bluuebunny/crossref_metadata_2025 huggingface dataset:
PARADISE-MI – event rates and treatment effect of sacubitril/valsartan v ramipril by the presence or absence of transient pulmonary congestion and/or LVEF less or greater than 40
Authors: Petrie M , Solomon S , Claggett B L , Jering K , Steg G , Granger C , Lewis E , Kober L , Mann D , Rouleau J L , McMurray J J , Maggioni A , Braunwald E , Pfeffer M A
Published: October 2022

Background/Introduction

Sacubitril/valsartan was compared to ramipril in patients with acute myocardial infarction in the PARADISE-MI trial. In the whole trial population sacubitril/valsartan did not reduce the composite primary outcome of CV death or incident heart failure compared to ramipril. Whether or not event rates and/or treatment effects vary in patients with different baseline characteristics is unknown.

Purpose

To investigate a) event rates b) the treatment effect of sacubitril/valsartan compared to ramipril and c) safety by the presence or absence of transient pulmonary congestion and/or left ventricular ejection fraction (LVEF) ≤40%.

Methods

PARADISE-MI was a double-blind, randomised clinical trial that compared sacubitril/valsartan to ramipril in 5661 patients with an acute myocardial infarction with either LVEF ≤40% and/or transient pulmonary congestion. 3 groups were investigated: 1) LVEF ≤40% with pulmonary congestion (n=2012) and 2) LVEF ≤40% without pulmonary congestion (n=2596) and 3) LVEF not ≤40% with pulmonary congestion (n=1044).

Results

Patients with pulmonary congestion (with and without LVEF ≤40%) were more likely to have had a prior MI, prior CABG or PCI, had more atrial fibrillation and were more often treated with mineralocorticoid receptor antagonists and diuretics than patients with no pulmonary congestion and LVEF ≤40%. Patients with LVEF ≤40% and pulmonary congestion had more than twice the rate of the primary composite outcome compared to those with LVEF ≤40% without pulmonary congestion: 10.2 (95% CI 9.2–11.3) vs. 4.8 (4.3–5.5) events per 100 patient-years, respectively). Patients with pulmonary congestion and LVEF not ≤40% had an intermediate event rate (6.6, 5.5–7.9, events per 100 patient-years). A similar pattern of event rates was seen for the components of the primary outcome and for all secondary outcomes whether Clinical Events Committee or investigator-reported events were analysed. The treatment effect of sacubitril/ valsartan versus ramipril did not vary between the 3 congestion/ LVEF subgroups. The safety of sacubitril/valsartan compared to ramipril did not vary between congestion/LVEF subgroups.

Conclusion

Patients with pulmonary congestion with or without LVEF ≤40% had higher rates of primary and all secondary outcomes than those without pulmonary congestion and LVEF ≤40%. The treatment effect, and safety, of sacubitril/valsartan compared to ramipril was consistent in patients with or without pulmonary congestion and with or without LVEF ≤40%.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Novartis
Different clinical and pathological profiles of sudden cardiac death victims caused by coronary artery dissection or myocardial infarction with non-obstructed coronary arteries
Authors: Ciliberti G , Finocchiaro G , Guerra F , Papadakis M , Sharma S , Sheppard M
Published: October 2022

Background

Spontaneous coronary artery dissection (SCAD) is a potential cause of acute coronary syndrome and sudden cardiac death (SCD). Coronary fibromuscolar dysplasia (FMD) has been correlated to SCAD occurrence.The prevalence of SCAD and FMD among SCD victims are unclear. Myocardial infarction with non-obstructed coronary arteries (MINOCA) could represent a cause of SCD. Since SCAD could clinically manifest as acute myocardial infarction, expert consensus documents have often considered SCAD as a subtype of MINOCA (1,2), but studies which address direct comparison between these two conditions are lacking.

Purpose

To assess characteristics of decedents with SCAD and/or FMD found at autopsy, and to compare their clinical and pathological profile with MINOCA SCD victims.

Methods

We reviewed a database of 5325 consecutive cases of SCDs referred to our cardiac pathology center between 1994 and July 2017.

Results

We identified 21 (0.4%) with SCAD and 37 (0.7%) victims with MINOCA (3), whereas FMD was found only in 2 (0.04%). SCAD decedents were females in 81%, versus 38% of MINOCA (p=0.02).

No signs of coronary FMD were found among SCAD and MINOCA victims. Necrotic myocardium was identified in the totality of MINOCA and only in 8 (38%) of SCAD decedents (p<0.001). Pre-mortem cardiac symptoms were present in 100% of SCAD and 49% of MINOCA victims (p<0.001); illicit drug use was reported in none of SCAD versus 46% of MINOCA decedents (p=0.001).

Conclusions

SCAD is a rare cause of SCD. Compared to MINOCA, SCAD victims are more frequently females, always experienced pre-mortem cardiac symptoms and have no habit of substances abuse. At autopsy coronary FMD is not present among SCAD victims. SCAD and MINOCA shows different clinical and pathological profile. SCAD should not be considered a subtype of MINOCA.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Cardiac Risk in the Young (CRY) and the Charles Wolfson Charitable Trust.
The prognostic impact of coronary anatomy in myocardial infarction with nonobstructive coronary artery disease: a seven-year longitudinal follow-up
Authors: Tsaban G , Barret O , Peles I , Abramowitz Y , Shmueli H , Cafri C , Zahger D , Koifman E
Published: October 2022

Background

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is a common condition associated with major adverse events (MAE) that may occur presence of normal or nonobstructive coronary artery anatomy (NCAA and NOCAA, respectively). The prognostic impact presence of NOCAA on long-term outcomes of MINOCA patients remains unclear.

Methods

This is a retrospective study among consecutive MINOCA patients in a large referral medical center in Israel between the years 2005–2018. Patients with probable alternative cause for myocardial injury, as stress-induced cardiomyopathy and myocarditis, were excluded. Patients were classified according to their coronary angiography diagnosis into NCAA and NOCAA. The primary outcome was MAE, defined as the composite of all-cause mortality and recurrent acute coronary syndrome (ACS). We performed survival analyses using multivariable Cox regression, controlling for potential cofounders.

Results

Among 36,501 admitted with AMI during the study period, 1,544 patients (4.2%) had MINOCA. Among MINOCA patients, 651 (42%) had NCAA, and 893 (58%) had NOCAA. The mean age was 61.2±12.6 years, and 710 (46.0%) were females. The NOCAA group had more females and were older with higher rates of diabetes, hypertension, dyslipidemia, atrial fibrillation, and chronic renal failure (p<0.05 for all). At a median follow-up of 7 years, MAE occurred in 203 (22.7%) patients and 67 (10.3%) patients in the NOCAA and NCAA groups, respectively (p<0.01). In fully-adjusted multivariable model, NOCAA remained a significant risk factor for long-term MAE [adjusted-hazard-ratio (aHR) 1.67, 95% confidence-interval (95% CI) 1.25–2.23; p<0.001; figure]. Other factors associated with MAE were older age (aHR 1.05, 95% CI 1.03–1.06; p<0.001), left ventricular ejection fraction (LVEF) <40% (aHR 3.04, 95% CI 2.03–4.57; p<0.001)

Conclusion

Among MINOCA patients, NOCAA was associated with a worse long-term prognosis than NCAA. Other risk factors for long-term MAE were older age and LVEF <40%, while female sex and sinus rhythm at presentation were associated with lower MAE risk.

Funding Acknowledgement

Type of funding sources: None.
Prognostic impact of secondary prevention treatment following myocardial infarction with non-obstructive coronary arteries: Bayesian versus frequentist meta-analysis
Authors: Samaras A , Papazoglou A , Balomenakis C , Rampidis G , Bekiaridou A , Moysidis D , Giannakoulas G
Published: October 2022

Background

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a clinical entity with a plethora of causes and pathophysiologic mechanisms. Traditional secondary prevention medications may not offer benefit for patients with MINOCA, calling into question the routine use of such therapies in this population.

Material and methods

Literature search was conducted in MEDLINE (PubMed), Scopus by ELSEVIER and Cochrane Central Register of Controlled Trials (CENTRAL) databases until 08 March 2022. Random-effects frequentist and hierarchical Bayesian meta-analyses were performed to assess the prognostic impact of secondary prevention medications (β-blockers, RAAS inhibitors, statins, DAPT, ASA and P2Y12 inhibitors) on the occurrence of major adverse cardiovascular events (MACE) and all-cause mortality in MINOCA patients. Sensitivity analyses accounted for the effect of: i. small sample size, ii. limited study follow-up period, and iii. different ethnicity.

Results

Of 2,569 articles initially retrieved, 9 observational studies were deemed eligible for this analysis, encompassing a total of 14,003 patients suffering from MINOCA (mean follow-up range from 6 to 90 months, mean age = 64.9±10.4 years).Administration of ASA, DAPT and P2Y12 inhibitors was not significantly linked with MACE [pooled adjusted hazard ratios (aHRs) = 0.94, 0.88, and 0.97, with 95% confidence intervals (CIs): 0.56–1.59, 0.47–1.65, and 0.562–1.53, respectively]. RAAS inhibitors and statins were independently associated with lower risk of MACE (pooled aHRs = 0.61 and 0.55 with 95% Cis: 0.46–0.82, and 0.34–0.90, respectively) and all-cause mortality (pooled aHRs = 0.58 and 0.55 with 95% Cis: 0.37–0.91, and 0.43–0.72, respectively). B-blockers were associated with significantly lower risk of all-cause death according to the frequentist analysis (pooled aHR = 0.80, 95% CI: 0.67–0.96) and with non-significantly lower risk of MACE (pooled aHR = 0.81, 95% CI: 0.65–1.01) [Figure 1]. The results deriving from the Bayesian analyses were generally consistent with the frequentist analyses, with the exceptions of the Bayesian analyses on statin and β-blocker effects, which were affected by the pre-test probabilities set herein [Figure 2]. The overall heterogeneity observed in our analyses was relatively small, and there was not substantial publication bias. Furthermore, the performed sensitivity analyses supported the robustness of the observed outcomes.

Conclusion

In this meta-analysis, it appeared that predominantly RAAS inhibitors and statins across secondary prevention medications were consistently associated with lower risk of MACE or all-cause death during the follow-up period of patients that experienced MINOCA.

Funding Acknowledgement

Type of funding sources: None.
Impacts on the short-term outcome of patients with Tako-Tsubo syndrome
Authors: Mousavi R A , Kronberger C , Han E , Litschauer B , Badr Eslam R
Published: October 2022

Background

Tako-Tsubo syndrome (TTS) is a form of acute heart failure which mostly affects postmenopausal women, often following an emotional or physical trigger factor. There are many hypotheses for the development of TTS but the complete pathophysiology still remains unclear. Although most patients recover after a few days, some have to be treated at the intensive care unit (ICU) and may even die from the condition.

Purpose

The aim of this study was to find out if pre-existing diseases, cardiovascular risk factors (CVRF), comorbidities and trigger factors have any impact on the short-term outcome of TTS patients.

Methods

Data of all patients who presented to our centre with TTS from 2009–2017 were gathered retrospectively. Baseline characteristics, including somatic and psychiatric pre-existing diseases, CVRF (smoking, hypertension, diabetes, dyslipidaemia) as well as physical and emotional trigger factors were collected. Somatic diseases were additionally categorised into cardiac, autoimmune, malignant and other diseases. Admission to intensive care unit post TTS and/or in-hospital death were defined as poor short-term outcome. Outcome predictors were analysed with binary logistic regression model using the combined variable admission to an ICU and/or death.

Results

Out of 102 patients, 84 (82.4%) were females and 18 (17.6%) males with a median age of 65±15 years. 30 (29.4%) patients had an emotional and 23 (22.5%) a physical trigger factor. 27 (26.5%) had a psychiatric and 88 (86.3%) a somatic pre-existing disease. 33 (32.4%) patients were smokers, 58 (56.3%) had hypertension and 18 (17.5%) were diabetics. 19 patients (18.6%) had to be admitted to ICU and 8 patients (7.8%) died.

No pre-existing diseases, baseline characteristics, CVRF or comorbidities behaved as significant independent predictor for bad outcome in TTS patients. Physical trigger was the only significant predictor for ICU admission and/or death (p=0.012).

Conclusion

Our study showed that patients with physical trigger factors have a higher risk of ICU admission and/or death than patients with emotional or no stressful trigger factors before TTS and should therefore be monitored closely. Interestingly, contrary to many other acute cardiac diseases, pre-existing diseases, cardiovascular risk factors and comorbidities do not seem to have any impact on the short-term outcome of patients with TTS.

Funding Acknowledgement

Type of funding sources: None.
The role of peak NT-proBNP/peak cardiac troponin T ratio obtained within 3 days of admission to discriminate Takotsubo from acute coronary syndrome
Authors: Rallidis L , Kosmas N , Iordanidis D , Kiouri E , Zapantiotis D , Samiotis E , Varounis C , Filippatos G
Published: October 2022

Background

Takotsubo syndrome (TS) is not usually diagnosed until a patient with suspected acute coronary syndrome (ACS) is found to have no hemodynamically significant lesions on coronary angiography (CA).

Purpose

We explored whether a cardiac biomarker profile can contribute to early diagnosis of TS, which could be useful when CA is either not available or does not provide a definitive diagnosis.

Methods

Ratios of N-terminal-pro brain natriuretic peptide (NT-proBNP) and cardiac troponin T (cTnT) [admission and peak levels of the two consecutive days following admission, expressed in pg/mL] were compared in 41 patients with TS and 50 ACS patients.

Results

Both admission NT-proBNP/cTnT ratio and peak NT-proBNP/peak cTnT ratio were higher in patients with TS compared to those with ACS (38.8±57.1 vs 15.2±33.1, p=0.038 and 29.1±26.2 vs 2.2±3.9, p<0.001, respectively). Only the association of peak NT-proBNP/peak cTnT ratio remained statistically significant after adjustment for age and gender when multiple linear regression analysis was used (R square=0.746, p<0.001). ROC curve analysis of peak NT-proBNP/peak cTnT ratio discriminated patients with TS as opposed to those with ACS (AUC=0.921 with 95% CI: 0.851–0.990, p<0.001). A cut-off value of peak NT-proBNP/peak cTnT ratio >5.5 had a sensitivity of 85%, a specificity of 90% and an accuracy of 88.1% in detecting TS as opposed to ACS.

Conclusions

Peak NT-proBNP/peak cTnT ratio >5.5 obtained within the first 3 days of admission has a good diagnostic accuracy to identify patients with TS among those presenting with ACS. This could be useful for the early discrimination between the two entities when CA is not easily available, particularly in patients without ST-segment elevation and low or intermediate-risk.

Funding Acknowledgement

Type of funding sources: None.
Distinctive characteristics among MINOCA and Takotsubo patients and their prognostic value in a multicenter prospective cohort
Authors: Mantzouranis E , Leontsinis I , Sakalidis A , Ntalakouras I , Kordalis A , Antonopoulos A , Dagre A , Poulimenos L , Mamarelis I , Tsioufis K
Published: October 2022

Background/Introduction

In the acute care setting, the working diagnosis of MINOCA exhibits increasing recognition and includes a broad spectrum of conditions, most of them yet not adequately understood. TakoTsubo syndrome (TTS) represents a significant proportion of such cases and despite its predominance on female gender as well as its imaging characteristics on the typical apical form it is not easily distinguishable from other MINOCA causes without the contribution of cardiac magnetic resonance (CMR).

Purpose

The aim of our study is to investigate for distinctive characteristics related to the index event among MINOCA cases from a multi-center prospective cohort with a mean follow up period of 18 months.

Methods

We divided our study population (n=74) into TTS (n=30) and non-TTS (n=44) according to multimodality imaging results. Information regarding the index event (Sep 2019-Feb 2021) were retracted from the medical notes.

Results

CMR results led to a post-discharge diagnosis reconsideration in 12 cases (16.2%). Female gender (n=29; 96.7% vs n=22; 50%, P<0.001), older age (mean age 66±11 vs 59±11, P=0.04) and history of hypertension (n=21; 70% vs n=19; 44.3%, p=0.035) were more frequent in TTS group. There was no statistically significant difference in body mass index, baseline renal function, history of dyslipidemia, diabetes and smoking between the two groups. During the index event, peak troponin levels 576 pg/ml (IQR: 184–9915) vs 767 pg/ml (IQR: 47–47000), P=0.005], were lower in the TTS group, whereas NSTEMI presentation was the commonest among all patients. Angina was the dominant symptom for both groups. However, severe angina expressed as more than 2 episodes within 24 hours was more frequent among the TTS population (n=19; 65.5% vs n=10; 22.7%, P=0.001). TTS probability assessed with the INTERTAK score was higher among the TTS group (68±10 vs 38±21, P<0.001). In hospital major cardiovascular events incidence was higher in the non-TTS group (n=2 vs n=11, P=0.06). Multivariate analysis revealed that the presence of severe angina (OR, 8.118, 95% CI: 1.173–56.157, P=0.038) is highly predictive of TTS in the acute care setting even independently of INTERTAK probability.

Conclusions

These preliminary results indicate that the presence of several anginal attacks may strengthen the predictive value of the INTERTAK score during MINOCA evaluation in the acute setting. Confirmation in a larger population is warranted.

Funding Acknowledgement

Type of funding sources: None.
Variation in health-care quality and outcomes according to time of chest pain presentation: a state-wide prospective cohort study
Authors: Navani R V , Dawson L , Andrew E , Nehme Z , Bloom J , Cox S , Anderson D , Stephenson M , Lefkovits J , Taylor A , Kaye D , Smith K , Stub D
Published: October 2022

Background

Previous studies examining temporal variation in cardiovascular care have largely been limited to assessing weekend and after-hours effects whereby those presenting on the weekend or after-hours have a poorer outcome. However, emerging evidence suggests more complex patterns in patterns and outcomes may exist.

Purpose

We aimed to determine patterns of temporal variation in chest pain presentations and subsequent health-care quality and outcomes.

Methods

This was an observational, prospective-cohort study of adult patients aged 18 and over who were attended by emergency medical services for non-traumatic chest pain between 1 January 2015 and 30 June 2019 in Victoria, Australia. Major exclusion criteria included pre-hospital diagnosis of ST elevation myocardial infarction or an out of hospital cardiac arrest. The exposure variable was time of day and day of week stratified into 168 hourly time periods. The primary outcome measure was 30-day mortality.

Results

The study cohort comprised 196,365 ambulance attendances for acute non-traumatic chest pain; mean age 62.4 years (SD 18.3) and 99,497 (50.7%) females. Three temporal patterns were observed for chest pain presentations (Figure 1): (1) a diurnal pattern with a sharp increase in presentations from 8 am, peaking around midday, before decreasing into late evening with a nadir between 3–4 am, (2) a weekend effect where Saturday and Sunday had a relatively lower rate of presentations compared to during the week, and (3) a Monday – Sunday gradient where more presentations were likely earlier in the week, than later. Six patterns were identified across pre-hospital and hospital key performance indicators (KPI) (diurnal, in/after-hours, weekend effect, Monday – Sunday gradient, a peak period and morning vs afternoon/evening effect. Risk of 30-day mortality was associated with weekend presentation (OR 1.15, 95% CI 1.06–1.24, p=0.001) and morning presentation between midnight and midday (OR 1.17, 95% CI 1.09–1.25, p<0.001) (Figure 2).

Conclusion

Chest pain presentations, care quality and outcomes demonstrate complex temporal variation beyond the already established weekend and after-hours effect. Such relationships should be considered during resource allocation and quality improvement programs in order to improve treatment quality across all days and times of the week.

Funding Acknowledgement

Type of funding sources: None.
Prevalence and predictors of acquired long QT syndrome in the ER department
Authors: De Almeida Fernandes D , Camoes G , Ferreira D , Queijo C , Guimaraes J M , Ribeiro C , Goncalves L , Pina R , Antonio N
Published: October 2022

Introduction

Long QT syndrome (LQTS) is a rare heterogeneous syndrome that may be congenital or acquired, the latter being more common. Its real-world prevalence remains to be determined. We aimed to determine the prevalence of this syndrome in patients admitted to the emergency room (ER) and characterize the subset of patients with severely prolonged QT.

Methods

A retrospective analysis of ECG of all consecutively admitted patients in the ER of a tertiary hospital between the 28th of January and the 17th of March 2020 was made. All patients with Bazzett corrected QT interval greater than 470ms in men and 480ms in women were included. Repeated ECGs or with bad electrocardiographic quality, congenital LQTS, atrial fibrillation and pacemaker rhythm were excluded. Clinical data with a special focus on QT prolonging drugs and clinical factors were recorded. Statistical comparison was made between the groups with and without QT interval greater than 500ms.

Results

A total of 6280 ECGs of 5056 patients were analysed. After evaluation, 390 ECGs from 387 different patients were considered. Prevalence of LQTS at admission was 7.95%. Patients were more commonly men (53.1%) with an average age of 73.6±14.7 years old and mean QTc interval of 502.14±32.2ms. Only 20% of the patients were symptomatic, with the most common form of presentation being syncope (50%). No ventricular arrhythmias were recorded.

Regarding patients with a QT interval greater than 500ms, these were more frequently female (59.9% vs 37.2%, p<0.001), were more frequently on QT prolonging drugs (77.8% vs 67.3%; p=0.002). Presence of clinical risk factors was not a risk factor per se (p=0.811) but a greater number of risk factors was linked to more severely prolonged QT (p=0.040). The main contributing factor was intake of antibiotics (odds ratio (OR) 3.497; CI 95% 1.074–11.321; p=0.038) followed by female gender (OR 2.518; CI 95% 1.668–3.800; p<0.001) and use of antipsychotics (OR 1.960; CI 95% 1.159–3.316; p=0.012).

Conclusions

Acquired LQTS is particularly prevalent in the ER setting. The complex interaction of clinical factors and drug iatrogenesis and the unpredictability of its manifestations render its management and recognition difficult but essential. Female patients on antibiotics and antipsychotics are at particularly high risk. Efforts must be made in order to avoid, detect and treat acquired LQTS as early as possible.

Funding Acknowledgement

Type of funding sources: None.
Dexamethasone improves cardiovascular outcomes in critically ill COVID-19, a real world scenario multicenter analysis
Authors: Jirak P , Van Almsick V , Dimitroulis D , Mirna M , Seelmaier C , Shomanova Z , Semo D , Dankl D , Mahringer M , Lichtenauer M , Hoppe U , Reinecke H , Pistulli R , Larbig R , Motloch L
Published: October 2022

Background

Severe COVID-19 pneumonia requiring intensive care treatment remains a clinical challenge to date. Dexamethasone was reported as a promising treatment option, leading to a reduction of mortality rates in severe COVID-19 disease. However, the effect of dexamethasone treatment on cardiac injury and pulmonary embolism remains largely elusive.

Methods

In total 178 critically ill COVID-19 patients requiring intensive care treatment and mechanical ventilation were recruited in three European medical centres and included in the present retrospective study. 113 patients (63.5%) were treated with dexamethasone for a median duration of 10 days (IQR 9–10). 65 patients (36.5%) constituted the non-dexamethasone control group.

Results

While peak inflammatory markers were reduced by dexamethasone treatment, the therapy also led to a significant reduction in peak troponin levels (231% vs. 700% indicated as relative to cut off value, p=0.001). Similar, dexamethasone resulted in significantly decreased peak D-Dimer levels (2.16 mg/l vs. 6.14mg/l, p=0.002) reflected by a significant reduction in pulmonary embolism rate (4.4% vs. 20.0%, p=0.001). The antithrombotic effect of dexamethasone treatment was also evident in the presence of therapeutic anticoagulation (pulmonary embolism rate: 6% vs. 34.4%, p<0.001). Of note, no significant changes in baseline characteristics were observed between the dexamethasone and non-dexamethasone group.

Conclusion

In severe COVID-19, antiinflammatory effects of dexamethasone treatment seem to be associated with a significant reduction in myocardial injury. Similar, a significant decrease in pulmonary embolism, independent of anticoagulation, was evident, emphasizing the beneficial effect of dexamethasone treatment in severe COVID-19.

Funding Acknowledgement

Type of funding sources: None.
Major adverse cardiac events in critically ill COVID-19 patients
Authors: Lopes V , Baptista J P , Moreira N , Goncalves L
Published: October 2022

Background

Critically ill patients hospitalized with COVID-19 are at high risk of developing major adverse cardiac events (MACE).

Purpose

This study aimed to identify independent predictors of MACE after intensive care unit (ICU) admission which could be used to identify high-risk patients who may benefit from preventive strategies.

Methods

We retrospectively analyzed patients consecutively admitted to an ICU with COVID-19 and followed them for a median period of 7 months. Patients admitted due to trauma or emergent surgery were excluded. Logistic regression analysis was performed to evaluate which clinical characteristics predicted MACE. MACE was defined as all-cause ICU mortality, new-onset heart failure, acute coronary syndrome, ventricular arrythmias, pulmonary embolism, myocarditis, and stroke (ischemic or hemorrhagic).

Results

A total of 297 patients was included in the analysis. Median age was 62 (IQR 17) years, and most patients were male (198 patients, 66.7%). From a total of 297 patients, 108 (36.4%) developed at least one MACE: ICU all-cause mortality (92 patients, 31.0%), new-onset heart failure (27 patients, 9.1%), acute coronary syndrome (7 patients, 2.4%), ventricular arrythmias (7 patients, 2.4%), pulmonary embolism (13 patients, 4.4%), myocarditis (4 patients, 1.3%), and stroke (5 patients, 1.7%).

Univariate logistic regression analysis showed that the clinical variables associated with MACE were male sex, older age, APACHE II score, SAPS II score, hypertension, hyperlipidemia, known coronary artery disease, heart failure, new-onset atrial fibrillation, need for invasive mechanical ventilation, duration of mechanical ventilation, and vasopressor use. In multivariate logistic regression analysis, we found that the MACE's independent predictors were older age, higher APACHE II score, and new-onset atrial fibrillation. Main results are presented in Table 1.

Conclusion(s)

Among critically ill COVID-19 patients, older age, higher APACHE II score, and new-onset atrial fibrillation independently predicted MACE.

Funding Acknowledgement

Type of funding sources: None.
Mechanical circulatory support devices in left main occlusion: a multicenter study from 2008 to 2020
Authors: Oliveira Campinas A , Braga M , Alexandre A , Costa R , Dias De Frias A , Calvao J , Brandao M , Passos Silva M , Pires De Morais G , Carlos Silva J , Brochado B , Luz A , Silveira J , Gomes C , Torres S
Published: October 2022

Introduction

Evidence of benefit in the use of mechanical circulatory support devices (MCS) in patients with acute myocardial infarction (AMI) is scarce. We aimed to evaluate the clinicalcharacteristics, prognosis and factors associated with the use of MCS in patients with AMI due to left main (LM) occlusion.

Methods

We performed a retrospective multicenter study of 128 consecutive patients with AMI with ≤12h of presentation with LM occlusion submitted to immediate reperfusion between January 1, 2008, until December 31, 2020 in three terciary hospitals of Portugal. Among this cohort, we divided patients into two groups according to the use of MCS devices.

Results

Regarding the baseline characteristics no statistically significant differences were found, except for the presence of cerebrovascular disease (2.9% in group with vs 16.9% in group without MCS, p=0.007) and peripheral artery disease (8.8% in group with vs 22% in group without MCS, p=0.037). We observed that the use of MCS devices was statistically different between the three centers (47.8%, 42%, 8.7%, p<0.001). No differences were found at presentation for ST-segment elevation vs non-ST segment elevation AMI (p=NS). The presence of cardiogenic shock (72.4% vs 45.8%, p=0.002), cardiac arrest (27.5% vs 23.7%, p=0.034) and more severe thrombolysis in myocardial infarction (TIMI) flow at presentation (55.1% vs 35.6%, p=0.015) were more frequent in group with MCS. The rate of 1-year cumulative mortality was high in both groups (31/59=52.5% in the group without vs 47/69=68.1%, p=NS). Also, no statistically significant differences were found in terms of survival, but we observed a trend to higher mortality in those who received MCS as Kaplan-Meier survival curves show (log rank=0.062). Finally, in multivariable analysis, older age [odds ratio (OR), 0.935; 95% CI, 0.87–0.99], the presence of diabetes (OR, 0.223; 95% CI, 0.056–0.88), peripheral artery disease (OR, 0.070; 95% CI, 0.009–0.566) and extra-hospitalar cardiac arrest (OR, 0.06; 95% CI, 0.007–0.543) were characteristics associated with lower odds of receiving MCS. Contrarily, male sex (OR, 5; 95% CI, 1–20.4) and the presence of cardiogenic shock (OR, 5.7; 95% CI, 1.42–23) were factors associated with higher use of MCS.

Conclusion

The use of MCS does not seem to modify prognosis in patients admitted withAMI due to left main occlusion. Only cardiogenic shock and male gender were predictors of MCS use.

Funding Acknowledgement

Type of funding sources: None.
Utility of the Age Shock Index in 27312 patients with an acute coronary syndrome
Authors: Rocha Carvalho P , Monteiro J , Carvalho C , Mateus P , Goncalves F , Fontes P , Moreira J I
Published: October 2022

Introduction

The Shock Index (SI), defined as the ratio of heart rate (HR) to systolic blood pressure (SBP), represents a bedside reflection of the integrated response from the cardiovascular and autonomic systems and has been reported to predict adverse prognosis in patients with acute coronary syndromes (ACS).

Age Shock Index (ASI), the product of SI multiplied with age, could also be useful in this setting, but its prognostic value is yet to be determined in ACS patients.

Methods

Acute myocardial infarction patients included in a national registry between October 2010 and January 2022. Optimal shock index cutoff was determined according to ROC curve analysis. Patients were categorized into two groups based on their initial ASI. Baseline characteristics, management and outcomes were compared between the two groups. The primary outcome was in-hospital cardiovascular death.

Results

A total of 27312 patients were included with a mean age of 66±13 years, 72.3% male, 47.5% with ST-elevation myocardial infarction. Based on ROC analysis, which showed AUC=0.80, the optimal ASI cutoff was 44 (with a sensitivity of 73% and a specificity of 74%); 19997 patients (73.2%) had an ASI <44 and 26.8% had an ASI ≥44. The former group was older (mean age of 75±10.0 vs 63±13.0 years, p<0.001), and had more comorbidities: arterial hypertension (77.3% vs 66.3%, p<0.001), diabetes mellitus (39.8% vs 28.1%, p<0.001), peripheral artery disease (7.1% vs 4.4%, p<0.001) and previous history of heart failure (11.0% vs 4.3%, p<0.001).

Patients with ASI ≥44 had higher Killip class at admission and worse left ventricular ejection fraction on discharge (46.0±13.0 vs 53.0±11.0, p<0.001).

In a multivariate regression analysis, after adjusting for possible confounders, ASI ≥44 was an independent predictor of cardiovascular death (HR 3.09, 95% CI: 2.56–3.71, p<0.001).

ASI was a significantly better predictor of cardiovascular death than Shock Index (AUCASI = 0,80 vs AUCSI = 0.72, p<0,0001), but not in comparison to GRACE score (AUCASI=0.80 vs AUCGRACE=0.85, p<0.001) and TIMI (score AUCASI=0.80 vs AUCGRACE=0.84, p<0.001).

At one year, using a Kaplan Meyer survival analysis, mortality was higher in patients with ASI ≥44 (log rank p<0.001)

Conclusion

ASI can identify almost immediately ACS patients at high risk of cardiovascular death, and combined with its simple use, makes it a practical tool for early risk stratification in these patients.

Funding Acknowledgement

Type of funding sources: None.
Acute total occlusion of the unprotected left main coronary artery – patient characteristics and outcomes
Authors: Calvao J , Braga M , Brandao M , Campinas A , Alexandre A , Amador A F , Costa C , Carvalho M M , Pinto R A , Proenca T , Silva J C , Pires-Morais G , Silva M P , Brochado B , Macedo F
Published: October 2022

Background

Acute total occlusion of the unprotected left main coronary artery (ATOLMCA) is a dramatic entity with very high mortality. Owing to its infrequency, there is limited and inconsistent data regarding this population.

Purpose

To describe the clinical presentation, short- and long-term outcomes of patients with ATOLMCA.

Methods

This retrospective multicentric cohort study included all patients presenting with acute (<12h) myocardial infarction (MI) due to ATOLMCA (Thrombolysis In Myocardial Infarction - TIMI=0) between January 2008 and December 2020 in three tertiary hospitals.

Results

In the period of the study, 11,036 emergent coronary angiographies were performed in the participating centers, 59 of which were ATOLMCA (0.5%). Mean age of patients at the time of the event was 61.2 (±12.2) years. Seventy-three percent were male. At presentation, 72.9% of patients were in cardiogenic shock, and aborted cardiac arrest occurred in 27.1%. Right dominance was present in all patients except one, who had a balanced dominance. Primary percutaneous coronary intervention (PCI) was performed in 89.8% of the patients, with angiographic success being achieved in 55.6% of the procedures. Overall, the in-hospital mortality rate was 57.6%. Mortality was significantly higher in patients without angiographic criteria for PCI success (87.5 vs 36.7%, p<0.001). Among survivors, 91.7% were still alive at 1-year and 66.7% at 5 years of follow-up.

Conclusion

Patients with ATOLMCA have a dismal prognosis. Most patients present with cardiogenic shock, and a significant number develop cardiac arrest during the acute phase. Despite medical care, in-hospital mortality is high. Patients with left dominance may not even reach the hospital. Among survivors, long term outcomes are reasonable. Further studies are needed in order to improve the management and outcomes of patients with ATOLMCA.

Funding Acknowledgement

Type of funding sources: None.
Binary endocardial appearance for Fabry disease diagnosis: a systematic review and meta-analysis
Authors: Segura P , Alvarez-Vargas M , Nieto-Gutierrez W , Quispe-Vicuna C , Pariona M , Bulwer B
Published: October 2022

Objective

This study aimed to determine the performance of the endocardial binary appearance (binary sign [BS]) on echocardiography for Fabry-Anderson disease (FD) diagnosis.

Methods

A diagnostic systematic review was performed, which included studies with >20 patients selected, with enough reported data to compute the 2 × 2 tables, and with a BS evaluation against a genetic test. Evidence was searched up to October 4, 2020, in the following databases: PubMed, Scopus, EMBASE, and Web of Science. The risk of bias was evaluated using the Quality Assessment of Diagnostic Accuracy Studies 2 tool and certain evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach.

Results

Four studies were included in the systematic review. All studies were cross-sectional that included 524 patients that compared the BS vs. the alpha-galactosidase-A and/or genetic test, alpha-galactosidase-A and globotriaosylceramide isoform, and genetic test alone. The BS was found to have a sensitivity of 41% (confidence interval [CI] 95% = 17–71) and specificity of 91% (CI 95% = 60–99) and area under the curve of 0.71 (CI 95% = 0.64–0.78) for diagnostic of FD, with a certain of evidence low.

Conclusion

The BS has a good performance in confirming the diagnosis of FD, but not for screening. However, the evidence had low certainty, thus future studies could modify these results.

Funding Acknowledgement

Type of funding sources: None.
Lung ultrasound predicts left-sided filling pressures in patients with cardiogenic shock admitted to the cardiac intensive care unit
Authors: Szekely Y , Brahmbhatt D H , Scolari F L , Doumouras B S , Billia F
Published: October 2022

Background

Left and right filling pressures, as well as cardiac output, are key targets in optimising treatment of cardiogenic shock (CS). Invasive pulmonary artery catheters can provide these data but are associated with complications and are not available in all hospital settings. Lung ultrasound (LUS) can detect pulmonary congestion in patients with heart failure (HF) and may be an alternative to invasive monitoring. We assessed the correlation between LUS score and invasive haemodynamic parameters in patients with CS admitted to the cardiac intensive care unit (CICU) of a North American cardiac centre.

Methods

We prospectively evaluated consecutive patients who underwent pulmonary artery catheter insertion in the CICU. Haemodynamic parameters including right atrial pressure (RAP) and pulmonary capillary wedge pressure (PCWP) were measured and cardiac output (CO) was calculated using the thermodilution method. This was immediately followed by an 8-zones LUS done by a critical care cardiologist who was blinded to the invasive hemodynamic measurements. The LUS score was calculated by counting the total number of B-lines in all 8 zones, with a higher score indicating greater congestion. Correlations between LUS score and hemodynamic parameters were evaluated using Pearson's correlation.

Results

Ninety-six measurements from 60 patients were included, aged 58±14 years with 27% female. The most common diagnosis at admission was cardiogenic shock, followed by acute myocardial infarction and HF exacerbation. Most patients were at SCAI stages C and D at the time of assessment. The mean number of B-lines at LUS was 10.1±8.2. Mean RAP was 8.5±4.6 mmHg, PCWP 16.2±6.3 mmHg and CO of 5.0±1.8 L/min. The total number of B-lines was correlated with PCWP (r=0.66, P<0.001, see Figure 1), RAP (r=0.26, P<0.001) and cardiac output (r=−0.23, p=0.02). Due to the correlation of B-lines in LUS with PCWP, we then evaluated the area under the ROC of the LUS to identify patients with PCWP ≥15 mmHg. The number of positive zones (≥3 B-lines) showed an AUC of 0.81 (0.72–0.89), P<0.001. In 36 patients, we had repeated measurement with more than 12 hours apart. The delta change in PCWP was correlated with delta change in the number of B-lines (r=0.59, P<0.001).

Conclusion

Elevated LUS score in patients with CS is associated with worse invasively-measured LV filling pressures, but less so with RAP or CO. LUS can serve as a useful adjunct to the clinical assessment of patients with CS who do not receive invasive hemodynamic monitoring, either at a single timepoint or to detect changes in clinical status over time, to guide ongoing management.

Funding Acknowledgement

Type of funding sources: None.
A 10-year cohort on prognostic outcomes in patients presenting with acute myocardial infarction complicated by cardiogenic shock and/or cardiac arrest
Authors: Chew N , Teo V , Tan C , Kong G , Chin Y H , Ambhore A , Low A , Lee C H , Chan M Y , Tan H C , Ph L O H
Published: October 2022

Background

Cardiogenic shock (CS) and cardiac arrest (CA) complicating acute myocardial infarction (AMI) portend unfavourable outcomes. This study examined the prognosis of patients presenting with AMI complicated by CS and/or CA.

Methods

Consecutive patients presented with AMI to a percutaneous coronary intervention-capable tertiary institution between 2011 and 2021 were studied. Patients were stratified based on the presence or absence of CS (CS+ or CS−) and CA (CA+ or CA−). The primary outcome was 30-day cardiovascular-related mortality. Subgroup analyses based on AMI-type and sex were conducted. Kaplan-Meier curves for cardiovascular-related mortality based on the AMI-type and sex were constructed.

Results

The study included 11,608 AMI patients, 283 of whom had CS+/CA+, 1,068 had CS+/CA−, 54 had CS−/CA+ and 10,203 had CS−/CA−. Cardiovascular-related mortality was significantly higher for CS+/CA+ (57.6%), followed by CS+/CA− (41.6%), CS−/CA+ (20.4%) and CS−/CA− (2.4%). Kaplan-Meier curves demonstrated CS+/CA+ group had the highest mortality (HR=36.26; 95% CI: 29.71–44.25, p<0.001), followed by CS+/CA− (HR=21.59; 95% CI: 18.47–25.24, p<0.001) and CS−/CA+ (HR=9.18; 95% CI: 5.02–16.80, p<0.001), with CS−/CA− as the reference. Those with NSTEMI had consistently higher cardiovascular-related mortality rates than their STEMI counterparts for all groups, apart from the CS+/CA+ group. The sex-specific analysis demonstrated that the survival curves for females with CS+/CA+, CS+/CA− and CS−/CA+ converged, whilst the survival curves for males diverged over time. The multivariable Cox regression revealed the presence of CS and CA are independent predictors of cardiovascular-related mortality, but not NSTEMI, when adjusted for age, gender, diabetes, left ventricular ejection fraction, chronic renal failure, and culprit vessel.

Conclusions

AMI associated with CA and CS portends the least favourable survival, followed by those with CS or CA alone. Excess mortality was observed in the traditionally perceived lower-risk groups, particularly in women. This calls for increased awareness amongst clinicians when managing this subset of high-risk patients.

Funding Acknowledgement

Type of funding sources: None.
Door to support in acute myocardial infarction complicated by cardiogenic shock: an updated meta-analysis
Authors: Iannaccone M , Franchin L , Hanson I D , Boccuzzi G G , Basir M B , Truesdell A G , O'Neil W W
Published: October 2022

Introduction

The impact of time to hemodynamic support in acute myocardial infarction complicated by cardiogenic shock (AMICS) has yet to be defined. The aim of this meta-analysis was to evaluate the impact of timing of Impella mechanical circulatory support (MCS) initiation on early and midterm mortality.

Methods

A systematic literature review and meta-analysis was conducted using PubMed and Cochrane databases. All studies reporting short-term mortality rates and timing of Impella placement in AMICS were included. Meta-regression analysis and sensitivity analysis were performed on the primary endpoint, short-term mortality (≤30 days), and secondary endpoints (midterm mortality, device-related bleeding, and limb ischemia).

Results

Of 1289 studies identified, 13 studies (6810 patients; 2970 patients identified as receiving Impella pre-PCI and 3840 patients receiving Impella during/post-PCI) were included in this analysis. Median age was 63.8 years (IQR, 63–65.7); 76% of patients were male, and a high prevalence of cardiovascular risk factors was noted across the entire population. Short-term mortality was significantly reduced in those receiving pre-PCI vs. during/post-PCI Impella support (37.2% vs 53.6%, RR 0.7; CI 0.56–0.88). Midterm mortality was also lower in the pre-PCI Impella group (47.9% vs 73%, RR 0.81; CI 0.68–0.97). The rate of device-related bleeding (RR 1.05; CI 0.47–2.33) and limb ischemia (RR 1.16; CI 0.63–2.15) were similar between the two groups.

Conclusion

This analysis suggests that Impella MCS placement prior to PCI in AMICS may have a positive impact on short- and midterm mortality compared with post-PCI, with similar safety outcomes.

Funding Acknowledgement

Type of funding sources: None.
The utilization and mortality benefits of pulmonary artery catheterization in patients with cardiogenic shock
Authors: Gill J , Jeelani H , Patel H
Published: October 2022

Introduction

Pulmonary artery catheterization (PAC) can provide essential hemodynamic data to assist in managing critical patients with cardiogenic shock. The use of PAC has been controversial as clinical studies have shown a lack of benefit. However, with the recent widespread availability of mechanical circulatory assists devices, the application and benefits of PAC are expected to rise.

Purpose

To determine the impact of PAC on inpatient outcomes and the utilization of advanced heart failure devices in these patients.

Methods

The National Inpatient Sample from 2016 to 2018 was queried to identify patients with cardiogenic shock. Of these patients, we compared those who received invasive hemodynamic monitoring (IHM) with PAC to those who did not receive PAC. Patients under age 18 and those undergoing surgical or transcatheter cardiac procedures during the same admission were excluded. Multivariate logistic regression was used to select matched samples between groups accounting for patient/hospital demographics and medical comorbidities. The primary endpoint was a comparison of in-hospital mortality, length of hospitalization, and medical costs. The secondary endpoints compared the utilization of mechanical circulatory assists devices: percutaneous ventricular assist devices (pVAD), extracorporeal membrane oxygenation (ECMO), and left ventricular assist device (LVAD), and the incidence of post-PAC complications: pneumothorax, sepsis, and hemorrhage/hematoma.

Results

We identified a total of 279,619 patients admitted with cardiogenic shock, of these patients 25,166 (9%) received IHM with PAC. Patients who had PAC had decreased in-hospital mortality (22.3% vs 29.7%; p<0.001), increased length of hospitalization (12 days vs 9 days; p<0.001), and increased medical costs ($65,884 vs $47,983; p<0.001). Furthermore, in patients with PAC there was increased utilization of pVAD (4.5% vs 1.9%; p<0.001), ECMO (0.07% vs 0.01%; p<0.001), and LVAD (2.2% vs 0.3%; p<0.001). There was no difference in the prevalence of post-PAC complications between both groups.

Conclusions

The use of IHM with PAC was associated with improved mortality and utilization of mechanical circulatory assist devices in patients with cardiogenic shock without increasing risk for post-procedural complications. Therefore, the increased average duration and medical costs of hospitalization with PAC patients likely resulted from improved patient survival. Therefore, the present study indicated that IHM with PAC is safe and beneficial for patients with cardiogenic shock.

Funding Acknowledgement

Type of funding sources: None.