and prognostic accuracy for cardiovascular mortality, all-cause mortality, as well as the composite end point of cardiovascular mortality and hospitalizations for AMI or heart failure.RESULTS:The mean (SD) follow-up was 2921 (168) days. Absolute hs-cTnI concentrations were significantly higher than the hs-cTnT concentrations. The relationship between analyzed biomarkers and significant coronary lesions on coronary angiography, as quantified by the area under the ROC curve (AUC), revealed no difference between hs-cTnT [AUC, 0.81; 95% CI, 0.77-0.86] and hs-cTnI (AUC, 0.81; 95% CI, 0.76-0.86; P = NS). NT-proBNP was superior to both hs-cTn assays regarding prognostic accuracy for both cardiovascular and all-cause mortality and for the composite end point during follow-up, also in multivariate analyses.CONCLUSIONS:The hs-cTnT and hs-cTnI assays displayed a similar ability to predict significant coronary lesions in NSTE-ACS patients. NT-proBNP was superior to both hs-cTn assays as a marker of long-term prognosis in this patient group.

N-terminal pro-B-type natriuretic peptide (NT-proBNP) and cardiac troponins (cTns) measured with sensitive assays provide strong prognostic information in patients with stable coronary artery disease. However, the relationship between these biomarkers and myocardial contractile function, as well as infarct size, in this patient group, remains to be defined. The study population consisted of 160 patients referred to a follow-up echocardiography scheduled 1 year after coronary revascularization. Concentrations of NT-proBNP, high-sensitive cTnT (hs-cTnT) and sensitive cTnI assays were assessed. Left ventricular function was measured as global peak systolic longitudinal strain by speckle tracking echocardiography and infarct size was assessed by late-enhancement MRI. NT-proBNP and sensitive cTnI levels were significantly associated with left ventricular function by peak systolic strain (R-values 0.243 and 0.228, p = 0.002 and 0.004) as well as infarct size (R-values 0.343 and 0.366, p = 0.014 and p = 0.008). In contrast, hs-cTnT did not correlate with left ventricular function (R = 0.095, p = 0.231) and only marginally with infarct size (R = 0.237, p = 0.094). NT-proBNP and sensitive cTnI levels correlate with left ventricular function and infarct size in patients with stable coronary artery disease after revascularization. As opposed to hs-cTnT, NT-proBNP and cTnI seem to be indicators of incipient myocardial dysfunction and the extent of myocardial necrosis.

AIMS:Acute coronary artery occlusion (ACO) occurs in ∼30% of patients with non-ST-segment elevation-acute coronary syndrome (NSTE-ACS). We investigated the ability of a regional non-invasive myocardial work index (MWI) to identify ACO.METHODS AND RESULTS:Segmental strain analysis was performed before coronary angiography in 126 patients with NSTE-ACS. Left ventricular (LV) pressure was estimated non-invasively using a standard waveform fitted to valvular events and scaled to systolic blood pressure. MWI was calculated as the area of the LV pressure-strain loop. Empirical cut-off values were set to identify segmental systolic dysfunction for MWI (<1700 mmHg %) and strain (more than -14%). The number of dysfunctional segments was used in ROC analysis to identify ACO. The presence of ≥4 adjacent dysfunctional segments assessed by MWI was significantly better than both global strain and ejection fraction at detecting the occurrence of ACO (P < 0.05). Regional MWI had a higher sensitivity (81 vs. 78%) and especially specificity (82 vs. 65%) compared with regional strain. Logistic regression demonstrated that elevated systolic blood pressure significantly decreased the probability of actual ACO in a patient with an area of impaired regional strain.CONCLUSION:The presence of a region of reduced MWI in patients with NSTE-ACS identified patients with ACO and was superior to all other parameters. The regional MWI was able to account for the influence of systolic blood pressure on regional contraction. We therefore propose that MWI may serve as an important clinical tool for selecting patients in need of prompt invasive treatment.

BACKGROUND:Many patients with suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) do not have significant coronary artery disease. The current diagnostic approach of repeated electrocardiography and cardiac biomarker assessment requires observation for >6 to 12 hours. This strategy places a heavy burden on hospital facilities. The objective of this study was to investigate whether myocardial strain assessment by echocardiography could exclude significant coronary artery stenosis in patients presenting with suspected NSTE-ACS.METHODS:Sixty-four patients presenting to the emergency department with suspected NSTE-ACS without known coronary artery disease, inconclusive electrocardiographic findings, and normal cardiac biomarkers at arrival were enrolled. Twelve-lead electrocardiography, troponin T assay, and echocardiography were performed at arrival, and all patients underwent coronary angiography. Significant coronary stenosis was defined as >50% luminal narrowing. Global myocardial peak systolic longitudinal strain was measured using speckle-tracking echocardiography. Left ventricular ejection fraction and wall motion score index were calculated.RESULTS:No significant stenosis in any coronary artery was found in 35 patients (55%). Global peak systolic longitudinal strain was superior to conventional echocardiographic parameters in distinguishing patients with and without significant coronary artery stenosis (area under the curve, 0.87). Sensitivity and specificity were calculated as 0.93 and 0.78, respectively, and positive predictive value and negative predictive value as 0.74 and 0.92, respectively. Feasibility of the strain measurements was excellent, with 97% of segments analyzed.CONCLUSIONS:Myocardial strain by echocardiography may facilitate the exclusion of significant coronary artery stenosis among patients presenting with suspected NSTE-ACS with inconclusive electrocardiographic findings and normal cardiac biomarkers.

AIMSIschaemic myocardial segments tend to stretch as the intraventricular pressure rises steeply during the isovolemic contraction phase, before they contract during ejection. We hypothesized that the time they remain stretched, called duration of early systolic lengthening (DESL), correlates with final infarct size as defined by contrast enhanced magnetic resonance imaging (CE-MRI). We also assessed whether DESL could identify patients with acute coronary occlusion, and compared it with traditional measures for myocardial function.METHODS AND RESULTSIn this retrospective study, 150 consecutive patients with Non-ST-elevation acute coronary syndrome (NSTE-ACS) referred for coronary angiography were included. Speckle tracking echocardiography was performed prior to angiography to determine DESL. The final infarct size was quantified at follow-up 9 ± 3 months after initial admission in 61 patients and echocardiography performed in 143 patients. DESL showed good correlation with the final infarct size (r = 0.67, P < 0.001). Thirteen patients had no visible sign of infarct on CE-MRI (minimal myocardial damage), and DESL was significantly shorter in these patients than in patients with signs of infarct (27 ± 19 vs. 84 ± 41 ms, P < 0.001). Compared with left ventricular ejection fraction, wall motion score index, and global longitudinal strain, DESL showed the best accuracy in detecting patients with minimal myocardial damage, with an area under the receiver operating characteristic curve of 0.92 (0.82 to 0.99, P < 0.001). DESL was more prolonged in patients with coronary occlusions, compared with those without occlusions (86 ± 45 vs. 63 ± 31 ms, P < 0.01). DESL was significantly shorter at follow-up, compared with baseline (P = 0.04).CONCLUSIONSDESL could identify patients with minimal myocardial damage, differentiate between occlusion and non-occlusion, and may be helpful in the risk stratification of patients with NSTE-ACS.

Sensitive troponin assays and N-terminal pro–B-type natriuretic peptide in acute coronary syndrome: Prediction of significant coronary lesions and long-term prognosis Jørgen Gravning, MD, a,b,c Marit Kristine Smedsrud, MD, a,b,c Torbjørn Omland, MD, PhD, c,d Christian Eek, MD, PhD, b Helge Skulstad, MD, PhD, b Lars Aaberge, MD, PhD, b Bjørn Bendz, MD, PhD, b John Kjekshus, MD, PhD, b,c Lars Mørkrid, MD, PhD, e and Thor Edvardsen, MD, PhD, FESC a,b,c Oslo, and Lørenskog, Norway