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Cardiovascular disease is the leading cause of death in women. Decades of grassroots campaigns have helped to raise awareness about the impact of cardiovascular disease in women, and positive changes affecting women and their health have gained momentum. Despite these efforts, there has been stagnation in the overall reduction of cardiovascular disease burden for women in the past decade. Cardiovascular disease in women remains understudied, under-recognised, underdiagnosed, and undertreated. This Commission summarises existing evidence and identifies knowledge gaps in research, prevention, treatment, and access to care for women. Recommendations from an international team of experts and leaders in the field have been generated with a clear focus to reduce the global burden of cardiovascular disease in women by 2030. This Commission represents the first effort of its kind to connect stakeholders, to ignite global awareness of sex-related and gender-related disparities in cardiovascular disease, and to provide a springboard for future research.

Key Points Approximately 50% of patients with ST-segment elevation myocardial infarction (STEMI) have multivessel disease Whether patients with STEMI and multivessel disease should receive percutaneous coronary intervention (PCI) of only the culprit vessel or complete revascularization, either in a simultaneous or staged approach, remains uncertain Increasing evidence from randomized controlled trials suggests that multivessel PCI is safe or even beneficial in selected patients, compared with culprit vessel-only PCI Results from adequately-powered randomized controlled trials are still needed to determine the optimal reperfusion strategy in patients with STEMI and multivessel disease The optimal reperfusion strategy in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease is still uncertain. In this Review, Mehran and colleagues discuss the available evidence on the different treatment options for patients with STEMI and multivessel disease, highlighting current guideline recommendations and providing future directions on reperfusion strategies in these patients. Approximately 50% of patients with ST-segment elevation myocardial infarction (STEMI) have multivessel disease. The optimal reperfusion strategy in these patients is still uncertain. Whether percutaneous coronary intervention (PCI) of only the culprit vessel or a strategy of complete revascularization, either in a simultaneous or staged multivessel PCI approach, should be performed remains unclear. Although a large number of observational studies have mostly shown worse clinical outcomes associated with a multivessel PCI approach, increasing evidence from randomized controlled trials suggests that multivessel PCI is safe, while reducing the need for revascularization in selected patients, compared with culprit vessel-only PCI. However, adequately-powered studies are still needed to determine the best treatment strategy in patients with STEMI and multivessel disease, particularly to demonstrate a reduction in the hard end point of death or myocardial infarction. In this Review, we provide a comprehensive summary of current evidence on the different treatment options for patients with STEMI and multivessel disease, highlighting current guideline recommendations and providing future directions on reperfusion strategies in these patients.

Atherosclerosis and plaque disruption have a central pathological role in the majority of patients who present with an acute coronary syndrome (ACS), but non-atherosclerotic processes are also important contributors to a substantial number of ACS events and require different diagnostic and therapeutic strategies. In the absence of obstructive coronary artery disease, intravascular imaging techniques might be needed to delineate the underlying aetiology, together with a high index of suspicion for other important causes of ACS. In this Review, we discuss five non-atherosclerotic causes of ACS, including spontaneous coronary artery dissection, coronary artery embolism, vasospasm, myocardial bridging and stress-induced cardiomyopathy (Takotsubo syndrome). Important diagnostic findings, management strategies and prognostic data for these non-atherosclerotic mechanisms of ACS are reviewed.Non-atherosclerotic processes are important contributors to a substantial number of acute coronary syndrome events. In this Review, Gulati and colleagues discuss the diagnosis, management and prognosis of patients with spontaneous coronary artery dissection, coronary artery embolism, vasospasm, myocardial bridging or stress-induced cardiomyopathy (Takotsubo syndrome).

ST-segment elevation myocardial infarction (STEMI) is the most acute manifestation of coronary artery disease and is associated with great morbidity and mortality. A complete thrombotic occlusion developing from an atherosclerotic plaque in an epicardial coronary vessel is the cause of STEMI in the majority of cases. Early diagnosis and immediate reperfusion are the most effective ways to limit myocardial ischaemia and infarct size and thereby reduce the risk of post-STEMI complications and heart failure. Primary percutaneous coronary intervention (PCI) has become the preferred reperfusion strategy in patients with STEMI; if PCI cannot be performed within 120 minutes of STEMI diagnosis, fibrinolysis therapy should be administered to dissolve the occluding thrombus. The initiation of networks to provide around-the-clock cardiac catheterization availability and the generation of standard operating procedures within hospital systems have helped to reduce the time to reperfusion therapy. Together with new advances in antithrombotic therapy and preventive measures, these developments have resulted in a decrease in mortality from STEMI. However, a substantial amount of patients still experience recurrent cardiovascular events after STEMI. New insights have been gained regarding the pathophysiology of STEMI and feed into the development of new treatment strategies. ST-segment elevation myocardial infarction (STEMI) is an acute coronary syndrome in which transmural ischaemia (mostly caused by the formation of a thrombus on a ruptured atherosclerotic plaque) leads to cardiomyocyte death. STEMI is associated with considerable morbidity and mortality worldwide.

The distributed blocking flowshop scheduling problem (DBFSP) with new job insertions is studied. Rescheduling all remaining jobs after a dynamic event like a new job insertion is unreasonable to an actual distributed blocking flowshop production process. A deep reinforcement learning (DRL) algorithm is proposed to optimise the job selection model, and local modifications are made on the basis of the original scheduling plan when new jobs arrive. The objective is to minimise the total completion time deviation of all products so that all jobs can be finished on time to reduce the cost of storage. First, according to the definitions of the dynamic DBFSP problem, a DRL framework based on multi‐agent deep deterministic policy gradient (MADDPG) is proposed. In this framework, a full schedule is generated by the variable neighbourhood descent algorithm before a dynamic event occurs. Meanwhile, all newly added jobs are reordered before the agents make decisions to select the one that needs to be scheduled most urgently. This study defines the observations, actions and reward calculation methods and applies centralised training and distributed execution in MADDPG. Finally, a comprehensive computational experiment is carried out to compare the proposed method with the closely related and well‐performing methods. The results indicate that the proposed method can solve the dynamic DBFSP effectively and efficiently.

Data on percutaneous coronary intervention (PCI) for left main coronary artery (LMCA) disease in patients of diverse race/ethnicity are scant. This study aimed to assess the impact of race/ethnicity on clinical outcomes at 12-month follow-up of patients with LMCA disease who underwent PCI with drug-eluting stent implantation. All patients who underwent PCI for LMCA disease between 2010 and 2019 at a tertiary care center were prospectively enrolled. Clinical outcomes were assessed per each race/ethnic group. The primary end point was the composite of all-cause death, myocardial infarction, or stroke at 12 months. A total of 774 consecutive patients with known race/ethnicity were prospectively enrolled (62.1% [n = 481] Caucasian, 17.2% [n = 133] Hispanic, 12.7% [n = 98] Asian, and 8.0% [n = 62] African-American). Compared with Caucasians, the hazard rate of the primary end point tended to be lower in Asian patients (6.1% vs 14.2%; hazard ratio [HR] 0.41, 95% confidence interval [CI] 0.16 to 1.03) and similar in African-American (13.7% vs 14.2%; HR 0.93, 95% CI 0.40 to 2.16) and Hispanic patients (14.2% vs 14.2%; HR 1.02, 95% CI 0.58 to 1.78). Hazard rates of target vessel or lesion revascularization were comparable among the 4 groups. Cox multivariable regression adjustment confirmed consistent findings and revealed higher hazard rates of postdischarge bleeding in African-Americans compared with Caucasians (HR 5.89, 95% CI 1.00 to 34.5). In conclusion, within a racially/ethnically diverse cohort of patients who underwent PCI for LMCA disease, when compared with Caucasians, Asians had lower risk of all-cause death, myocardial infarction, or stroke, whereas African-Americans had increased risk of postdischarge bleeding.

Background We investigated the association of insulin resistance (IR) with coronary plaque morphology and the risk of cardiovascular events in patients enrolled in the Providing Regional Observations to Study Predictors of Events in Coronary Tree (PROSPECT) study. Methods Patients with acute coronary syndromes (ACS) were divided based on DM status. Non-DM patients were further stratified according to homeostasis-model-assessment IR (HOMA-IR) index as insulin sensitive (IS; HOMA-IR ≤ 2), likely-IR (LIR; 2 < HOMA-IR < 5), or diabetic-IR (DIR; HOMA-IR ≥ 5). Coronary plaque characteristics were investigated by intravascular ultrasound. The primary endpoint was major adverse cardiac events (MACE); a composite of cardiac death, cardiac arrest, myocardial infarction, and rehospitalization for unstable/progressive angina. Results Among non-diabetic patients, 109 patients (21.5%) were categorized as LIR, and 65 patients (12.8%) as DIR. Patients with DIR or DM had significantly higher rates of echolucent plaque compared with LIR and IS. In addition, DIR and DM were independently associated with increased risk of MACE compared with IS (adjusted hazard ratio [aHR] 2.29, 95% confidence interval [CI] 1.22–4.29, p = 0.01 and aHR 2.12, 95% CI 1.19–3.75, p = 0.009, respectively). Conclusions IR is common among patients with ACS. DM and advanced but not early stages of IR are independently associated with increased risk of adverse cardiovascular events. Trial Registration ClinicalTrials.gov Identifier: NCT00180466.

The dependability characteristic of the control software of manufacturing systems is highlighted more than before, going through repeated changes to cope with various and varying requirements. Formal methods are researched to be applied to automation system engineering to obtain a more effective and efficient quality assurance. One of the approaches, a formal specification language named Generalised Test Tables has been developed with the aim of intuitiveness and accessibility for automation application developers. The result of the experiments conducted to assess the usability of this language is presented here. Focussing on evaluating effectiveness and user satisfaction, three paper‐based experiments have been conducted with students at the bachelor and master level. The evaluation results point to positive usability in both comparative effectiveness to conventional language, that is, Petri Nets, and subjective perception of user satisfaction.

The Cyber-Physical Production System (CPPS) is a concept derived from software (cyber) and hardware (physical) applications and is based on global information exchange between such systems. The CPPS is known as a trend of Industry 4.0 (I4.0) focusing on flexibility regarding new products and adaptability to new requirements. This paper focuses on two I4.0 scenarios described by the Platform Industrie 4.0 that describe challenges for the industry towards its digital future. First, it looks at the Order Controlled Production (OCP) scenario that deals with flexible and self-configuring production networks. It describes the dynamic organization of production resources required to execute a production order. Second, the Adaptable Factory (AF) application scenario is discussed, which focuses on the configuration of production resources and describes the adaptability of an individual facility through (physical) modification. This paper first provides a detailed analysis of the requirements from these scenarios. Furthermore, it analyses the current Multi-Agent System (MAS) architectures and agent-based planning and decision support systems requirements. MAS can be used to create application-independent I4.0 systems with arbitrary hardware automation platforms. To create a scalable communication network that also supports application independence and enables the semantically machine-readable description of the exchanged data, the OPC UA standard was adopted. As a result of the study, the concept shows how different and independent automation platforms can be seamlessly connected via OPC UA. The proposed MAS concept has been evaluated in different use cases, namely OCP and AF.

Liquid leakage from pipelines is a critical issue in large-scale chemical process plants since it can affect the normal operation of the plant and pose unsafe and hazardous situations. Therefore, leakage detection in the early stages can prevent serious damage. Developing a vision-based inspection system by means of IR imaging can be a promising approach for accurate leakage detection. IR cameras can capture the effect of leaking drops if they have higher (or lower) temperature than their surroundings. Since the leaking drops can be observed in an IR video as a repetitive phenomenon with specific patterns, motion pattern detection methods can be utilized for leakage detection. In this paper, an approach based on the Kalman filter is proposed to track the motion of leaking drops and differentiate them from noise. The motion patterns are learned from the training data and applied to the test data to evaluate the accuracy of the method. For this purpose, a laboratory demonstrator plant is assembled to simulate the leakages from pipelines, and to generate training and test videos. The results show that the proposed method can detect the leaking drops by tracking them based on obtained motion patterns. Furthermore, the possibilities and conditions for applying the proposed method in a real industrial chemical plant are discussed at the end.