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Introduction: Recent reports on COVID-19 patients have shown that elevated troponin (Tn) levels on hospital admission are associated with adverse outcomes. However, no data exists on the predictive role of Tn kinetics parameters in COVID-19 patients. Aim: To analyze the incidence, clinical outcomes and predictors of Tn kinetics parameter, including rise/fall pattern and peak values, in a large cohort of COVID-19 hospitalized patients. Methods: All consecutive patients admitted to an urban tertiary-care health system between February and June 2020 with COVID-19 were included. Patients were grouped according to presence of myocardial injury defined as a high-sensitivity TnI level ≥0.1 ng/ml. A TnI level between 0.4-0.99 was defined as low positive range Tn elevation. Results: We included 5862 COVID-19 patients, 1558 (27%) of whom experienced myocardial injury. Advance age, male sex and higher comorbidity burden, including COPD, hypertension, CAD, atrial fibrillation, HF, CKD, and diabetes were more common in patients with myocardial injury. A total of 828/1558 (53.2%) of patients with myocardial injury died as compared to 634/4304 (14.7%) of those without (OR 6.57, 95% CI 5.76-7.48; p Conclusions: Myocardial injury is an independent predictor of all-cause mortality in COVID-19 patients,with a stepwise increase in the risk of mortality reflecting increasing extent of myocardial damage.

Introduction: Despite the increasing number of complex percutaneous coronary interventions (CPCI), data regarding outcomes following CPCI in patients with diabetes mellitus (DM) are scarce. Hypothesis: Compared to the general population, diabetic patients undergoing CPCI have worse prognosis. Methods: We analyzed data of patients who underwent PCI in a tertiary-care center between 2009 and 2017. Patients were divided into 2 groups (CPCI and non-CPCI) stratified by presence of DM. CPCI was defined as having ≥1 of the following: stent length >60 mm, ≥3 stents implanted, ≥3 lesions, ≥3 target vessels, bifurcation with ≥2 stents, or chronic total occlusion. The main outcome was major adverse cardiac events (MACE), a composite of death, myocardial infarction (MI) and target vessel revascularization (TVR) at 1 year. Results: Out of 20,412 patients included, 5,038 (24.7%) underwent CPCI. Patients with DM constituted 46.5% (n=9,494) of the overall cohort and 44.5% (n=2,240) of CPCI group. Among patients undergoing CPCI, diabetics were younger, more likely to be female, and had more cardiovascular risk factors (kidney disease, dyslipidemia, and hypertension) than non-diabetics. In addition, diabetic patients had more advanced coronary disease (multivessel disease, high syntax score, and longer lesion length). At 1 year, diabetic patients had higher risk of MACE than non-diabetic, regardless of PCI complexity ( Figure 1 ). Nonetheless, there was a significant interaction between CPCI and diabetes in terms of mortality at 1 year (p-interaction=0.009). In contrast, compared to non-diabetics, a higher risk of TVR ( adj HR 1.49, 95% CI [1.24 - 1.78], p adj HR 1.45, 95% CI [1.05 - 1.98], p=0.02) was observed in diabetics undergoing non-CPCI but not CPCI. Conclusion: Diabetic patients are at higher risk of MACE than the general population regardless of PCI complexity. Yet, 1-year mortality is substantially higher in diabetics undergoing CPCI than non-CPCI.

Introduction: Prognosis in high-bleeding risk (HBR) patients after percutaneous coronary intervention (PCI) is largely dependent on risk of ischemic/bleeding events. Inflammation is known to increase the ischemic risk following PCI in the general population, yet its impact on HBR patients remains unknown. Hypothesis: We assessed the hypothesis that inflammation, as reflected by elevated high-sensitivity C - reactive protein (hsCRP), increases the risk of ischemic and bleeding events in HBR patients undergoing PCI. Methods: We included patients who underwent PCI at a tertiary care center between 2014 and 2017. Patients were classified as HBR if they met ≥1 major or ≥2 minor criteria according to the Academic Research Consortium (ARC)-HBR consensus. Patients were then stratified into high (≥3 mg/l) and low (10 mg/l were excluded. The main outcomes of interest were major adverse cardiac events (MACE) (composite of all-cause death, MI, and target vessel revascularization) and bleeding events. Results: Out of 7,186 patients included, 3,403 (42.3%) fulfilled the ARC-HBR definition of whom 1,046 (34.4%) had high hsCRP. These patients were frequently female, younger, and had more cardiovascular risk factors (diabetes, kidney disease, and peripheral artery disease) yet similar angiographic features (multivessel disease, syntax score, and lesion length) than those with low hsCRP. Although risk of MACE at 1 year was similar in HBR patients with either high or low hsCRP, mortality risk was significantly higher in the former group ( Figure 1 ). In addition, HBR patients with high hsCRP were more likely to have periprocedural bleeding (OR 1.72, 95% CI [1.14-2.58], p=0.01) but similar risk of 1-year major bleeding as HBR patients with low hsCRP ( Figure 1 ). Conclusion: In conclusion, inflammation is associated with periprocedural bleeding and 1-year mortality in HBR patients undergoing PCI.

Introduction: Cardiovascular disease is the leading cause of mortality worldwide, irrespective of race/ethnicity. Previous studies reported that minority patients with ACS have distinct clinical, genetic and socioeconomic backgrounds that may affect clinical outcomes. Hypothesis: To investigate post percutaneous coronary intervention (PCI) outcomes according to race/ethnicity in a contemporary ACS population. Methods: We included consecutive patients undergoing drug-eluting stent implantation for STEMI, non-STEMI or unstable angina (UA) between 2012-2017. The study population was stratified into Caucasian, African American, Hispanic and Asian. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE) defined as a composite of death, spontaneous myocardial infarction or stroke at 1 year. Results: Of the 6800 patients included, 3377 (49.7%) were Caucasian, 1408 (20.7%) Hispanic, 1156 (17.0%) Asian and 859 (12.6%) African American. Caucasians were the oldest, Hispanics and Asians had the highest prevalence of diabetes mellitus (DM) and African Americans had more insulin dependent DM and chronic kidney disease. Hispanics and African Americans had the highest STEMI rate, while Asians were more likely to present with UA, have private insurance and be discharged on aspirin and clopidogrel. Compared to Caucasians, Asians had a lower rate of MACCE at 1 year (3.9% vs. 7.1%; p Conclusions: Among patients undergoing PCI for ACS, Asian race is associated with favorable cardiovascular outcomes compared to Caucasian. No significant differences were observed for Hispanics and African Americans.

Introduction: Perioperative cardiovascular events are an important cause of morbidity and mortality associated with non-cardiac surgery (NCS), especially in patients with recent percutaneous coronary intervention (PCI) who require dual antiplatelet therapy. Objective: To illustrate the types and timing of different noncardiac surgeries occurring within 1 year of PCI, and to evaluate the risk of thrombotic and bleeding events according to perioperative antiplatelet management. Methods: All patients undergoing NCS within 1 year of PCI at a tertiary-care center between 2011 and 2018 were included. The primary outcome was major adverse cardiac events (MACE; composite of death, myocardial infarction, stent thrombosis or target vessel revascularization). The key secondary outcome was major bleeding, defined as ≥2 units of blood transfusion. All outcomes were evaluated at 30 days after NCS. Results: A total of 1092 NCS (corresponding to 747 patients) were included and classified by surgical risk (low: 50.9%, intermediate: 38.4%, high: 10.7%) and priority (elective: 88.5%, urgent/emergent: 11.5%). High-risk and urgent/emergent surgeries tended to occur earlier post-PCI compared to low-risk and elective ones ( Figure-A ). The incidence of MACE and bleeding was time-dependent, with an increased risk in surgeries occurring in the first 6 months post-PCI ( Figure-B ). Perioperative antiplatelet cessation occurred in 487 (44.6%) NCS and was more likely for intermediate-risk procedures and after 6 months of PCI. There was no significant association between antiplatelet cessation and cardiac events. Conclusions: Among patients undergoing NCS within 1 year of PCI, the perioperative risk of MACE is inversely related to time from PCI. Preoperative interruption of antiplatelet therapy was observed in less than half of all cases and was not associated with an increased risk of cardiac events.

Background: Insulin treated diabetes mellitus (ITDM) is associated with more extensive atherosclerotic disease and worse cardiovascular prognosis compared to non-ITDM patients. Hypothesis: We sought to examine 1-year outcomes in ITDM and non-ITDM patients compared to non-DM patients following contemporary percutaneous coronary intervention (PCI). Methods: We followed consecutive patients undergoing PCI at a large tertiary center from 2009-2016. Prospectively collected data were retrospectively examined. Patients were grouped based on DM and treatment status at baseline. 1-year outcomes were analyzed in a time to event manner and adjusted using multivariable Cox regression methods. Major adverse cardiovascular events (MACE) were defined as a composite of death, myocardial infarction (MI) or target vessel revascularization (TVR). Results: During the study period, 16,889 patients underwent PCI including 13.7% (n=2313) ITDM, 34.0% non-ITDM (n=5737) and 52.3% non-DM (n=8839) patients. ITDM and non-ITDM patients were younger than non-DM patients, with greater prevalence of females and non-white patients, higher body mass index and greater prevalence of prior revascularization and chronic kidney disease. ITDM patients were more likely to present with stable angina compared to others. With respect to angiographic characteristics, the prevalence of B2/C type lesions was similar between the groups. At 1-year, both ITDM and non-ITDM patients had greater risk of 1-year MACE and MI compared to non-DM patients, however ITDM patients had significantly higher rates of MACE, death, MI, and TLR ( figure ). Conclusions: The negative prognostic effect of DM following contemporary PCI is heightened in the presence of insulin treatment, compared to non-DM patients, despite use of contemporary PCI techniques and use of new generation DES.

Introduction: New Generation drug eluting stents (DES) have overcome the limitations of bare metal stents and first generation DES resulting in lower risk of ischemic events in women. Hypothesis: We sought to compare increasing total stent length per patient for 3-yr outcomes in DM and non-DM women after percutaneous coronary intervention (PCI) with new generation DES. Methods: The WIN-DES collaboration is a pooled database of women undergoing PCI with coronary stents in 26 randomized trials. We compared total stent length per patient treated with new generation DES in quartiles (Among DM - Q1: 8-18mm, Q2: 18-24mm, Q3: 24-38mm and Q4: 38+mm; among non-DM Q1: 8-18mm, Q2: 18-24mm, Q3: 24-36mm and Q4: 36+mm). 3-yr outcomes were analyzed in a time to event manner and adjusted using multivariable methods. Major adverse cardiovascular events (MACE) were defined as a composite of death, myocardial infarction (MI) or target lesion revascularization (TLR). Results: The study sample comprised 5403 patients, of which 31.8% (n = 1719) had DM. In both DM and non-DM groups, patients in Q4 had greater prevalence of B2/C type and calcified lesions with smaller stent diameter compared to others. 3-yr MACE increased from Q1-Q4 in DM and non-DM patients, albeit DM patients experienced higher event rates ( Figure ). After multivariable adjustment, findings were unchanged, and increasing stent length remained associated with greater risk of 3-yr MACE in DM (p-trend=0.003) and non-DM (p-trend Conclusions: Despite the use of new generation DES, increasing total stent length per patient was associated with greater risk of MACE in both DM and non-DM women undergoing PCI. Women with DM experienced worse outcomes, and a greater risk of TLR regardless of total stent length. Meticulous attention to stent optimization and post PCI pharmacotherapy is needed to mitigate long-term adverse outcomes in women.

Background: Relative risk reduction with statin therapy has been consistent across nearly all subgroups studied to date. However, in analyses of 2 randomized controlled primary prevention trials (ASCOT [Anglo-Scandinavian Cardiac Outcomes Trial–Lipid-Lowering Arm] and JUPITER [Justification for the Use of Statins in Prevention: An Intervention Trial Evaluating Rosuvastatin]), statin therapy led to a greater relative risk reduction among a subgroup at high genetic risk. Here, we aimed to confirm this observation in a third primary prevention randomized controlled trial. In addition, we assessed whether those at high genetic risk had a greater burden of subclinical coronary atherosclerosis. Methods: We studied participants from a randomized controlled trial of primary prevention with statin therapy (WOSCOPS [West of Scotland Coronary Prevention Study]; n=4910) and 2 observational cohort studies (CARDIA [Coronary Artery Risk Development in Young Adults] and BioImage; n=1154 and 4392, respectively). For each participant, we calculated a polygenic risk score derived from up to 57 common DNA sequence variants previously associated with coronary heart disease. We compared the relative efficacy of statin therapy in those at high genetic risk (top quintile of polygenic risk score) versus all others (WOSCOPS), as well as the association between the polygenic risk score and coronary artery calcification (CARDIA) and carotid artery plaque burden (BioImage). Results: Among WOSCOPS trial participants at high genetic risk, statin therapy was associated with a relative risk reduction of 44% (95% confidence interval [CI], 22–60; P P =0.004) despite similar low-density lipoprotein cholesterol lowering. In a study-level meta-analysis across the WOSCOPS, ASCOT, and JUPITER primary prevention, relative risk reduction in those at high genetic risk was 46% versus 26% in all others ( P for heterogeneity=0.05). Across all 3 studies, the absolute risk reduction with statin therapy was 3.6% (95% CI, 2.0–5.1) among those in the high genetic risk group and 1.3% (95% CI, 0.6–1.9) in all others. Each 1-SD increase in the polygenic risk score was associated with 1.32-fold (95% CI, 1.04–1.68) greater likelihood of having coronary artery calcification and 9.7% higher (95% CI, 2.2–17.8) burden of carotid plaque. Conclusions: Those at high genetic risk have a greater burden of subclinical atherosclerosis and derive greater relative and absolute benefit from statin therapy to prevent a first coronary heart disease event. Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique identifiers: NCT00738725 (BioImage) and NCT00005130 (CARDIA). WOSCOPS was carried out and completed before the requirement for clinical trial registration.

Background: Obesity is associated with increased cardiovascular risk. Paradoxically, however, patients with higher body mass index (BMI) might have better outcomes after acute coronary syndrome treated with percutaneous coronary intervention (PCI). The effect of different BMI categories on long-term cardiac outcomes in women receiving drug-eluting stents (DES) has not been well characterized. Methods: We pooled patient-level data for female participants from 26 randomized trials of DES in patients with coronary artery disease. Patients were stratified according to BMI category in BMI &lt 25 (normal weight), 25 to 30 (overweight), &gt 30 to 35 (obese) or &gt 35 (Morbidly obese). Primary endpoint was major adverse cardiac events (MACE), defined as the composite of death, myocardial infarction or target lesion revascularization. Secondary endpoint was all-cause mortality. Results: From 11,557 women included in the pooled database, 9,420 had received DES and had BMI data available. Patients with higher BMI were significantly younger and more likely to have hypertension, hyperlipidemia and diabetes mellitus. However, they exhibited lower anatomical and procedural complexity. There were no differences in crude 3-year MACE rates across the 4 groups (14.6% vs. 12.9% vs. 14% vs. 13.2%; p = 0.34) but normal BMI group was associated with increased all-cause mortality (5.9% vs. 4.0% vs. 4.2% vs. 4.5%; p = 0.01). Following multivariable adjustment the 3-year risk of MACE progressively decreased with increase in BMI category (HR: 0.76, 95% CI: 0.61 - 0.94; HR: 0.71, 95% CI: 0.54 - 0.92; HR: 0.52, 95% CI: 0.38 - 0.73; p &lt 0.001; for overweight, obese and severely obese, respectively). Similarly, risk of 3-year mortality independently decreased in all BMI categories compared with normal BMI (HR: 0.41, 95% CI: 0.28 - 0.61; HR: 0.51, 95% CI: 0.32 - 0.80; HR: 0.48, 95% CI: 0.28 - 0.81; for overweight, obese and severely obese, respectively, p &lt 0.001). Conclusion: Following PCI with DES, lower rather than higher BMI appears to be associated with higher risk of cardiac events and mortality. The reason for this paradoxical effect of obesity is not clear but may include unknown or unmeasured confounding variables or more aggressive therapies.

Introduction: Sedentary behavior (SB) has been associated with an increased risk of cardiovascular disease (CVD) in high-income countries. However, the burden and impact of SB in low- and middle-income countries is not well known. This study examined self-reported sedentary behavior and the association with CVD risk in Grenada, a middle-income country. Methods: A modified WHO STEPS survey was administered to a random sample of the Grenadian adult population, and sedentary behavior was assessed. Participants were asked to quantify the amount of time per day spent sitting (at home or work), reclining (excluding during sleep), or traveling in a vehicle. SB was assessed in hourly intervals and also grouped into two categories: 3 hours or less (approximately two thirds of the sample) and greater than 3 hours (approximately one third). Frequency of SB was compared across gender (age-standardized), age, and education groups. The relationship between SB and log-transformed 10-year CVD risk (Framingham) was evaluated using multivariable linear regression. Statistical analyses were performed using STATA v. 10. Results: Of 2622 participants, 32.4% reported greater than 3 hours per day of SB. SB was more common among men, among the youngest (age 18-29) and oldest (age 70+) individuals, and among those with higher education ( Table ). In univariate analysis, SB was adversely associated with 10-year CVD risk (p Conclusions: Sedentary behavior in Grenada is more common among men, extremes of age, and higher education levels. Increased SB is not independently associated with 10-year CVD risk when controlling for gender, age and education. This is in contrast to findings in high-income countries. These results call for further exploration of the patterns of sedentary behavior, an emerging health issue in low- and middle-income countries, and its effect on CVD risk. Table Frequency of reported sedentary behavior (figures are %; all p-values within groups N Greater than 3 hours per day Gender Men 1129 35.2 * Women 1493 30.3 * Age (years ) ≤18-29 634 39.1 30-39 428 30.6 40-49 580 23.6 50-59 448 28.1 60-69 249 28.1 ≥70 283 48.4 Education No schooling to Primary 1532 29.0 Secondary School 639 34.7 Post Graduate 419 39.9 * Age-standardized rates