bluuebunny/crossref_metadata_2025 huggingface dataset:
Impact of misdiagnosis on the treatment and prognosis of acute aortic syndrome
Authors: Ramos Gonzalez-Cristobal I , Ferrera C , Carrero A , Gutierrez F , Gonzalez Del Castillo J , Dominguez M J , Martinez I , Cobiella J , Noriega F J , Viana-Tejedor A , Perez Villacastin J , Maroto-Castellanos L , Vilacosta I
Published: May 2024

Funding Acknowledgements

None.

Introduction

Acute aortic syndrome (AAS) embraces a spectrum of pathologies with relatively low prevalence but associated with high mortality. The clinical presentation of AAS is highly variable and the differential diagnosis with other much more common diseases such as myocardial infarction (AMI) or pulmonary embolism (PE) is often difficult to achieve.

AAS detection requires a high index of suspicion and the delay in diagnosis is associated with increased morbidity and mortality.

Purpose

The aim of this study is to characterize the diagnostic approach to AAS patients in the emergency department (ED) and to study the impact of the initial diagnostic suspicion on the treatment and prognosis of patients with AAS.

Methods

The "Aorta Code" is an inter-hospital and interdisciplinary care protocol for the management of patients with AAS in a 4-Hospital network. Patients with AAS were prospectively and consecutively collected from 2019 to 2022. The sample was classified into two groups according to whether the initial suspicion was AAA or another clinical entity. The diagnosis of AAS was established by computed tomography in all patients. Time, clinical, treatment and prognostic variables were analyzed.

Results

A total of 113 patients with AAS were included. Of them, only 38% (34) were initially suspected of having an AAS (Figure). AMI and PE were the initial diagnosis in 34% of patients (Figure). There were no significant differences in age, history of hypertension or other cardiovascular risk factors between the groups (table). Anterior chest pain was more frequent in the "AAS-suspicion" group. The diagnostic time delay was longer in patients with initial misdiagnosis (table). Patients with type A AAS with initial misdiagnosis underwent surgery in a lower proportion (table). Although the differences were not significant, patients with initial misdiagnosis had more postoperative complications and higher mortality.

Conclusion

It is essential to maintain a high index of diagnostic suspicion for AAS in the ED. Initial misdiagnosis is associated with a delayed diagnosis, delayed surgical treatment and a lower rate of surgery. In addition, although it is a small sample size, this group of patients had more postoperative complications and higher mortality.
STEMI antiplatelet pretreatment strategy - national multicenter registry experience
Authors: Rocha De Almeida A , Carias De Sousa M , Congo K , Neves D , Patricio L
Published: May 2024

Funding Acknowledgements

None.

Background/Introduction

Antiplatelet therapy is the cornerstone treatment for ST-segment elevation myocardial infarction (STEMI). Dual antiplatelet therapy (DAPT) including aspirin and a potent P2Y12 inhibitor (P2Y12i) is recommended as the default strategy. However, the timing of DAPT remains controversial: European Cardiology Society (ESC) guidelines ceased recommending pretreatment with P2Y12i in STEMI, based on ATLANTIC trial results.

Purpose

This study aims to evaluate the effect of DAPT with potent P2Y12i pretreatment DAPT in STEMI patients, comparing with DAPT with clopidogrel and aspirin only pretreatment.

Methods

We have analyzed the antiplatelet pretreatment strategy results of a retrospective cohort of 2283 STEMI patients, from a multicenter national registry, from 2011 till 2019. We compared 3 groups: DAPT with potent P2Y12i, DAPT with clopidogrel and aspirin only. Primary endpoints were death, major adverse cardiovascular events (MACE), including reinfarction, heart failure, sustained ventricular arrhythmia, cardiogenic shock, mechanical complication and stroke, and successful PCI. Safety endpoint was major hemorrhagic events between different strategies.

Results

A total of 2283 STEMI patients where included, with a mean age of 66±13 years and 27% (n=627) were female. The population was divided in 3 groups, according with pretreatment strategy: DAPT with potent P2Y12i, DAPT with clopidogrel and aspirin only. 334 patients undergone DAPT with potent P2Y12i, and 86% (n=296) had a successful PCI, 21% (n=69) had a MACE and 9% (n=31) died in hospital. The group of patients submitted to DAPT with clopidogrel were 1815, and 80% (n=1448) had a successful PCI, 29% (n=527) had a MACE and 11,5% (n=209). The group pretreated only with aspirin were 124 patients, of which, only 14% (n=17) had a successful PCI, 38% (n=47) had a MACE and 39% (n=49) died. Regarding safety outcomes, 1,5% (n=5) patients with DAPT with potent P2Y12i had a significant hemorrhage, comparing with 3% (n=53) of patients with DAPT with clopidogrel and 3% (n=4) of aspirin only group of patients.

There was a statistically significant higher rate of successful PCI with DAPT with potent P2Y12i (p<0,05 OR 2), a statistically significant lower number of MACE (p<0,05 OR 0,6) and in hospital deaths (p=0,04 OR 0,67), comparing with DAPT with clopidogrel and aspirin only groups. There was no statistically significant difference between groups in terms of hemorrhagic events (p=0,7).

According to our retrospective multicenter national registry, pretreatment with potent P2Y12i is associated with better results, namely higher rate of successful PCI, less MACE and in hospital death, contrary to recent trials. Our study has some bias: the pretreatment with DAPT was standard of care during the registry, and the choice for aspirin only strategy might be due to higher risk patients, as the choice was not randomized.Antiplatelet treatment comparison
Cardiac rehabilitation makes a difference: lipid control targets and prognosis
Authors: Gomez Gonzalez A , Lopez Flores C , Lucas Garcia M , Padilla Rodriguez G , Escalona Garcia F J , Martinez Quesada M M
Published: May 2024

Funding Acknowledgements

None.

Introduction

Cardiac rehabilitation (CR) has become a fundamental element in the recovery of patients with acute coronary syndrome, since it achieves greater therapeutic adherence and better control of cardiovascular risk factors (CVRF).

Purpose

We aim to describe the characteristics of patients with ST-elevation acute coronary syndrome (STEACS) included in a cardiac rehabilitation program, as well as the achievement of prevention objectives and the occurrence of mayor adverse cardiovascular events (MACE).

Methods

We present a prospective registry of 664 patients admitted to a Coronary Unit with a diagnosis of STEACS during the years 2017-2020. They were classified according to their participation in a CR program. We compared history, lipid-lowering treatment (prior, at discharge and titration), lipid levels at discharge and at 1-year follow-up, and degree of compliance with lipid targets. MACE were observed at 2-year follow-up.

Results

From 664 patients, 351 were excluded due to lack of follow-up or early mortality. From a total of 313 patients (mean age 59.9±11.2 and 81% male), 55.3% were included in the CR program, with this group presenting a lower mean age (55.46±8.7 vs 65.39±11.5 p<0.001), as well as a higher frequency of a history of early ischemic heart disease and smoking, and a lower frequency of arterial hypertension and diabetes (Table). Lipid-lowering treatment at discharge was similar in both groups. In patients undergoing CR there was a lower level of total cholesterol and low-density lipoprotein cholesterol (LDLc) at one year (126.2±27 vs 137.2±34, p=0.002; 57.8±23 vs 67.5±26, p<0.001) compared to the group without CR. A greater reduction in LDLc (41.4% vs 0.86%, p<0.001) was achieved even from higher initial LDLc values. Titration of lipid-lowering treatment was also greater, with the old target of LDLc < 70 being achieved in a greater number of cases (81.5% vs 59.3%, p<0.001). At 1-year follow-up, the new cholesterol reduction target (LDL <55 or 50% reduction) was achieved in only 26.8% of patients, with a greater reduction being obtained in the CR group (34.1% vs 17.9%; p=0.02).

At 2-year follow up, in CR group we found low rates of re-infarction (3.2% vs 4.1%), new revascularization (5.8% vs 7.3%), not statistically significant, but we could observe differences in mortality from all causes (0% vs 4.8%, p<0.01).

Conclusions

Participation in a CR program is associated with better lipid control in patients admitted for STEACS. These programs represent a basic tool for achieving increasingly demanding LDLc targets. Longer follow-up is needed to detect clinically important adverse events.
Exposure to hyperoxemia and mortality in cardiac intensive care unit patients
Authors: Alviar C , Jentzer J , Van Diepen S , Metkus T , Miller P E , Kashani K B
Published: May 2024

Funding Acknowledgements

None.

Background

Hyperoxemia (a high PaO2, i.e. >200-300 mmHg) has been associated with adverse outcomes in general critical care settings as well as in acute cardiovascular care conditions. The association between hyperoxemia and mortality has not been characterized in the heterogeneous population admitted to the cardiac intensive care unit (CICU). We aimed to examine the association between hyperoxemia on CICU admission with in-hospital mortality.

Methods

We retrospectively analyzed Mayo Clinic CICU patients from January 2007 to April 2018. PaO2 closest on admission was analyzed as a continuous variable (per 100 mmHg) and categorized as: 60-100 mmHg (51.9%), 101-150 mmHg (28.6%), 151-200 mmHg (10.6%), 201-300 mmHg (6.4%), and >300 mmHg (2.5%). Those without PaO2 on admission and those with hypoxemia were excluded. The primary outcome was all-cause in-hospital mortality evaluated using logistic regression, after adjusting for age, Charlson Comorbidity Index, M-CARS, and use of IMV and NIPPV.

Results

A total of 3,368 patients were included (median 70.3 years, 39.4% women). Admission diagnoses included ACS (37.0%, with 19.8% STEMI), HF (67.8%), shock (33.0%) and cardiac arrest (25.3%). Median admission PaO2 was 99 (IQR 78, 136) mmHg, with no difference in median PaO2 between hospital survivors and inpatient deaths (99 versus 98, p = 0.38). A J-shaped relationship was observed between admission PaO2 and in-hospital mortality (Figure A), with slightly higher mortality below 100 mmHg and incrementally higher mortality above this threshold (esp. at >200 mmHg). The incremental association between higher PaO2 and mortality (adjusted OR 1.17 per 100 mmHg higher, 95% CI 1.01-1.34, P = 0.03) was focused in the highest PaO2 group (i.e., >300 mmHg; Figure B).

Conclusion

Hyperoxia (esp. PaO2 >300 mmHg) on CICU admission is associated with increased in-hospital mortality, demonstrating a J-shaped association with an inflection point of lowest mortality around 100 mmHg. Further studies are warranted to assess if specific oxygen targets influence outcomes in critically ill cardiac patients.
Higher mortality among off-hours versus regular-hours admissions to the cardiac intensive care unit (CICU): insights from the critical care cardiology trials network registry (CCCTN)
Authors: Mahmood U , Isath A , Namrata F , Bali A , Berg D , Bohula E , Guo J , Morrow D , Cooper H
Published: May 2024

Funding Acknowledgements

None.

Background

The outcomes of patients admitted to general intensive care units vary significantly according to the time of admission. Whether this applies to the CICU setting is unknown.

Purpose

We sought to determine if patient characteristics, admission source, critical care therapy utilization, and clinical outcomes differ according to whether CICU admission occurred during regular-hours or off-hours.

Methods

CCCTN is a multicenter prospective registry of consecutive admissions to CICUs in North America coordinated by the TIMI Study Group. For this analysis of admissions during calendar year 2022, "regular-hours" was defined as 7 a.m.- 7 p.m. Monday-Friday, and "off-hours" was defined as 7 p.m.- 7 a.m. on weekdays or at any time on Saturday or Sunday. Logistic regression analysis was used to adjust in-hospital mortality rates for admission time (on-hours vs. off-hours), age, sex, SOFA score, and cardiac arrest.

Results

Among 5238 CICU admissions, 2956 (56.4%) occurred during off-hours. Patient demographics (mean age: 67.0 years, 35.7% female, 51.1% white) and comorbidities were generally similar among off-hours and regular-hours admissions. The median SOFA score was 3.0 in both groups. Compared to regular-hours admissions, off-hours admissions were more likely to originate from the ED (39.9% vs. 29.4%, p<0.0001) and less likely to originate from a procedural area (24.5% vs. 41.8%, p<0.0001). ST-elevation MI was a more common admission diagnosis among off-hours vs. regular-hours admissions (19.2% vs. 16.4%, p=0.009). Primary CICU indications of respiratory insufficiency, unstable arrhythmia, cardiac arrest, and distributive/mixed shock were more common among off-hours admissions (Table). Mechanical ventilation, IV vasoactive therapy, and targeted temperature management (TTM) were utilized more frequently among patients admitted during off-hours. Median ICU (2.5 vs. 2.0d) and hospital length of stay (6.2 vs. 5.8d) were longer for off-hours admissions (both p<0.0001). Crude CICU mortality (11.4% vs. 8.5%, p=0.0005) and in-hospital mortality (15.6% vs. 11.7%, p<0.0001) were significantly higher among off-hours admissions (Figure). After adjustment, off-hours admission remained significantly associated with higher in-hospital mortality (OR 1.2, 95% CI 1.02 – 1.49, p=0.03).

Conclusions

Off-hours and regular-hours admissions to the CICU had similar baseline characteristics but differed significantly regarding source of admission, indication for admission, and utilization of critical care therapies. These differences were associated with worse clinical outcomes among off-hours admissions, which may suggest the need for more intensive staffing in CICUs during these times.FigureTable
Percutaneous coronary intervention and risk of major adverse cardiovascular events in patients with coronary artery ectasia and acute coronary syndrome
Authors: Villalobos-Pedroza M , Araiza-Garaygordobil D , Vega-Servin N S , Arias-Mendoza M A , Solis-Jimenez F , Eid-Lidt G
Published: May 2024

Funding Acknowledgements

None.

Background

Coronary artery ectasia (CAE) is defined as segmental or diffuse dilation of a coronary artery with a diameter of at least 1.5 times the normal adjacent segment, affecting more than one-third of the length of the artery. It has been described as a relatively infrequent finding with a prevalence from 0.3% to 5%, however, in our population we have previously found it higher, up to 6.7%.

In patients with STEMI and ectatic infarct-related artery (EIRA), performing percutaneous coronary intervention (PCI) has been reported to provide better in-hospital outcomes (3), but long-term prognosis remains controversial, with a high mortality risk and cardiovascular events after PCI.

No standard approach has been defined for interventional treatment in the acute setting. High thrombus burden and coronary dilation make interventional treatment more challenging.

Aim

The aim of the present study was to assess the rate of MACE in the long-term according to the use of PCI in patients with CAE and ACS.

Methods

This was a retrospective analysis of a randomized controlled trial (OVERTIME NCT). Sixty-two consecutive patients with ACS (STEMI or NSTEMI) in whom coronary angiography demonstrated CAE were included.

Results

The mean age of the 62 patients was 55.7+/- 10.6 years. Of them, 12.9% were women and 87.1% were men. The most common presentation was STEMI in 52 patients (83.8%) and 10 patients (19.2%) presented with NSTEMI. After coronary angiography, 48.4% received PCI and 51.6% did not. Baseline clinical characteristics were not different between groups.

During follow up, 8 patients (12.9%) presented a MACE. We found that the risk of MACE was not statistically different, by PCI use (HR 0.67, 95% CI 0.16-2.84, p = 0.5) (Figure 1). We also analyzed the intracoronary use of glycoprotein IIb/IIIa inhibitors, with no long-term differences between groups.

Conclusions

In patients with CAE and ACS, we found non-statistically significant differences in the risk of MACE between patients who were treated with PCI compared to those without PCI.
Real-world clinical outcome related to veno-arterial extracorporeal membranous oxygenator: a single-center experience
Authors: Lee S , Kang E , Heo M , Ahn C
Published: May 2024

Funding Acknowledgements

None.

Background

Veno-arterial extracorporeal membranous oxygenator (VA-ECMO) is one of the most powerful devices that rapidly restore sufficient organ perfusion in patients with cardiogenic shock. Despite abundant experiences of successful resuscitation with VA-ECMO, evidences for clinical benefit of VA-ECMO are still lacking.

Purpose

We summarised clinical outcomes related to VA-ECMO and investigated predictors regarding survival at discharge.

Methods

Patients who treated with peripheral VA-ECMO between 2006 and 2022 were included from a Hospital in South Korea. Eligible patients were analysed in stratification with ECMO initiation year (year 2006–2010, year 2011–2016, and year 2017–2022). Survival status at discharge were investigated.

Results

Among total of 693 patients included, 223 (32.2%) were survived at discharge. Survivors had stayed in hospital for median 28 (19–52) days. The overall volume of ECMO initiation (86 runs vs. 250 runs vs. 357 runs) and the rate of extracorporeal CPR (3.5% vs. 18.4% vs. 38.1%) have increased over time. The median duration of VA-ECMO treatment has increased over time (52.6 hours vs. 63.6 hours vs. 85.8 hours). The serum lactate test has been performed more frequently over time (15.1% vs. 79.6% vs. 99.2%). Among 470 patients who died in the index hospitalization, 154 (32.8%) patients died in the first 24 hours after initiation of VA-ECMO. In a multivariate regression model, age over 70 (OR, 0.54; 95% CI, 0.32–0.89), extracorporeal CPR (OR, 0.42; 95% CI, 0.24–0.71), and lactate level ≥8.0 mmol/L (OR, 0.24; 95% CI, 0.15–0.37) were associated with unfavorable outcome while hemoglobin was a predictor of favorable clinical outcome (OR, 1.16; 95% CI, 1.07–1.25).

Conclusion

The volume of VA-ECMO has increased and clinical severity has also become higher than before. The rate of survival at discharge after VA-ECMO treatment remains stable; however, the rate of patients who died in the first 24 hours is still high. Age, extracorporeal CPR, hemoglobin and lactate levels were predictors of clinical outcome after VA-ECMO treatment.
Out of hospital sudden cardiac arrest as a prognostic factor for in-hospital mortality in patients admitted with cardiogenic shock
Authors: Sokolski M , Krupka D , Chelmonski A , Mazur K , Barteczko B , Jarosz A , Bochenek M , Biegus J , Zymlinski R , Gozdzik W , Przybylski R , Kuliczkowski W
Published: May 2024

Funding Acknowledgements

None.

Background

The mortality in cardiogenic shock (CS) is still high despite new comprehensive therapies. Cardiac arrest (CA) frequently complicates CS which can have an unfavourable effect on the course after admission.

Purpose

The study aimed to analyse the clinical characteristics and prognosis of patients admitted with CS after out-of-hospital cardiac arrest (OHCA) compared to the group without OHCA.

Methods

The studied group consisted of a total of 80 patients with an average age of 62 ± 13 years (81 % male) admitted to tertiary hospital with CS in the period 2021-2022. The severity of the shock according to the Society for Cardiac Angiography and Interventions (SCAI) SHOCK classification among the whole population was from C to E: 7 (9%), 38 (48%), and 35 (43%), respectively. The cohort was divided into 2 subgroups: the OHCA group consisted of 23 individuals (29%) and the without OHCA (non-OHCA group) consisted of 57 individuals.

Results

The groups did not differ in terms of demographic parameters and comorbidities. There were no differences in baseline heart rate 95 [50;114] vs. 91 [77;105] beats per minute and mean artery pressure 75 [70;97] vs. 82 [70;97] mmHg for OHCA vs. non-OHCA, respectively, all p> 0.05. Patients from OHCA group had higher baseline creatinine level 1.65 [1.35;1.88] vs. 1.37 [1.08; 1.65] mg/dL, p=0.019, white blood cell count 12 [9;16] vs. 17 [12;23] × 109/L, p=0.015 and lower pH from blood gas analysis 7.0 [6.9;7.2] vs. 7.3 [7.2;7.4], p<0.001). In the OHCA group, 90% of cases of CS were caused by acute coronary syndrome (ACS), while in the group without OHCA, 76% were due to ACS and 20 % due to the progression of chronic heart failure, p=0.032. Mechanical Circulatory Support (MCS) was used in almost every patient (98% non-OHCA vs. 95% OHCA), however, the OHCA group was more often treated with V-A ECMO 14 (64%) vs. 16 (28%) in the non-OHCA, p=0.004. The overall number of in-hospital deaths was 57 (71%). The OHCA group had significantly higher in-hospital mortality 22 (96%) compared to the non-OHCA patients 35 (61%), p=0.002.

Conclusion

Patients experiencing CS complicated by OHCA have more often ischaemic ethology of shock, have a greater degree of organ damage and a lower pH in blood gas analysis at admission, and have extremely high in-hospital mortality rates when compared with patients facing CS but without prior OHCA, which underscores the urgent need for improved prevention methods, interventions, and public awareness.
Incidence of left ventricle thrombus formation in patients with STEMI in the current era of antithrombotic treatment
Authors: Dibra L , Collaku M , Pavli E , Dado E , Gjana A , Kristo A , Tafaj E , Katana E , Kastrati A , Dibra A
Published: May 2024

Funding Acknowledgements

None.

Introduction

Left ventricular (LV) thrombus formation is a serious complication of acute ST-segment elevation myocardial infarction (STEMI) which may result in ischemic stroke and systemic thromboembolism. There is limited evidence on the incidence and impact of LV thrombus in STEMI patients in the current era of antithrombotic treatment.

Purpose

To evaluate the incidence of LV thrombus formation in STEMI patients and to assess clinical predictor factors of LV thrombus formation leading to in-hospital major cardiac events (MACCE).

Methods

We prospective collected data from 504 STEMI patients treated with primary percutaneous intervention (PCI) in our large volume university hospital from April 2019 to September 2019. All patients underwent echocardiography examination at presentation and at hospital discharge.

Results

Mean age of the patients was 66.2 years and 78.8% were male. The incidence of LV thrombus formation was 5% in overall cohort and 9.4% in anterior STEMI. Among patients with LV thrombus, the majority had anterior STEMI (96% vs 48.4%; p<0.001), lower LV ejection fraction (LVEF)(35% vs 43%; P<0.001), more increased LV dimension /volume (36%vs7.3%; p<0.001), more apical aneurism/dyskinesia presence (36% vs 9%; p<0.001), longer ischemia time (25 hours vs 14 hours; p<0.002), more increased TPI values (p-0.22) and underwent less coronary angiography (p<0.02) and primary PCI (P=0.021). Increased LV dimension/volume was associated with 3.35 times higher risk of having LV thrombus (p=0.023). Also anterior STEMI was associated with 14 times higher risk of having LV thrombus=0.012. Patients with LV thrombus had a numerically higher incidence of in-hospital MACCE events (20% vs 13.5%; p=0.36).

Conclusion

The incidence of LV thrombus formation in STEMI still remain high regardless of primary PCI treatment and current antithrombotic treatment, and is higher in patients with anterior STEMI, lower LVEF, adverse ventricular remodeling, apical aneurism/dyskinesia presence, late hospital presentation and longer ischemia time. The presence of LV thrombus was independently associated with in-hospital MACCE events.
Women with acute heart failure receive help from a cardiologist faster than men-gender disparities in acute heart failure
Authors: Plonka J , Chruscicki D , Wezyk N , Dabrowska K , Rzepiela L , Zielinski R , Feusette R , Gierlotka M
Published: May 2024

Funding Acknowledgements

None.

Introduction

Acute heart failure (AHF) is a life-threatening condition that requires quick diagnosis and immediate treatment. Emergency Department (ED) is a major stage for hospitalized patients with AHF. Recent studies have highlighted that the efficacy of any intervention and treatment may be time dependent.

Purpose

The aim of the study was to analyze the management of patients with AHF depending on gender before treatment in Intensive Cardiac Care Unit (ICCU).

Materials and methods

In the period from 06/2019 to 01/2021, 767 patients with a diagnosis of acute heart failure (AHF) were urgently admitted to the ED. The most severely unwell 122 patients diagnosed with AHF required treatment in the ICCU . The time of onset of AHF symptoms (SYMPTOMS), first medical contact (FMC) and the time of cardiologist consultation (CC) in the Emergency Department were determined.

Results

In the study group of 767 patients with AHF presenting to the ED, women constituted 37%.They were less likely to be admitted to the Cardiology Department with a diagnosis of AHF than men (29.5% versus 40.2%) however they died more often in the ED (6.0% versus 2.7%). Among the 122 patients with AHF treated in the ICCU, the majority were men (72%), the mean age was 68 years and the median LVEF = 30% [IQR 20-38%]. In both sexes, the phe.notype of acute decompensated heart failure predominated (68% in women and 82% in men), although acute pulmonary oedema was slightly more common in women (26% versus 15% in men). Women contacted a doctor or called an ambulance faster than men (median time SYMPTOMS to FMC shorter by 1.6 days) and the time from FMC to consultation with a cardiologist was shorter (median time SYMPTOMS to FMC shorter by 0.17th day). Consequently, the delay time from the onset of symptoms to cardiology consultation was twice shorter in women than in men: 3.1 [IQR 0.3-8.4] days vesus 6.9 [IQR1.3-15.3], p=0.05.

Conclusion

Women with acute heart failure treated in the Intensive Cardiac Care Unit see a doctor faster and also receive specialist help from a cardiologist faster than men.
Left ventricular systolic function in patients with acute coronary syndrome-risk profile
Authors: Dobjani A , Bogevska Naumovska I , Vraynko E , Shehu E , Taravari H , Andova V , Pejkov H , Vavlukis M
Published: May 2024

Funding Acknowledgements

None.

Introductions and objectives

Left ventricular (LV) systolic dysfunction is one of the most important determinants of long-term outcome in acute coronary syndrome (ACS).

Aim

To determine the impact of the patient’s risk profile on the LV systolic function.

Methods

A single-center cross-sectional cohort study that included 3093 patients with ACS without pre-existing LV dysfunction. The comparison was performed between patients who did or did not develop a reduction in LV systolic function during the index event (<50%/≥50%), analyzing patients’ demographic, clinical, biochemical data, LV functional data, and anatomical distribution of the coronary artery disease (CAD).

Result

1369 patients out of 3093 developed LV systolic dysfunction (44.3%). They were predominantly males 75.1% (1028), p=0.002; older (63.39±11.04 vs 61.21±11.12, p<0.00000); had higher level of cardiac troponin (p=0.00002), higher stress glycemia (9.2±5.3; p=0.0000001), HbA1c (6.9±1.8, p=0.000003), WBC (11.7±4.1, p=0.00001), blood urea nitrogen (BUN) (6.8±3.7, p=0.000003), and creatinine (93.2±45.1 p=0.000167), and had anemia (OR 0.35 (CI 0.29–41, p=0.000012). They had more severe CAD (SINTAX score 16.8±8.4 p=0.000012). Patients with preserved LV systolic function were predominantly females (29.7%, OR 1.1 95% CI 1.0-1.2), p = 0.002), younger (p<0.00000), and severely metabolically burdened (hypothyreosis (2.7%, OR 1.28 95% CI 0.93-1.76, p=0.052), higher levels of triglycerides (2.2±1.7 vs 1.9±1.5, p = 0.001), cholesterol (5.3±1.4 vs 5.2±1.4, p = 0.002), non-HDL-C (4.1±1.5 vs 3.9±1.3, p=0.006), however less likely to have pre-existing DM (OR 0.8 (CI 0.78–0.92), p=0.000094). They were more often NSTEMI [851 (49.4%), p = 0.000012]. Independent variables associated with a reduction in LV function were: advanced age, male gender, previous DM and anemia, stress glycemia, WBC, creatinine, and BUN.

Conclusion

Patients who developed reduced LV function had a very specific risk profile with bigger neuro-hormonal activation and inflammation, higher degree of myocardial damage, and worse renal function, whereas those with preserved LV systolic function after ACS were younger, predominantly females, more severely metabolically burdened, more often with NSTEMI and without LAD involvement.
Exploring the utility of the CSWG SCAI classification in patients with HF-CS requiring inotropic therapy
Authors: Ris T , Atazadah M , Van De Veerdonk M C , Nap A
Published: May 2024

Funding Acknowledgements

None.

Background

The Society for Cardiovascular Angiography and Interventions (SCAI) classification has been a well-established tool for risk stratification in heart failure cardiogenic shock (HF-CS). The recent CSWG SCAI classification provides easily obtainable parameters to classify CS severity. However, its utility has been mostly investigated in an intensive care unit (ICU) setting. Therefore, data on a more broad cohort of patients in whom inotropic therapy is deemed necessary is lacking.

Purpose

This study aimed to analyze the trajectory of patients necessitating inotropic therapy due to HF-CS and the utility of the proposed CSWG SCAI criteria in time.

Methods

We retrospectively analyzed patients admitted with acute HF who received inotropic therapy due to developing HF-CS at any time during admission. Patients with out-of-hospital cardiac arrest and acute coronary syndrome were excluded. SCAI stages were assigned retrospectively using the latest CSWG SCAI criteria during admission, pre-inotropic therapy, and at worst SCAI. The diagnostic performance of the CSWG SCAI criteria for predicting mortality during admission was assessed.

Results

This study included 333 patients with HF-CS. Of these patients, 221 (66%) were male, with a mean age of 70 years. The majority of patients were admitted with SCAI A (45%) and B (36%), and inotropic therapy was most often initiated in SCAI stage B (46%). Notably, 21% patient of the patients at time of inotropic therapy were still in SCAI A. In 52% of all patients inotropes was initiated within 24 hours of admission. The most frequently observed worst SCAI classification was C (41%). Lactate and blood pressure (BP) were responsible for the majority of SCAI B-D classifications at admission and pre-inotropic therapy, while pH was an important determent for SCAI E. However, vasoactive therapy was the most common determent for worst SCAI (71%), followed by BP (24%). Mortality rates for pre-inotropic therapy SCAI for classes A-E were 30%, 39%, 47%, 55%, and 48%. Mortality rates for worst SCAI C-E were 29%, 39%, and 59%. The area under the curve for predicting mortality was higher for worst SCAI as compared to pre-inotropic therapy SCAI (0.633 vs. 0.573, p=0.03). There was no difference in mortality between early (<24h) vs. late (>24h) initiation of inotropic therapy (p=0.43).

Conclusion

In our study the CSWG SCAI criteria proved to be challenging to apply in patients in whom inotropic therapy is considered, especially for patients classified as SCAI E. However, improvement of the CSWG SCAI performance was observed when it was applied at the time corresponding to the worst SCAI stage to predict mortality. More studies are required to further optimize the SCAI criteria in this specific subset of patients. In summary, our study provides valuable insights into the application of the CSWG SCAI classification in a diverse HF-CS population, specifically those requiring inotropic therapy.
Pulmonary artery catheter and veno-arterial ECMO training for cardiology fellows: evaluation of a simulation-based program
Authors: Alviar C , Lorin J , Andriotis A , Pradhan D , Pashun R , Wan K L , Schimmer H , Padilla-Lopez M , Tarabanis C , Keller N M , Bangalore S , Baneras Rius J
Published: May 2024

Funding Acknowledgements

None.

Introduction

Proficiency in pulmonary artery catheter (PAC) use and extracorporeal membrane oxygenation (ECMO) therapy is crucial for delivering high-quality critical care and improving patient outcomes in cardiac intensive care units (CICUs). Both procedures are conducive to immersive simulation training. Our study focuses on evaluating the efficacy of a simulation-based training program in these specific domains for cardiology fellows.

Methods

Cardiology fellows participated in two blended learning courses: one on PAC and one on veno-arterial ECMO. The PAC course consisted of a pre-course test of 12 multiple-choice questions assessing knowledge of indications, contraindications, and interpretation of PAC, a 45-minute didactic lecture, followed by a case-based, hands-on simulation training session for 60 minutes. The ECMO course consisted of a pre-course test of 15 multiple-choice questions assessing indications, contraindications, ECMO physiology, and circuit management, a 30-minute didactic lecture, followed by a case-based, hands-on simulation training session. Fellows completed a multiple-choice post-course test within 72 hours post-simulation training. All test questions were designed by experts in cardiac critical care.

Results

A total of 18 cardiology fellows completed the PAC simulation and 16 completed the ECMO simulation. For the PAC group the average score on the pre-exam was 60%, while on the post exam, the average score increased significantly to 86%, representing a 26% increase (p=0.04). For the ECMO training, the average score on the pre-exam was 67%, and on the post exam, the average score increased substantially to 90% in the ECMO exam, there was a 23% increase in the average post-exam score compared to the pre exam was recorded (p=0.05).

Conclusion

Simulation-based training in PAC and ECMO has a highly positive impact on the knowledge acquisition of cardiology fellows, with statistically significant increases in average post-exam scores in both areas. These findings not only validate the value of immersive simulation-based training programs but also underscore the need for further investigation into the implementation of educational initiatives aimed at enhancing care in cardiogenic shock.
Referral and outcomes of mechanical thrombectomy for pulmonary embolism - a single-centre experience
Authors: Aguiar Neves A I , Teixeira R , Leite M , Nunes F , Almeida M , Lobo A , Pires-Morais G , Santos L , Melica B , Rodrigues A , Braga P , Fontes-Carvalho R
Published: May 2024

Funding Acknowledgements

None.

Introduction

Acute pulmonary embolism (PE) is a significant cause of morbidity and mortality, and percutaneous catheter-based treatments have emerged as an effective treatment option alongside thrombolysis. However, data concerning long-term outcomes are scarce.

Methods

All patients referred to a tertiary centre for pulmonary angiography with the intent to perform mechanical thrombectomy in the context of acute PE between January 2016 and August 2023 were retrospectively included and clinical data and outcomes were collected.

Results

Fifty-two patients (58% female; mean age 66±18 years) were referred to pulmonary angiography in the setting of acute PE, of whom 40 patients (77%) underwent continuous aspiration mechanical thrombectomy with an overall success rate of 70%. Twenty-eight percent of patients had bilateral thrombus. Thirty-two patients had intermediate-high risk or high-risk PE, and the mean Pulmonary Embolism Severity Index (PESI) was 146 points. Thirteen patients (25%) underwent thrombolysis prior to angiography, while 15 patients (28%) had an absolute or relative contraindication for thrombolysis.

Ventilation/perfusion scans were performed in ten patients (19%) during the follow-up period, of whom five patients (10%) had evidence of residual illness, with no significant differences between the thrombectomy and non-thrombectomy groups (p=0.8).

The overall mortality rate over the complete follow-up period was 39%, while 25% of patients died within 48 hours of the procedure. Predictors of mortality on univariate analysis included older age (HR 1.06 [95% CI 1.00-1.11, p = 0.03]), history of chronic obstructive pulmonary disease (HR 3.88 [95% CI 1.41-10.69, p = 0.01]), history of previous deep vein thrombosis or PE (HR 3.40 [95% CI 1.34-8.63, p = 0.01]), thrombolysis prior to referral for mechanical thrombectomy (HR 5.94 [95% CI 1.93-18.26, p <0.01), shock or haemodynamic instability (HR 8.50 [95% CI 2.44-29,52, p <0.01]) and resuscitated cardiac arrest (HR 5.98 [95% CI 2.34-15.30, p <0.01]). On Cox multivariate analysis, the presence of shock or haemodynamic instability was a predictor of increased mortality (HR 5.23 [95% CI 1.12-24.3, p = 0.04]).

Conclusions

Intermediate and high risk acute PE is a clinical entity with a high morbidity and mortality rate regardless of treatment strategy, particularly during the index hospitalization and in patients with shock or haemodynamic instability.
Microvascular dysfunction associated with reduced nailfold capillary density in patients with ischemia with no obstructive coronary artery disease
Authors: Sakalidis A , Dimitriadis K , Bora M , Karanikola A E , Aznaouridis K , Papanikolaou A , Dris I , Leontsinis I , Mantzouranis E , Iliakis P , Vlachakis P K , Tsioufis P , Koulouriotis A , Aggeli K , Tsioufis K
Published: May 2024

Funding Acknowledgements

None.

Introduction

The impairment of microvascular function present in coronary microcirculation with chronic angina without obstructive coronary arteries. There are insufficient data in the literature regarding possible generalized microangiopathy in this population.

Aim

The aim of this study is to demonstrate whether patients with Angina with No Obstructive Coronary Artery Disease (ANOCA) compared to individuals without coronary microvascular dysfunction (CMD) are characterized by a different level of nailfold capillaroscopy abnormalities.

Methods

We examined 18 participants without CMD - non-CMD group [9 female, 50%, mean age: 54.4±8.1 years) and 26 patients with ANOCA - CMD group (22 female, 84,6%, mean age : 53.2±10.7 years).

Functional coronary angiography was performed for the assessment of coronary microcirculation in all patients. Coronary flow reserve (CFR) and index of microvascular resistance (IMR) were measured in the left anterior descending coronary artery using a temperature/pressure sensor-tipped guidewire.

In addition, the assessment of skin microcirculation was performed by capillaroscopy, a non-invasive technique to evaluate small vessels of the microcirculation in the nailfold, using stereomicroscope in all patients.

Results

In CMD group, mean CFR and IMR were 1.34±0.6 and 44.8±28, respectively. Out of the 26 MVD patients with abnormal CFR, 7 of them (27%) had a normal value of IMR, indicating functional microvascular dysfunction. On the other hand, 18 patients (69%) had an abnormal IMR, indicating structural microvascular dysfunction. Capillary density in patients with MVD was significantly decreased compared to the control group (7.6±2.2 vs 10.9±1.8 vessels/mm, p=0.04). The difference in capillary density between the two groups was statistically significant after adjustment for multiple comparisons (p<0.05). No significant difference was found in body mass index, renal function, medical history of dyslipidemia, diabetes mellitus and smoking status between the two groups (p<0.05).

Conclusion

Nailfold capillary density was reduced in ANOCA patients compared to control group. These data may provide new insights regarding possible generalized microangiopathy in CMD patients.

These results suggest that there is an association between microcirculatory impairment at both heart and peripheral vascular bed level.
Is International Criminal Law Ready to Accommodate Online Harm?
Authors: Zarmsky Sarah
Published: May 2024

New technologies have the potential to both advance accountability for international crimes and to aid in their perpetration. Most of the existing literature to date focuses on the former, such as how digital evidence can be used in international criminal law (ICL) proceedings, or in the case of the latter, has taken a mainly rights-based approach (such as how technology can infringe upon rights to privacy or freedom of expression). This article answers the understudied question of how technology can serve as the vehicle by which certain international crimes are committed or lead to new offences, and how current ICL frameworks may be able to accommodate these ‘online harms’ to ensure that the law recognizes the full scope of harms caused to victims, who currently may not be able to access redress through the international criminal justice system. It identifies three examples of online harm that have a foreseeable nexus to the perpetration of international crimes, including hate speech and disinformation, sharing footage of crimes to the internet, and online sexual violence. The article evaluates the online harms alongside similar harms that have been encompassed by core ICL crimes, including genocide, crimes against humanity, and war crimes, to assess how online harms might fit into ICL frameworks (e.g. as an aggravating factor at sentencing, a new mode of commission of an existing crime, or a new crime). It concludes that some types of online harm may be more feasible to account for than others, and identifies where the existing ICL architecture falls short, which is important for providing a basis for future research as to how to best include novel online harms under ICL. Finally, the article emphasizes that as technology will only continue to develop and serve as a vehicle for an increasing array of harms, finding ways to account for online harm and bring redress to victims should be an issue at the forefront of ICL.
The FAcilitates Chromatin Transcription complex regulates the ratio of glycolysis to oxidative phosphorylation in neural stem cells
Authors: Lou Yuhan , Wu Litao , Cai Wanlin , Deng Huan , Sang Rong , Xie Shanshan , Xu Xiao , Yuan Xin , Wu Cheng , Xu Man , Ge Wanzhong , Xi Yongmei , Yang Xiaohang
Published: May 2024

Defects in the FAcilitates Chromatin Transcription (FACT) complex, a histone chaperone composed of SSRP1 and SUPT16H, are implicated in intellectual disability. Here, we reveal that the FACT complex promotes glycolysis and sustains the correct cell fate of neural stem cells/neuroblasts in the Drosophila 3rd instar larval central brain. We show that the FACT complex binds to the promoter region of the estrogen-related receptor (ERR) gene and positively regulates ERR expression. ERR is known to act as an aerobic glycolytic switch by upregulating the enzymes required for glycolysis. Dysfunction of the FACT complex leads to the downregulation of ERR transcription, resulting in a decreased ratio of glycolysis to oxidative phosphorylation (G/O) in neuroblasts. Consequently, neuroblasts exhibit smaller cell sizes, lower proliferation potential, and altered cell fates. Overexpression of ERR or suppression of mitochondrial oxidative phosphorylation in neuroblasts increases the relative G/O ratio and rescues defective phenotypes caused by dysfunction of the FACT complex. Thus, the G/O ratio, mediated by the FACT complex, plays a crucial role in neuroblast cell fate maintenance. Our study may shed light on the mechanism by which mutations in the FACT complex lead to intellectual disability in humans.
Sandwich boosting for accurate estimation in partially linear models for grouped data
Authors: Young Elliot H , Shah Rajen D
Published: May 2024

We study partially linear models in settings where observations are arranged in independent groups but may exhibit within-group dependence. Existing approaches estimate linear model parameters through weighted least squares, with optimal weights (given by the inverse covariance of the response, conditional on the covariates) typically estimated by maximizing a (restricted) likelihood from random effects modelling or by using generalized estimating equations. We introduce a new ‘sandwich loss’ whose population minimizer coincides with the weights of these approaches when the parametric forms for the conditional covariance are well-specified, but can yield arbitrarily large improvements in linear parameter estimation accuracy when they are not. Under relatively mild conditions, our estimated coefficients are asymptotically Gaussian and enjoy minimal variance among estimators with weights restricted to a given class of functions, when user-chosen regression methods are used to estimate nuisance functions. We further expand the class of functional forms for the weights that may be fitted beyond parametric models by leveraging the flexibility of modern machine learning methods within a new gradient boosting scheme for minimizing the sandwich loss. We demonstrate the effectiveness of both the sandwich loss and what we call ‘sandwich boosting’ in a variety of settings with simulated and real-world data.
Civilian and Military Medical School Graduates’ Readiness for Deployment: Areas of Strength and Opportunities for Growth
Authors: Cole Rebekah , Durning Steven J , Shen Cynthia , Reamy Brian V , Rudinsky Sherri L
Published: May 2024

Introduction

Past research has examined civilian and military medical schools’ preparation of physicians for their first deployment. Most recently, our research team conducted a large-scale survey comparing physicians’ perceptions of their readiness for their first deployment. Our results revealed that military medical school graduates felt significantly more prepared for deployment by medical school than civilian medical school graduates. In order to further investigate these results and deepen our understanding of the two pathways’ preparation of military physicians, this study analyzed the open-ended responses in the survey using a qualitative research design.

Materials and Methods

We used a descriptive phenomenological design to analyze 451 participants’ open-ended responses on the survey. After becoming familiar with the data, we coded the participants’ responses for meaningful statements. We organized these codes into major categories, which became the themes of our study. Finally, we labeled each of these themes to reflect the participants’ perceptions of how medical school prepared them for deployment.

Results

Four themes emerged from our data analysis: (1) Civilian medical school equipped graduates with soft skills and medical knowledge for their first deployment; (2) Civilian medical school may not have adequately prepared graduates to practice medicine in an austere environment to include the officership challenges of deployment; (3) Military medical school prepared graduates to navigate the medical practice and operational aspects of their first deployment; and (4) Military medical school may not have adequately prepared graduates for the realism of their first deployment.

Conclusions

Our study provided insight into the strengths and areas for growth in each medical school pathway for military medical officers. These results may be used to enhance military medical training regardless of accession pathway and increase the readiness of military physicians for future large-scale conflicts.