BACKGROUND:Guideline-directed medical therapies (GDMTs), such as beta-blockers, antiplatelet drugs, lipid-lowering drugs, and renin-angiotensin system agents, have been associated with reduced risk of mortality after acute myocardial infarction (AMI). However, this survival benefit conferred by GDMTs in nonagenarians and centenarians (≥ 90 years old) is not well-defined. METHODS:We investigated restricted mean survival times of patients ≥ 90 years of age with first-onset AMI treated with GDMTs from 2007 to 2020 in the Singapore Myocardial Infarction Registry. Primary analyses involved stratification by number of GDMTs prescribed at discharge, with derivation of pairwise restricted mean survival ratios free from all-cause mortality at 1, 3, and 5 years. Secondary analyses evaluated individual GDMTs within combinations of 1-3 GDMTs. RESULTS:The analysis included 3264 patients: 0 GDMTs (561 patients, 17.2%), 1-2 GDMTs (1294 patients, 39.6%), 3 GDMTs (904 patients, 27.7%), and 4 GDMTs (505 patients, 15.5%), with a median follow-up duration of 5.71 years. Patients who received 4 GDMTs at discharge were younger, had more comorbidities, were more likely to be smokers, and were more likely to have undergone percutaneous coronary intervention than those prescribed fewer GDMTs. A greater number of GDMT classes at discharge was associated with longer survival free from all-cause mortality at 1, 3, and 5 years. Each drug class within combinations of 1-3 GDMTs was associated with significant survival benefit at all time points, except for beta-blockers. CONCLUSIONS:Prescription of any number of GDMTs to nonagenarians and centenarians after first-onset AMI is associated with significant survival benefit.

Electronic health records (EHR) aggregate extensive data critical for advancing patient care and refining intervention strategies. EHR data is essential for epidemiological study, more commonly referred to as cohort study, where patients with shared characteristics or similar diseases are analyzed over time. Unfortunately, existing studies on cohort modeling are limited, struggling to derive fine-grained cohorts or effectively utilize cohort information, which hinders their ability to uncover intrinsic relationships between cohorts. To this end, we propose NeuralCohort, a cohort-aware neural representation learning method that precisely segments patients into finer-grained cohorts via an innovative cohort contextualization mechanism and captures both intra- and inter-cohort information using a Biscale Cohort Learning Module. Designed as a plug-in, NeuralCohort integrates seamlessly with existing backbone models, enhancing their cohort analysis capabilities by infusing deep cohort insights into the representation learning processes. The effectiveness and generalizability of NeuralCohort are validated across extensive real-world EHR datasets. Experimental results demonstrate that NeuralCohort consistently improves the performance of various backbone models, achieving up to an 8.1% increase in AUROC.

Background: The incidence of left ventricular thrombus (LVT), a significant complication postacute myocardial infarction (AMI), has seen a decline in the percutaneous coronary intervention era. Patients may not undergo coronary revascularization due to medical contraindications or patient preference. Objectives: This study compared post-AMI LVT patients treated with or without revascularization. Methods: This was a retrospective study of 263 consecutive post-AMI patients diagnosed with LVT from November 2012 to January 2021, retrieved from an echocardiography database. Patients were stratified by their revascularization status. Results: Mean (SD) follow-up duration was 2.1 ± 2.1 years. Most post-AMI LVT patients underwent revascularization via percutaneous coronary intervention (71.5%; n = 188). Unrevascularized patients (24.0%; n = 63) were older (P < .001), more often female (P < .001), more comorbid, less likely to have anterior AMI (P < .001), or treated with anticoagulation (P < .001). In multivariable analysis, at least anticoagulation + P2Y12 inhibitor (adjusted hazard ratio [aHR], 1.84; 95% CI, 1.14-2.96; P = .01), but not revascularization (aHR, 1.25; 95% CI, 0.74-2.13; P = .40), was associated with LVT resolution. Both absence of revascularization (aHR, 2.30; 95% CI, 1.09-4.85; P = .03) and LVT resolution (aHR, 6.06; 95% CI, 2.99-12.3; P < .001) were associated with higher mortality after adjusting for age, sex, anemia, anterior AMI, and ejection fraction. Conclusion: Lack of revascularization in post-AMI LVT patients was associated with higher mortality but not LVT resolution. Optimizing medical therapy remains a key treatment goal.

Abstract Background Transaortic valvular implantation (TAVI) has revolutionised the management of aortic stenosis (AS). Uptake in Asia has caught up in recent years, after an initial lag due to expensive cost, limited subsidies, and scarce accessibility. Hence, longitudinal outcomes of TAVI remain largely unknown in Asian patients. Purpose This study aims to present the 5-year mortality endpoints in an Asian cohort followed up over a decade. Methods 253 patients with symptomatic severe aortic stenosis status post TAVI were retrospectively enrolled at a tertiary academic hospital from 2010-2021. The main outcomes were defined as short-term (30-day), mid-term (1-year) and long-term (5-year) all-cause mortality. Baseline demographics, procedural findings and clinical outcomes were analysed. Kaplan-Meier curves and multiple Cox regression analyses were constructed. Results The mean age was 75.2 + 10.2 years. 120 (47.4%) patients were female and 167 (66%) were Chinese. 168 patients (66.7%) received balloon-expandable valves, 80 patients (31.7%) underwent self-expandable valves, and 4 patients (1.6%) had mechanical-expandable valves. Malignancy was associated with worse short-term mortality at 30-days (HR 3.65, p = 0.054), while pulmonary disease and previous stroke were associated with worse long-term mortality at 5-years (HR 2.27, p = 0.012 and HR 2.02, p = 0.064). Worse all-cause mortality at 30-days, 1-year and 5-years were associated with high NT-Pro BNP levels (HR 1.04, p = 0.046; HR 1.05, p = 0.002 and HR 1.04, p < 0.001), the presence of peripheral arterial disease (PAD) (HR 4.32, p = 0.056; HR 4.48, p = 0.006 and HR 2.43, p = 0.023) and chronic kidney disease (CKD) (HR 6.19, p = 0.006; HR 6.77, p < 0.001 and HR 2.09, p = 0.008). Society of Thoracic Surgery (STS) score (HR 1.11, p = 0.001; HR 1.13, p < 0.001 and HR 1.12, p < 0.001) and Valve Academic Research Consortium (VARC) III endpoints of acute kidney injury (AKI) (HR 6.68, p = 0.047, HR 10.8, p < 0.001 and HR 6.99, p < 0.001), cardiogenic shock (HR 26.3, p < 0.001, HR 12.0, p < 0.001 and HR 4.29, p = 0.011) and structural complications (HR 40.3, p < 0.001, HR 18.1, p < 0.001 and HR 5.18, p = 0.008) were associated with worse all –cause mortality at time-points of 30-days, 1-year and 5-years respectively. On multivariate analyses adjusted for comorbidities and outcomes, STS score and structural complications were independent predictors of 30-day, 1-year, and 5-year all-cause mortality (HR 1.16; p = 0.003, HR 1.09, p = 0.003 and HR 1.10, p < 0.001) and (HR 62.7, p < 0.007; HR 18.9, p < 0.001 and HR 10.6, p = 0.001) respectively. Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) use was protective of survival within 1-year (HR 0.37, p = 0.022). Conclusions STS score and VARC III endpoints of structural complications were reliable predictors of all-cause mortality in Asian patients with TAVI. ACE inhibitor and ARB use was protective against mortality at 1-year.Cox regression analysesKaplan-Meier curves

BACKGROUND:Door-to-balloon time (DTBT) for ST-elevation myocardial infarction (STEMI) is a performance metric by which primary percutaneous coronary intervention (PPCI) services are assessed. METHODS:Consecutive patients presenting with STEMI undergoing PPCI between January 2007 to December 2019 from the Singapore Myocardial Infarction Registry were included. Patients were stratified based on DTBT (≤60 min, 61-90 min, 91-180 min) and Killip status (I-III vs. IV). Outcomes assessed included all-cause mortality and major adverse cardiovascular events (MACE) at 30-days and 1-year. RESULTS:In total, 13,823 patients were included, with 82.59% achieving DTBT ≤90 min and 49.77% achieving DTBT ≤60 min. For Killip I-III (n = 11,591,83.85%), the median DTBT was 60[46-78]min. The 30-day all-cause mortality for DTBT of ≤60 min, 61-90 min and 91-180 min was 1.08%, 2.17% and 4.33% respectively (p < 0.001). On multivariate analysis, however, there was no significant difference for 30-day and 1-year outcomes across all DTBT (p > 0.05). For Killip IV, the median DTBT was 68[51-91]min. The 30-day all-cause mortality for DTBT of ≤60 min, 61-90 min and 91-180 min was 11.74%, 20.48% and 35.06% respectively (p < 0.001). On multivariate analysis for 30-day and 1-year outcomes, DTBT 91-180 min was an independent predictor of worse outcomes (p < 0.05), but there was no significant difference between DTBT of ≤60 min and 61-90 min (p > 0.05). CONCLUSION:In Killip I-III patients, DTBT had no significant impact on outcomes upon adjustment for confounders. Conversely, for Killip IV patients, a DTBT of >90 min was associated with significantly higher adverse outcomes, with no differences between a DTBT of ≤60 min vs. 61-90 min. Outcomes in STEMI involve a complex interplay of factors and recommendations of a lowered DTBT of ≤60 min will require further evaluation.

In healthcare analytics, particularly when dealing with binary diagnosis or prognosis tasks, unique challenges arise from the inherent asymmetry between positive and negative samples. Positive samples, denoting patients who develop a disease, are defined based on stringent medical criteria. In contrast, negative samples are defined in an open-ended manner, leading to a vast potential set. Despite this fundamental asymmetry, the role of negative samples remains underexplored in prior research, possibly due to the enormous challenge of investigating an infinitely large negative sample space. To bridge this gap, we propose an innovative approach to facilitate cohort discovery within negative samples, leveraging a Shapley-based exploration of interrelationships between these samples, which holds promise for uncovering valuable insights concerning the studied disease, and related comorbidity and complications. We quantify each sample’s contribution using data Shapley values, subsequently constructing the Negative Sample Shapley Field to model the distribution of all negative samples. Next, we transform this field through manifold learning, preserving the essential data structure information while imposing an isotropy constraint in data Shapley values. Within this transformed space, we pinpoint cohorts of medical interest via density-based clustering. We empirically evaluate the effectiveness of our approach on our hospital’s electronic medical records. The medical insights derived from the discovered cohorts are validated by clinicians, which affirms the medical value of our proposal in unveiling meaningful insights aligning with existing domain knowledge, thereby bolstering medical research and well-informed clinical decision-making.

Background: Cardiogenic shock (CS) complicating myocardial infarction is associated with poor outcomes. Data among Asian populations are scarce. We aimed to investigate the long-term outcomes, prognostic factors, and predictors of CS among Asian ST elevation myocardial infarction (STEMI) patients. Methods: This was a retrospective cohort study of consecutive patients undergoing primary percutaneous coronary intervention (PPCI) for STEMI within our regional STEMI network between 2015 and 2019. The long-term outcomes of those with and without CS were compared. Clinical predictors of outcomes and development of CS were investigated. Results: A total of 1791 patients who underwent PPCI were included. Patients completed at least 2 years' follow-up with a median follow-up period of 2.6 years (IQR 1.0, 3,9). Overall, 208/1791 (11.6 %) STEMI patients developed CS. These patients were older (61.1 +/- 12.5 vs 57.8 +/- 12.2, P < 0.001) and mostly men (87.0 %). All-cause mortality (59.9 % vs 4.7 % P < 0.001), cardiac mortality (43.8 % vs 2.2 %, P < 0.001) and major adverse cardiovascular events (MACE) was significantly higher in the CS group (59.1 % vs 14.0 %, P < 0.001). Independent predictors of survival were higher index LVEF (adjusted hazards ratio [aHR] 0.967, 95 %CI 0.951-0.984, p < 0.001) and higher arterial pH at onset of shock (aHR 0.750, 0.626-0.897, p = 0.002). Increased serum lactate concentration independently predicts poor prognosis (aHR 1.084, 95 % CI 1.046-1.124, p < 0.001). Conclusion: In Asian STEMI patients who underwent PPCI, CS was associated with poor outcomes. Higher LVEF on index admission was associated with better outcomes; while lactic acidosis independently predicted mortality.

AIM:Patients with metabolic dysfunction-associated steatotic liver disease (MASLD) are at increased risk of incident cardiovascular disease. However, the clinical characteristics and prognostic importance of MASLD in patients presenting with acute myocardial infarction (AMI) have yet to be examined. METHODS:This study compared the characteristics and outcomes of patients with and without MASLD presenting with AMI at a tertiary centre in Singapore. MASLD was defined as hepatic steatosis, with at least one of five metabolic criteria. Hepatic steatosis was determined using the Hepatic Steatosis Index. Propensity score matching was performed to adjust for age and sex. The Kaplan-Meier curve was constructed for long-term all-cause mortality. Cox regression analysis was used to investigate independent predictors of long-term all-cause mortality. RESULTS:In this study of 4446 patients with AMI, 2223 patients with MASLD were matched with patients without MASLD using propensity scores. The mean follow-up duration was 3.4 ± 2.4 years. The MASLD group had higher rates of obesity, diabetes and chronic kidney disease than their counterparts. Patients with MASLD had early excess all-cause mortality (6.8% vs. 3.6%, p < .001) at 30 days, with unfavourable mortality rates sustained in the long-term (18.3% vs. 14.5%, p = .001) compared with those without MASLD. After adjustment, MASLD remained independently associated with higher long-term all-cause mortality (hazard ratio 1.330, 95% confidence interval 1.106-1.598, p = .002). CONCLUSION:MASLD embodies a higher burden of metabolic dysfunction and is an independent predictor of long-term mortality in the AMI population. Its early identification may be beneficial for risk stratification and provide therapeutic targets for secondary preventive strategies in AMI.

Abstract Introduction Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) is a mature, small B-cell lymphoma that typically co-expresses CD5 and CD23. Molecular-targeted therapies have produced remarkable therapeutic benefits in CLL, yet many patients are resistant to treatment. This study aims to identify subpopulations in CLL by conventional flow cytometry and clustering analysis. Methods One-hundred-and-forty-one CLL cases were taken from a public database and analyzed by uniform manifold approximation and projection (UMAP). Differences in size, granularity, and intensities of CD19, CD20, CD79a, CD5, CD23, CD10, and FMC7 were plotted with BD FACSDiva Software. Eighteen cases with a new diagnosis of CLL at our institution between January 1, 2021 to December 31, 2022 were analyzed. Only peripheral blood samples were included. Markers including forward scatter, side scatter, and fluorescent intensities of CD19, CD20, CD5, CD23, CD10, surface kappa, and surface lambda were used to identify discrete CLL clusters in UMAP plots. Results: Public Dataset Clustering analysis of conventional flow cytometry data from 141 cases from a public database reveals discrete populations of cells exhibiting varying sizes, granularity and fluorescent intensities. Among the 141 cases, 33 (23.4%) had 1 cluster, 64 (45.4%) with 2 clusters, 42 (29.8%) with 3 clusters and 2 (1.4%) with 4 clusters. Among the cases with 2 clusters, a smaller population of cells deviated from the main neoplastic population. This smaller population had a higher forward and side scatter, and brighter intensities in CD45 and CD19, consistent with prolymphocytes. Among the cases with 3 clusters, a third population recurrently had a smaller size by forward scatter. A few cases additionally had varying intensities by CD23 and CD19. Among the 2 cases with 4 clusters, only slight deviations by UMAP were seen and may be artifactual. Institutional Dataset Clustering analysis of 18 cases at our institution revealed complex patterns of cell clusters exhibiting varying sizes, granularity and surface receptor expression intensity. Among the 18 cases, 1 (5.6%) had 1 cluster, 1 (5.6%) with 2 clusters, 10 (55.6%) with 3 clusters, 3 (16.7%) with 4 clusters, and 3 (16.7%) with 5 clusters. Similar to the public dataset, the third population, in addition to the predominant population and prolymphocytes, consistently varied by lower forward scatter. Additional clusters, such as a population with varying CD23 signal intensities, were identified in some cases. Conclusions In our study, multiple clonal subsets in CLL/SLL are detected by conventional flow cytometry analysis. These subclonal populations may result in therapy resistance for these patients, and identifying them by flow cytometry analysis may provide additional prognostic information in the clinical setting. Furthermore, the ability to detect these subclonal populations may allow for isolation of specific clones for future investigation in research settings.

Background:Recent studies have shown potential in introducing machine learning (ML) algorithms to predict outcomes post-percutaneous coronary intervention (PCI). Aims:We aimed to critically appraise current ML models' effectiveness as clinical tools to predict outcomes post-PCI. Methods:Searches of four databases were conducted for articles published from the database inception date to 29 May 2021. Studies using ML to predict outcomes post-PCI were included. For individual post-PCI outcomes, measures of diagnostic accuracy were extracted. An adapted checklist comprising existing frameworks for new risk markers, diagnostic accuracy, prognostic tools and ML was used to critically appraise the included studies along the stages of the translational pathway: development, validation, and impact. Quality of training data and methods of dealing with missing data were evaluated. Results:Twelve cohorts from 11 studies were included with a total of 4,943,425 patients. ML models performed with high diagnostic accuracy. However, there are concerns over the development of the ML models. Methods of dealing with missing data were problematic. Four studies did not discuss how missing data were handled. One study removed patients if any of the predictor variable data points were missing. Moreover, at the validation stage, only three studies externally validated the models presented. There could be concerns over the applicability of these models. None of the studies discussed the cost-effectiveness of implementing the models. Conclusions:ML models show promise as a useful clinical adjunct to traditional risk stratification scores in predicting outcomes post-PCI. However, significant challenges need to be addressed before ML can be integrated into clinical practice.

Improved upstream primary prevention of cardiovascular disease (CVD) would enable more individuals to lead lives free of CVD. However, there remain limitations in the current provision of CVD primary prevention, where artificial intelligence (AI) may help to fill the gaps. Using the data informatics capabilities at the National University Health System (NUHS), Singapore, empowered by the Endeavour AI system, and combined large language model (LLM) tools, our team has created a real-time dashboard able to capture and showcase information on cardiovascular risk factors at both individual and geographical level- CardioSight. Further insights such as medication records and data on area-level socioeconomic determinants allow a whole-of-systems approach to promote healthcare delivery, while also allowing for outcomes to be tracked effectively. These are paired with interventions, such as the CHronic diseAse Management Program (CHAMP), to coordinate preventive cardiology care at a pilot stage within our university health system. AI tools in synergy allow the identification of at-risk patients and actionable steps to mitigate their health risks, thereby closing the gap between risk identification and effective patient care management in a novel CVD prevention workflow.

BACKGROUND:Cardiocerebral infarction (CCI), which is concomitant with acute myocardial infarction (AMI) and acute ischemic stroke (AIS), is a rare but severe presentation. However, there are few data on CCI, and the treatment options are uncertain. We investigated the characteristics and outcomes of CCI compared with AMI or AIS alone. METHODS:We performed a retrospective cohort study of 120 531 patients with AMI and AIS from the national stroke and AMI registries in Singapore. Patients were categorized into AMI only, AIS only, synchronous CCI (same-day), and metachronous CCI (within 1 week). The primary outcome was all-cause mortality, and the secondary outcome was cardiovascular mortality. The mortality risks were compared using Cox regression. Multivariable models were adjusted for baseline demographics, clinical variables, and treatment for AMI or AIS. RESULTS:Of 127 919 patients identified, 120 531 (94.2%) were included; 74 219 (61.6%) patients had AMI only, 44 721 (37.1%) had AIS only, 625 (0.5%) had synchronous CCI, and 966 (0.8%) had metachronous CCI. The mean age was 67.7 (SD, 14.0) years. Synchronous and metachronous CCI had a higher risk of 30-day mortality (synchronous: adjusted HR [aHR], 2.41 [95% CI, 1.77-3.28]; metachronous: aHR, 2.80 [95% CI, 2.11-3.73]) than AMI only and AIS only (synchronous: aHR, 2.90 [95% CI, 1.87-4.51]; metachronous: aHR, 4.36 [95% CI, 3.03-6.27]). The risk of cardiovascular mortality was higher in synchronous and metachronous CCI than AMI (synchronous: aHR, 3.03 [95% CI, 2.15-4.28]; metachronous: aHR, 3.41 [95% CI, 2.50-4.65]) or AIS only (synchronous: aHR, 2.58 [95% CI, 1.52-4.36]; metachronous: aHR, 4.52 [95% CI, 2.95-6.92]). In synchronous CCI, AMI was less likely to be managed with PCI and secondary prevention medications (P<0.001) compared with AMI only. CONCLUSIONS:Synchronous CCI occurred in 1 in 200 cases of AIS and AMI. Synchronous and metachronous CCI had higher mortality than AMI or AIS alone.

Background Given the rapidly growing burden of cardiovascular disease (CVD) in Asia, this study forecasts the CVD burden and associated risk factors in Asia from 2025 to 2050. Methods Data from the Global Burden of Disease 2019 study was used to construct regression models predicting prevalence, mortality, and disability-adjusted life years (DALYs) attributed to CVD and risk factors in Asia in the coming decades. Findings Between 2025 and 2050, crude cardiovascular mortality is expected to rise 91.2% despite a 23.0% decrease in the age-standardised cardiovascular mortality rate (ASMR). Ischaemic heart disease (115 deaths per 100,000 population) and stroke (63 deaths per 100,000 population) will remain leading drivers of ASMR in 2050. Central Asia will have the highest ASMR (676 deaths per 100,000 population), more than three-fold that of Asia overall (186 deaths per 100,000 population), while high-income Asia sub-regions will incur an ASMR of 22 deaths per 100,000 in 2050. High systolic blood pressure will contribute the highest ASMR throughout Asia (105 deaths per 100,000 population), except in Central Asia where high fasting plasma glucose will dominate (546 deaths per 100,000 population). Interpretation This forecast forewarns an almost doubling in crude cardiovascular mortality by 2050 in Asia, with marked heterogeneity across sub-regions. Atherosclerotic diseases will continue to dominate, while high systolic blood pressure will be the leading risk factor. Funding This was supported by the NUHS Seed Fund (NUHSRO/2022/058/RO5+6/Seed-Mar/03), National Medical Research Council Research Training Fellowship (MH 095:003/008-303), National University of Singapore Yong Loo Lin School of Medicine's Junior Academic Fellowship Scheme, NUHS Clinician Scientist Program (NCSP2.0/2024/NUHS/NCWS) and the CArdiovascular DiseasE National Collaborative Enterprise (CADENCE) National Clinical Translational Program (MOH-001277-01).

The authors present two cases of conjunctival pediatric- type follicular lymphoma. A 14-year-old Black boy and 14-year-old Black girl were each referred for evaluation of a painless salmon-colored conjunctival lesion. Both patients underwent excisional biopsy. Histopathology demonstrated follicles with germinal centers composed of atypical B-cells with high Ki67 proliferation index, positive staining for CD20, CD10, and BCL6, and negative for BCL2. This series contributes two cases to the limited literature and presents the first case reported in a female. [ J Pediatr Ophthalmol Strabismus. . 2024;61(4):e33-e38.]

Abstract Background Patients with obesity and metabolic dysfunction-associated steatotic liver disease (MASLD) have an increased risk of cardiovascular disease. This study seeks to examine the prognostic significance of obesity and MASLD in patients presenting with acute myocardial infarction (AMI). Methods This study compared the clinical characteristics and outcome of patients with and without obesity and MASLD at a tertiary centre in Singapore. Patients were stratified by their obesity and MASLD statuses into four groups. Obesity was defined as BMI ≥27.5. MASLD was defined as hepatic steatosis, which was determined using Hepatic Steatosis Index, and at least one of the five metabolic criteria. Cox regression analysis was used to investigate independent predictors of long-term all-cause mortality, adjusted for age, sex, ethnicity, previous AMI, AMI type, and left ventricular ejection fraction. Results A total of 5702 patients with AMI were included in this study. Among the cohort, 3803 were non-obese and without MASLD, 343 were non-obese with MASLD, 638 were obese without MASLD, and 918 were obese with MASLD. The mean follow-up duration was 3.1 ± 2.4 years. Non-obese patients with MASLD were most likely to develop complications of heart failure, cardiogenic shock, and stroke. On 30-day follow-up, there were no significant differences in all-cause mortality (p=0.312). However, on long-term follow-up, non-obese MASLD patients had the highest mortality (9.6%, p=0.019). After adjusting for confounders, patients who were non-obese with MASLD, and patients who were obese with MASLD, remained independently associated with higher long-term all-cause mortality (HR 1.400, 95% CI 1.077-1.820 and HR 1.222, 95% CI 1.005-1.485 respectively), with non-obese patients without MASLD as the reference. Conclusions This study demonstrates that regardless of obesity status, patients with MASLD have poorer outcomes in AMI. With its high metabolic burden, it is important to identify patients with MASLD for risk stratification and targeted treatment.Adjusted long-term all-cause mortality

Abstract Background Metabolic dysfunction-associated liver disease (MASLD) and chronic kidney disease (CKD) are both diseases that can cause increased cardiovascular risk. Recent studies have revealed that the combination of both is a more potent risk factor for ischemic heart disease. However, the mortality and outcomes of patients presenting with acute myocardial infarction (AMI) with varying combination of these two risk factors have yet to be examined. Aims Our research aims to examine the effects of concomitant MASLD and CKD on mortality in patients presenting with AMI. Methods This research examined the features and outcomes of individuals experiencing AMI at our institution. The patients were stratified into 4 groups – patients without MASLD or CKD (MASLD(-)/CKD(-)), patients with MASLD without CKD (MASLD(+)/CKD (-)), patients with CKD without MASLD (MASLD(-)/CKD(+)), and patients with both MASLD and CKD (MASLD(+)/CKD(+)). MASLD was identified as hepatic steatosis along with at least one of five metabolic criteria, and hepatic steatosis was assessed using the Hepatic Steatosis Index. CKD is defined as estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m². A Kaplan-Meier curve was generated to analyse long-term all-cause mortality, and Cox regression analysis was used to identify independent predictors of mortality. Results A total of 6757 patients who presented with AMI were examined over 3.2 ± 2.4 years. Of whom, 3766 (55.7%) individuals were in the MASLD(-)/CKD(-) group, 1945 (28.8%) in the MASLD(+)/CKD (-) group, 675 (10.0%) in the MASLD(-)/CKD(+) group and 371 (5.5%) in the MASLD(+)/CKD(+) group. The MASLD(+)/CKD(+) group had the highest risk of cardiogenic shock compared to their counterparts (p<0.001). The highest 30-day mortality rates were found in the MASLD(+)/CKD(+) group (17.8%), followed by MASLD(-)/CKD(+) (11.6%), MASLD(+)/CKD(-) (4.6%) and MASLD(-)/CKD(-) (4.0%) (p<0.001). In terms of long-term mortality, the Kaplan-Meier curve demonstrated that both MASLD(-)/CKD(+) and MASLD(+)/CKD(+) groups had unfavorable survival following an AMI. Conclusions Patients with AMI, in the presence of concomitant MASLD and CKD, had the highest 30-day mortality rates. They were at the highest risks of AMI-related complications such as heart failure and cardiogenic shock. This study highlights the prognostic impact of cardiovascular-liver-kidney-metabolic health on AMI, and future studies are warranted to mitigate this risk.Figure 1:30 – day all cause mortalityFigure 2:Long term mortality

BACKGROUND Right ventricular restrictive physiology (RVRP) is a common occurrence in repaired tetralogy of Fallot(rTOF). The relationship of RVRP with biventricular blood flow components and kinetic energy (KE) from 4-dimensional(4D)flow cardiovascular magnetic resonance (CMR) is unclear. OBJECTIVES The purpose of this study was to investigate the association of 4Dflow CMR parameters with RVRP inrTOF patients. METHODS A total of 103 rTOF patients and 62 age and sex-matched healthy control subjects were prospectively recruited. All participants underwent CMR (cine, 2-dimensional phase-contrast, and 4Dflow sequences), and cardio-pulmonary exercise test in adult populations. RVRP was identified from pulmonary artery flow curve using 2-dimensionalphase-contrast images. Biventricularflow components (direct flow, retained inflow, delayed ejection flow, and residual volume) and KE parameters normalized to end-diastolic volume (KEiEDV) were analyzed encompassing global, peaksystolic, average systolic, average diastolic, peak E-wave, and peak A-wave. RESULTS Compared with control subjects, rTOF patients had significantly lower RV direct flow and higher RV residual volume (bothP<0.001). All RV KEiEDV parameters, except peak A-wave, were higher in rTOF patients. In rTOF patients,70 of 103 (68%) had RVRP, with increasing RV direct flow (27% vs 20%;P<1/4>0.002) and RV peak E-wave KEiEDV(28.4 vs20.7mJ/mL;P 1/40.015) and decreasing RV residual volume (37% vs 42%;P 1/40.039) than rTOF without RVRP. Exercise capacity was impaired in rTOF, although comparable between RVRP subgroups. Multivariable analysis revealed RV direct flow was an independent predictor of RVRP (OR: 1.158; 95% CI: 1.074-1.249;P<0.001). CONCLUSIONS RVRP is associated with dilated RV, higher pulmonary regurgitation, and higher RV direct flow.(Integrated Computational modeling of Right Heart Mechanics and Blood Flow Dynamics in Congenital HeartDisease;NCT03217240) (JACC Asia. 2024;4:912-924) (c) 2024 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/)

Abstract Background We defined a novel noninvasive right ventricle (RV)–pulmonary artery (PA) coupling index as the ratio of cardiovascular magnetic resonance (CMR)-assessed RV direct flow (RVDF) and PA pulse wave velocity (PWV), and investigated its associations with exercise capacity and clinical risk in pulmonary arterial hypertension (PAH). Method 43 PAH patients (mean age 46±12 years, M:F 7:36) and 60 healthy volunteers (mean age 46±13 years, M:F 11:48) underwent CMR and cardiopulmonary exercise test (CPET) within one week. From cine CMR, RV ejection fraction (EF) and RV end-diastolic volume (RVEDV) were calculated using volumetric analysis; and tricuspid annular plane systolic excursion (TAPSE), feature tracking. PAPWV was the ratio of early systolic DPA flow and DPA area measured from instantaneous phase and magnitude through plane 2D flow CMR images across the pulmonary trunk, respectively. RVDF was the 4D flow CMR-assessed blood volume entering and exiting the RV in one cardiac cycle, indexed to RVEDV. RV-PA coupling was RVDF/PAPWV. Based on CPET-assessed peak oxygen consumption (PVO2), all 103 participants were stratified into two groups: PVO2>15 ml/kg/min; and PVO2≤15 ml/kg/min. Based on the REVEAL (Registry to Evaluate Early and Long-term PAH Disease Management) 2.0 score, the 43 PAH patients were stratified into low risk (score ≤6) and intermediate to high risk (score >6) groups. Results RVDF/PAPWV was significantly lower in PAH vs. controls (7.9 vs. 20.4 %/(m/s), P<0.001); and in PAH patients with intermediate to high risk vs. low risk (4.6 vs. 9.4 %/(m/s), P=0.001). On multivariable analyses, RVDF/PAPWV was an independent predictor of PVO2≤15 ml/kg/min (=0.302, P=0.001) among all participants, and of REVEAL 2.0 score >6 (=0.621, P=0.009) among PAH patients. Compared to RVEF and TAPSE, RVDF/PAPWV had numerically higher discrimination (p values non-significant based on Delong test) for PVO2≤15 ml/kg/min (AUC=0.914 vs. 0.872, 0.843); and among PAH patients, REVEAL 2.0 score >6 (AUC=0.851 vs. 0.723 and 0.728) (Figure). Conclusion CMR-derived noninvasive RVDF/PAPWV independently associates with exercise capacity and PAH clinical risk, supporting its utility as an imaging marker of disease progression and therapeutic response.

This study aim to investigate if remote intensive coaching for the first 6 months post-AMI will improve adherence to the twice-a-day antiplatelet medication, ticagrelor. Between July 8, 2015, to March 29, 2019, AMI patients were randomly assigned to remote intensive management (RIM) or standard care (SC). RIM participants underwent 6 months of weekly then two-weekly consultations to review medication side effects and medication adherence coaching by a centralized nurse practitioner team, whereas SC participants received usual cardiologist face-to-face consultations. Adherence to ticagrelor were determined using pill counting and serial platelet reactivity measurements for 12 months. A total of 149 (49.5

IntroductionObesity is an important risk factor for acute myocardial infarction (AMI), but the interplay between metabolic health and obesity on AMI mortality has been controversial. In this study, we aimed to elucidate the risk of short- and long-term all-cause mortality by obesity and metabolic health in AMI patients using data from a multi-ethnic national AMI registry.MethodsA total of 73,382 AMI patients from the national Singapore Myocardial Infarction Registry (SMIR) were included. These patients were classified into four groups based on the presence or absence of metabolic diseases, diabetes mellitus, hyperlipidaemia, and hypertension, and obesity: (1) metabolically-healthy-normal-weight (MHN); (2) metabolically-healthy-obese (MHO); (3) metabolically-unhealthy-normal-weight (MUN); and (4) metabolically-unhealthy-obese (MUO).ResultsMHO patients had reduced unadjusted risk of all-cause in-hospital, 30-day, 1-year, 2-year, and 5-year mortality following the initial MI event. However, after adjusting for potential confounders, the protective effect from MHO on post-AMI mortality was lost. Furthermore, there was no reduced risk of recurrent MI or stroke within 1-year from onset of AMI by the MHO status. However, the risk of 1-year mortality was higher in female and Malay AMI patients with MHO compared to MHN even after adjusting for confounders.ConclusionIn AMI patients with or without metabolic diseases, the presence of obesity did not affect mortality. The exception to this finding were female and Malay MHO who had worse long-term AMI mortality outcomes when compared to MHN suggesting that the presence of obesity in female and Malay patients may confer worsened outcomes.