bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of the effect of older age on the diagnostic specificity of high-sensitivity troponin I and high-sensitivity troponin T in patients with suspected acute myocardial infarction
Authors: Von Jeinsen B , Brandebussemeyer S , Gruen D , Bormann J , Psyrakis D , Wolter J.S , Kriechbaum S , Doerr O , Troidl C , Nef H , Hamm C.W , Liebetrau C , Keller T
Published: November 2020

Background

Cardiac troponins have become the gold standard for appropriate and rapid diagnosis of an acute myocardial infarction (AMI). However, elevated cardiac troponins levels can be observed in the absence of AMI in elderly patients and therefore a loss of specificity is seen in the diagnosis of AMI in elderly patients.

Purpose

This study aims to define old age in suspected AMI and to evaluate the effect of older age on the diagnostic specificity of a high sensitivity troponin I (hs-cTnI) and high sensitivity troponin T (hs-cTnT) assay in elderly women and men.

Methods

This study used data from patients with suspected AMI who were enrolled between 08–2011 and 10–2016 to a multicentre biomarker registry and an University Hospital and with available hs-cTnI and hs-cTnT upon admission (n=564 patients). First, we investigated the effect of age on the specificity of both hs-cTnI and hs-cTnT to detect AMI continuously. We then classified over seventy-year-olds as elderly (n=281; 49,8%) and compared the specificity of hs-cTnI and hs-cTnT between elderly and younger patients.

Results

In the group of older patients, 62.6% (n=176) were diagnosed with AMI compared with 50.9% (n=144) in younger age patients (p<0.01). Elderly patients had higher median levels of hs-cTnI and hs-cTnT than younger patients: 45.4 ng/L vs. 13.1 ng/L hs-cTnI (p<0.001) and 36.8 ng/L vs. 12.8 ng/L hs-cTnT (p<0.001) irrespective of the final diagnosis. Figure1 shows a shift in diagnostic specificity for the whole troponin concentration range in elderly patients compared to younger patients starting at the age of 60 years with clear impact in patients older than 70 years used as threshold for old age in further analyses. Applying the 99th percentile cut-off led to a specificity of 93.5% (95% CI: 88.1–97.0%) in younger patients vs. 88.6% (95% CI: 80.9–94.0%) in elderly patients for hs-cTnI and of 91.4% (95% CI: 85.4–95.5%) vs. 65.7% (95% CI: 55.8–74.7%) for hs-cTnT. To achieve the same specificity in elderly patients as in younger patients, optimized rule-in cut-offs were calculated with 2.6-fold of the 99th percentile for hs-cTnI (68.9 ng/L) and 3.1-fold of the 99th percentile for hs-TnT (43.9 ng/L).

Conclusions

The specificity of both, hs-cTnI and hs-cTnT is significantly reduced in elderly patients due to higher hs-cTnT and hs-cTnI levels in elderly patients at admission irrespective of the final diagnosis. A relevant loss in diagnostic specificity is observed at 70 years of age starting already at 60 years. Use of assay-specific adjusted cut-offs for hs-cTnI and hs-cTnT for elderly patients regains diagnostic specificity that leads to a more accurate decision-making concerning “rule-in” for older patients with suspected AMI.

Funding Acknowledgement

Type of funding source: None
Influence of apoe and slco1b1 genes on lipid spectrum and clinical presentation in patients with myocardial infarction and diabetic nephropathy
Authors: Siverina A , Skorodumova E.A , Kostenko V.A , Skorodumova E.G , Fedorov A.N , Rysev A.V
Published: November 2020

Objective

To evaluate effect of APOE and SLCO1B1 genes on course of myocardial infarction (MI) in patients with diabetic nephropathy (DN).

Materials and methods

185 patients treated about MI were examined (Male – 60.5%, 39.5% – females, average age 64.1±4.2 years). Patients were divided into 2 groups: the first (I) – 93 patients with MI and DN, the second (II) – 92 persons with MI without DN. Polymorphism of the APOE (rs769452) and SLCO1B1 (rs4149056) genes. In first 3 days level of total cholesterol (TH) and low density lipoproteins (LDL) were determined in all patients.

Results

Based on the data presented in table 1, patients with MI and DN had a statistically more frequent rate of the LeuPro genotype than in the comparison group, relative to group II – 6.2%, p<0.05. Heterozygotes of the ValAla gene (SLCO1B1) were also more often detected in patients of group I – 26.9% versus group II – 9.8%, p<0.05. Analysis of lipid profile indices in heterozygotes revealed a statistically significant difference only between LDL indices, p<0.05. Clinical presentation: acute heart failure (AHF) III–IV classes by Killip – 2.8 times more often in patients of group I, p<0.05. Chronic heart failure (CHF) NYHA III-IV developed 3 times more often in group I than in the second, p<0.05. High-grade ventricular heart rhythm disorders - more often in group I – 24.7%, relative to the control – 8.7%, p<0.05. Relapses of acute coronary syndrome (ACS) occurred 3 times more often in I than the second, p<0.05. Hospital mortality: I – 11.8%, II – 5.4%, p<0.05.

Conclusions

1. Heterozygous type of inheritance of the Leu28Pro polymorphism of APOE gene and Val174Ala of SLCO1B1 gene, in patients with MI and DN that was confirmed by high levels of TH and LDL, p<0.05.

2. Clinical course of MI in the group with DN against the background of genetically determined hyperlipidemia, and possibly, in association with it was characterized by multiple complications: AHF and CHF, ventricular arrhythmias, relapses of ACS and deaths.

Features of the clinical picture

Funding Acknowledgement

Type of funding source: None
Comparison of admission lung ultrasound and left ventricle end diastolic pressure in patients with ST-segment elevation myocardial infarction submitted to primary percutaneous coronary intervention
Authors: Araujo G.N.D , Beltrame R.B , Luchese J.L , Marques F.M , Scolari F.S , Machado G.M , Silveira A.S , Bergoli L.B , Goncalves S.G , Zimerman A.Z , Fuchs F.F , Wainstein M.W , Wainstein R.W
Published: November 2020

Background/Introduction

Elevated left ventricle end diastolic pressure (LVEDP) is related to diastolic dysfunction, increased retrograde pulmonary capillary pressure and pulmonary congestion. Diastolic dysfunction precedes the onset of systolic dysfunction in acute ischemia, and the prognostic utility of LVEDP in ST-segment elevation myocardial infarction (STEMI) is well known. Bedside lung ultrasound (LUS) is a simple and sensitive method for evaluating pulmonary congestion.

Purpose

The aim of this study was to assess the correlation between LVEDP and LUS and to evaluate their prognostic capacity in STEMI patients submitted to primary percutaneous coronary intervention (PPCI).

Methods

This was a prospective cohort of STEMI patients treated in a tertiary care hospital. LUS was performed by two independent operators before coronary angiography. Our protocol consisted of eight scanning zones; a zone was considered positive in case it presented three or more B lines. LVEDP was recorded before coronary angiography, assessed offline and blinded to LUS results.

Results

We have included 217 patients with mean age of 60 (±12.1) years and 63% were male. Killip 4 on admission was diagnosed in 16.5% of patients and total in-hospital mortality was 14.7%. Median LVEDP and LUS positive sites were 19 mmHg [13, 28] and 1 [0, 5], and spearman correlation between them was 0.33. LUS and LVEDP c-statistics for in-hospital mortality were 0.69 (0.58–0.79) and 0.60 (0.49–0.71), respectively. LUS and LVEDP c-statistics for in-hospital cardiogenic shock were 0.75 (0.67 – 0.83) and 0.65 (0.57–0.74), respectively. A multivariate analysis was performed including 4 or more positive LUS zones, LVEDP >22 mmHg, diabetes and admission creatinine. In patients with 4 or more positive LUS zones, odds ratios of cardiogenic shock and in-hospital mortality were 7.04 (2.89–18.30, p<0.001) and 4.52 (1.92–11.12, p=0.001), respectively. In patients with LVEDP higher than 22 mmHg, odds ratios for cardiogenic shock and in-hospital mortality were 1.43 (0.57–3.54, p=0.437) and 0.88 (0.36–2.09, p=0.768), respectively.

Conclusion

We found no significant correlation between LVEDP and LUS in a STEMI patient's cohort. Unlike LVEDP, LUS had a significant AUC to predict in-hospital mortality. LUS had a great magnitude hazard ratio for cardiogenic shock and in-hospital mortality when 4 or more scanning zones were positive. A high LVEDP did not predict cardiogenic shock or in-hospital mortality on this subset of STEMI patients.

LUS and LVEDP correlation

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Hospital de Clinicas de Porto Alegre and Universidade Federal do Rio Grande do Sul
Breast cancer patients have lower in-hospital mortality after acute coronary syndrome, a 5 year nationwide analysis
Authors: Huang Lucas C , Yue B , Wei X , Wu L , Abed R , Bachoo N , Lopes J , Isath A , Narasimhan B , Contreras J
Published: November 2020

Background

Breast cancer and cardiovascular disease (CVD) share common risk factors, and breast cancer therapies are well known to cause cardiotoxicity. Prior studies highlighted the higher burden coronary artery disease and the importance to further assess its consequences on breast cancer patients.

Purpose

We sought to evaluate the revascularization rate and in-hospital short-term outcomes of breast cancer patients following acute coronary syndrome (ACS) compared to the general female population.

Methods

We reviewed the Nationwide Inpatient Sample from 2010 to 2014 to identify female patients with principal diagnosis of ACS (ST-elevation and non ST-elevation myocardial infarction, and unstable angina). Two subgroups were identified, women with a history of breast cancer and women without, and were propensity matched.

Multivariate regression analyses were performed to evaluate the impact of breast cancer on primary outcome (in-hospital mortality) and secondary outcomes: occurrence of shock, acute kidney injury (AKI), mechanical ventilation (MV), and length of stay (LOS). We also compared the rate of cardiac procedures. Statistical significance of odd ratios (OR) is defined with p-value<0.05 and reported 95% confidence intervals (CI).

Results

We identified a total of 245,563 female patients with primary diagnosis of ACS, among them 10,625 (4.3%) had a history of breast cancer. The comorbidity of breast cancer was associated with statistically significant lower rates of mortality (OR 0.83, CI 0.74–0.94), shock (OR 0.87, CI 0.77–0.99), AKI (OR 0.90, CI 0.82–0.98), MV (OR 0.81, CI 0.71–0.92) and relative 5.4% decrease in LOS (CI: −7.8%, −3.0%). The cardiac procedural rates were similar for left heart catheterization (OR 0.96, CI 0.90–1.02), for percutaneous coronary intervention (OR 0.95, CI 0.89–1.02) and for CABG (OR 0.88, CI 0.78–1.00) compared to control group.

Conclusion

Breast cancer patients received a comparable catheterization and revascularization procedure rate and exhibited a statistically significant lower morbidity and mortality rates during hospitalization after an ACS event compared to the general female population.

Funding Acknowledgement

Type of funding source: None
Optimization of GRACE risk stratification by NT-proBNP combined with D-dimer in patients with non-ST-elevation myocardial infarction
Authors: Lu P.J , Gong X.W , Tian F.S , Yang Q , Liu Y.W , Yao Z.H , Wang J.X , Cui Z , Liu Y , Gao J
Published: November 2020

Background

GRACE risk score is the most widely used tool to predict the risk of death and myocardial infarction in patients with Non-ST-elevation myocardial infarction (NSTEMI). Some biomarkers have been shown to have a high predictive value for prognosis. But the models constructed using these studies have some drawbacks, including the using biomarkers that are not routinely monitored.

Aims

To explore the optimizing role of multiple biomarkers in GRACE risk stratification in NSTEMI and then develop a new scoring system based on GRACE.

Methods

1.This multi-center, prospective, cohort study enrolled 1357 patients (mean age 65±12 years; 57% male). Common clinical indicators were collected within the first 12h after admission. 2.The outcome was 1-year all-cause mortality and major adverse cardiac events (MACE: all-cause death,unstable angina, heart failure, recurrent myocardial infarction and stroke). 3.Cox multivariate anlysis was used to quantify the biomarker effect. C-index, NRI and IDI were calculated to verify that the biomarkers improve the predictive accuracy of GRACE.

Results

1. During follow-up (mean: 339 days), 57 participants died and 211 participants had 231 MACE. In COX analysis, NT-proBNP (P<0.0001), and d-dimer (P=0.0092) were significant independent biomarkers for death. NT-proBNP (P<0.0001), fibrinogen (P=0.0177) and d-dimer (P<0.0001) were significant independent biomarkers for MACE. 2. For all-cause death, the combination of NT-proBNP and D-dimer improved the predictive accuracy of GRACE the most. For MACE, trigeminal combination of NT-proBNP, fibrinogen, and D-dimer improved GRACE the most 3. NT-proBNP, D-dimer, fibrinogen, and GRACE comprise a new scoring system for assessing 1-year clinical events. Kaplan-Meier analysis revealed a significant rise in 1-year mortality and MACE between different score groups.

Conclusions

The combination of NT-proBNP, and d-dimer added the prognostic value of GRACE for all-cause death and MACE. Our newly developed scoring system can be easily calculated in clinical practice and strongly correlated with all-cause mortality and MACE.

Risk score and survival curve

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Major Science and Technology Projects of Tianjin Science and Technology Commission in 2016; Key Project of Healthcare Industry of Tianjin in 2016
Incidence, timing, predictors, and impact of sustained ventricular arrhythmia complicating st-segment elevation myocardial infarction
Authors: Auffret V , Bourenane H , Sharobeem S , Martins R , Leurent G , Bedossa M , Boulmier D , Le Breton H
Published: November 2020

Aims

To describe the incidence, predictors, and in-hospital impact of early SVA (eSVA, occurring < day 2 post-STEMI) and late SVA (lSVA, occurring ≥ day 2 post-STEMI) in STEMI patients. To derive and internally validate a risk score to identify patients at high-risk of lSVA.

Methods

Data of 13523 patients enrolled in the ORBI registry were analysed. Logistic regression was performed to identify predictors of eSVA, lSVA, and in-hospital all-cause mortality. Predictors of lSVA were used to build a risk score.

Results

eSVA occurred in 678 patients (5%) whereas 120 patients (0.9%) experienced lSVA at a median timing of 3 days post-STEMI. eSVA associated with a significantly higher risk of all-cause mortality (adjusted OR:1.90, 95% CI: 1.39–2.61, p<0.001) whereas only a trend was observed with lSVA (adjusted OR: 1.69, 95% CI:0.91–3.13, p=0.09). Multivariable predictors of eSVA are listed in Table 1. Multivariable predictors of lSVA are listed in the Figure. The score derived from these variables allowed the classification of patients into four risk categories: low (0–21), low-to- intermediate (22–34), intermediate-to-high (35–44), and high (≥45). Observed lSVA rates were 0.2%, 0.4%, 0.8%, and 2.5%, across the four risk categories, respectively. The model demonstrated good discrimination (20-fold cross-validated c-statistic of 0.76) and adequate calibration (Hosmer-Lemeshow p=0.40).

Conclusion

eSVA are 5-fold more common than lSVA in the setting of STEMI, mainly associate with other early complications, and portends a 2-fold higher risk of in-hospital mortality. Moreover, we developed a risk score identifying patients at high risk of lSVA for whom early ICU discharge may not be suitable.

Funding Acknowledgement

Type of funding source: None
Delay between symptom onset and hospital admission in patients with ST-elevation myocardial infarction: different trends in men and women
Authors: Witassek F , Rickli H , Roffi M , Pedrazzini G , Eberli F , Fassa A , Jeger R , Fournier S , Erne P , Radovanovic D
Published: November 2020

Introduction

The aim of this study was to analyse whether prehospital delay in ST-elevation myocardial infarction (STEMI) has changed in men and women since 2002.

Methods

We used data from the AMIS Plus registry of patients who were admitted for STEMI between 2002 and 2019. Patients who were transferred from another hospital or were resuscitated before admission were excluded. Patient delay was defined as the difference between symptom onset and hospital admission time. Trends in delay according to gender were depicted by medians per year with a 95% confidence interval. Differences between men and women were tested using the Mann-Whitney test. To analyse the adjusted effect of gender on delay, multivariable quantile regression was applied including the interaction between gender and admission year as well as the covariates age, diabetes, pain at presentation and myocardial infarction (MI) history.

Results

Among the 15,154 patients included (74.5% men), the overall median (IQR) delay between 2002 and 2019 was 150 (84; 345) minutes for men and 180 (100; 415) for women. Women were older (71.3y vs. 62.8y, p<0.001), had more often diabetes (20.0% vs. 16.9%, p<0.001), but less often MI history (11.2% vs. 14.9%, p<0.001) and less often pain at presentation (92.0% vs. 94.8%, p<0.001).

The unadjusted median delay decreased over the admission years. The decreasing trend was stronger in women than men: the unadjusted difference in delay between men and women decreased from 60 min in 2002 (p=0.003) to 15 min in 2019 (p=0.155) (Fig 1). The multivariable model confirmed a significant interaction between gender and admission year (p=0.042) indicating that the decrease in delay was stronger for women (−3.1 min per year) than for men (−1.4 min per year) even after adjustment. The adjusted difference between men and women decreased from 27.4 min in 2002 to −1.6 min for women in 2019. Additional independent predictors of longer delay were the covariates age (+1.6 min per additional year, p<0.001) and diabetes (+27.1 min, p<0.001). Conversely, pain at admission (−46.3 min, p<0.001) and MI history (−32.9 min, p<0.001) predicted a shorter delay.

Conclusions

The difference in delay between symptom onset and hospital admission in STEMI patients between men and women steadily diminished from 2002 to 2019. This might indicate that the public and health professionals' awareness of STEMI in women has ameliorated over time.

Unadjusted delay according to gender

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): AMIS Plus Foundation
Association of microRNA-224 and microRNA-155 expressions with coronary microvascular obstruction following primary angioplasty for acute ST-segment elevation myocardial infarction
Authors: Dharma S , Dakota I , Wijaya S , Ekawati E , Siswanto B
Published: November 2020

Background

Proinflammatory stimuli induce a variety set of microRNAs (miRs) expressions in human mononuclear cells that regulate long pentraxin-3 (PTX3) gene, which associates with a procoagulant state in the endothelial cells.

Purpose

We evaluated, for the first time, the association of miR-224 and miR-155 expressions with coronary microvascular obstruction (MVO) and plasma PTX3 concentration in patients with acute ST-segment elevation myocardial infarction (STEMI) treated by primary angioplasty.

Methods

The expression levels of miR-224 and miR-155 on admission were evaluated in 217 consecutive patients with STEMI (symptom onset <12h) undergoing primary angioplasty between January 2018 and August 2018, and results were analyzed by the median values. The miRs expression and plasma PTX3 concentration were measured by TaqMan real-time PCR and human ELISA kit, respectively. The primary outcome of the study was the occurrence of angiographic MVO, defined as a post-primary angioplasty TIMI grade <3 flow or TIMI grade 3 flow with myocardial blush grade 0 or 1.

Results

After adjustment with sex, age and plasma PTX3 concentration, miR-244 ≥ median group was associated with angiographic MVO (odds ratio, 2.81; 95% confidence interval 1.34 to 5.92, p=0.006). Spearman analysis showed no correlations between miR-224 and miR-155 expressions with plasma PTX3 concentration.

Conclusion

This study suggests that miR-224 expression, (but not miR-155), associates with angiographic MVO following primary angioplasty for STEMI. However, miR-224 and miR-155 expressions did not correlate with plasma PTX3 concentration. Future studies are needed to find the molecular inflammatory pathway related with miR-224 expression in MVO.

Funding Acknowledgement

Type of funding source: None
Development of 1- and 5-year outcomes between 2006 and 2018 in patients with uncomplicated ST-elevation myocardial infarctions and successful percutaneous coronary intervention
Authors: Schmucker J , Fach A , Osteresch R , Retzlaff T , Garstka D , Langer H , Hambrecht R , Wienbergen H
Published: November 2020

Introduction

While modern P2Y12-inhibitors and drug eluting stents (DES) have changed therapeutic options in patients with ST-elevation mycoardial infarctions (STEMI) during the last decade, there is few data on their impact in real world registries. Aim of the present study was to analyze changes in mortality and major adverse cardiac and cererobrovascular event rates (MACCE: death, reinfarction,stroke) during the last 13 years in patients with uncomplicated STEMI after successful percutaneous coronary intervention (PCI).

Methods

All consecutive STEMI-patients, admitted between 2006 and 2018 and successfully treated with PCI (TIMI flow ≥2) in a large German heart center entered analysis. To reduce confounding pts. with STEMI complicated by heart failure and pts. >70 yrs. of age were excluded.

Results

A STEMI-cohort of 5016 pts. was analysed, with a mean age of 55.9±8 yrs., 19% females, 16% diabetics and 59% smokers. At the beginning of the study period (2006) no patient was treated with ticagrelor/prasugrel and only 5% had a DES implanted. In 2018 92% were treated with prasugrel or ticagrelor and 96% with a DES. The reduction in 1-year-mortality during the study period was not significant: 2006–11: 3.4%, 2012–19: 3.1%, p=0.4, however the reduction in 1-year-MACCE was: 2006–11: 8.3%, 2012–18: 5.7%, p<0.01. This could mainly be attributed to a reduction in reinfarctions: 2006–11: 4.9%, 2012–18: 2.8%, p<0.01. Subgroup analysis revealed that with the exception of diabetics all subgroups showed a significant decline in MACCE-rates during the study period. It was more pronounced in women, non-smokers and patients with a high socioeconomic status (SES) (Table). Analysis of 5-year-data revealed a significant reduction in both 5-year-mortality (2006–09: 9.1%, 2010–13: 6.8%, p<0.01) and 5-year-MACCE-rates: 2006–09: 19.3%, 2010–13: 14.5%, p<0.01.

Conclusions

This analysis of registry data over a study period of 13 years reveals, that for patients with uncomplicated STEMI and successful PCI a significantly better 1- and 5-year-outcome could be achieved during the last years. This improvement of prognosis was more pronounced in specific subgroups, such as women, non-diabetics and patients with higher SES.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Stiftung Bremer Herzen, Gesundheit Nord
Electrocardiographic characteristics and associated outcomes in patients with Takotsubo syndrome. Insights from the RETAKO registry
Authors: Martin-Demiguel I , Nunez-Gil I , Perez-Castellanos A , Vedia O , Uribarri A , Duran-Cambra A , Martin-Garcia A , Corbi-Pascual M , Guillen Marzo M , Martinez-Selles M
Published: November 2020

Background

Our aim was to describe the prevalence and prognostic significance of electrocardiographic features in patients with Takotsubo syndrome (TTS).

Methods

Our data come from the Spanish Multicenter REgistry of TAKOtsubo syndrome (RETAKO). All patients with complete electrocardiogram were included.

Results

246 patients were studied, mean age was 71.3±11.5 and 215 (87.4%) were women. ST-segment elevation was seen in 143 patients (59.1%) and was present in ≥2 wall leads in 97 (39.8%). Exclusive elevation in inferior leads was infrequent (5 - 2.0%). After 48 hours, 198 patients (88.0%) developed negative T-waves in a median of 8 leads with a mean amplitude of 0.7±0.5 mV. Mean corrected QT interval was 520±72 ms and it was independently associated with the primary endpoint of all-cause death and nonfatal cardiovascular events (p=0.002) and all-cause death (p=0.008). A higher heart rate at admission was also an independent predictor of the primary endpoint (p=0.001) and of developing acute pulmonary edema (p=0.04). ST-segment elevation with reciprocal depression was an independent predictor of all-cause death (p=0.04). Absence of ST-segment deviation was a protective factor (p=0.005) for the primary endpoint. Arrhythmias were independently associated with cardiogenic shock (p<0.001).

Conclusion

Prolonged corrected QT interval, arrhythmia, heart rate at admission and broader repolarization alterations are associated with a poor outcome in TTS.

Typical ECG at admission and after 48h.

Funding Acknowledgement

Type of funding source: None
The association between early use of targeted temperature management and neurological outcome after cardiac arrest: a national registry research
Authors: Lin K.C , Huang W.C , Wang M.T , Kuo S.H , Jiang Y.C , Liang H.L , Hsu T.H , Chang Y.T , Huang C.H , Lin Y.S
Published: November 2020

Introduction

Targeted temperature management (TTM) was shown to have favorable outcome in patients with cardiac arrest. However, there were still limited publications about the impact of the time intervalsfromreturn of spontaneous circulation (ROSC) to the initiation of TTMin patients after cardiac arrest.The aim of this study is toinvestigate the association between the time intervalsfrom ROSC to the initiation of TTMand the favorable neurological outcomes.

Methods

The data used the Taiwan Network of Targeted Temperature Management for Cardiac arrest (TIMECARD) registry database. Patients with cardiac arrest received TTMwere collected from June 2018 to June 2019. Very early, early, late, very late, and delayed TTM groups were defined as the time from cardiac arrest to initiation of TTM 0 to 5 hours,5 to 8 hours, 8 to 11 hours, 11 to 14 hours, and >14 hours respectively. A totalof 559 patients were divided into5 groups: very early group (N=82), early (N=150), late (N=118), very late (N=71) and delayed group (N=138).

Results

The baseline character were not different among 5 groups. Favorable neurological outcomes (cerebral performance category 1 and 2) in the very early, early, late, very late and delayed groupswere 66.67%, 33.33%, 50%, 25%, and 14.29% respectively. The Cox analysis showed very late and delayed group had worse neurologic outcome (HR=1.829, 95% CI=1.04- 3.23, p=0.0371). There is also trend to have worse neurologic outcome in late group (HR=1.734, 95% CI=0.91- 3.30, p=0.0939).

Conclusion

This national registry study demonstrated that early initiation of TTM in patients with cardiac arrest was associated with improved favorable neurological outcomes compared with those with late initiation of TTM.

Funding Acknowledgement

Type of funding source: None
Short-term immediate post-shock pacing in adult advanced life support – a feasibility study of modified ALS algorithm
Authors: Telec W , Klosiewicz T , Zalewski R , Zukowska J , Baszko A , Puslecki M
Published: November 2020

Introduction

It is well known that the majority of patients remains transiently pulseless after successfull defibrillation shock during routine advanced cardiovascular life support (ACLS). The post-shock asystole is longer than 120 seconds in as many as 25% of patients. Not only asystole, but also profound postshock bradycardia and high degree AV blocks are described as common.

The need for post-shock pacing (PSP) in adult ACLS is unknown, but there is extensive use of that feature in implantable cardioverters – defibrillators (ICD). PSP feature is widely used in these devices. The wide utilisation of PSP in ICD patients warrants the research towards any possible benefit of it during ACLS measures.

Material and methods

We performed high-fidelity simulation study including 60 paramedic at 20 scenarios. The participants were asked to perform routine resuscitation scenarios according to the AHA ACLS algorithm.

In the control group paramedics had to resume compressions after each shock. In experimental group simultaneously with the compressions, transcutaneous pacing with 200 mA output and rate of 80 ppm was delivered. Several parameters were monitored: chest compression fraction, compressions depth and rate, percent of recoiled compression, compressions on correct depth, and other.

Results

There were no statistically significant differences between both groups in respect of compressions depth and rate, time needed to achieve advanced airway, initiate and achieve intravenous line, administer medications (Table 1). The detailed results are presented in Table 1.

Discussion

According to the best of the authors knowledge, this is the first study describing the feasibility of PSP in resuscitation. The quality of resuscitation depends on adherence to the protocol. Any additional element in the protocol can negatively affect the outcome. In the presented study we present that major ACLS steps are delivered without significant delay when PSP is utilised.

Conclusions

The implementation of PSP had no negative impact on adherence to ACLS protocol. The authors see the need for further intensive research in this area.

Figure 1. Design of the study.

Funding Acknowledgement

Type of funding source: None
Circulating presepsin (soluble CD14 subtype) as a novel marker of mortality in patients treated at medical cardiac intensive care units
Authors: Ishii J , Takahashi H , Nishimura H , Fujiwara W , Ohta M , Kawai H , Muramatsu T , Harada M , Yamada A , Naruse H , Motoyama S , Watanabe E , Izawa H , Ozaki Y
Published: November 2020

Background

Presepsin, a subtype of soluble CD14, is an inflammatory marker, which largely reflects monocyte activation. The association between presepsin levels and mortality in patients treated at medical cardiac intensive care units (CICUs) remains poorly known.

Objective

We aimed to understand the prognostic value of presepsin levels on admission to medical CICUs for mortality.

Methods

We prospectively studied 1636 heterogeneous patients (median age; 71 years) treated at medical (non-surgical) CICUs. Patients with stage 5 chronic kidney disease (estimated glomerular filtration rate [eGFR] <15 mL/min/1.73 m2) were excluded. Acute coronary syndrome was present in 46% of the patients, and acute decompensated heart failure in 36%. Upon admission, baseline plasma presepsin levels were measured. The primary endpoint was all-cause death.

Results

During a mean follow-up period of 44.6 months after admission, there were 323 (19.7%) deaths. Patients who died were older (median: 75 vs. 71 years, P<0.0001); had higher levels of presepsin (194 vs. 110 pg/mL, P<0.0001), B-type natriuretic peptide (BNP: 520 vs. 144 pg/mL, P<0.0001), high-sensitivity C-reactive protein (hsCRP: 4.7 vs. 2.0 mg/L, P<0.0001), and sequential organ failure assessment (SOFA) score (3 vs. 2, P<0.0001); and had lower levels of eGFR (55 vs. 69 mL/min/1.73m2, P<0.0001) and left ventricular ejection fraction (46% vs. 52%, P<0.0001) than those of the survivors. Multivariate Cox regression analyses revealed presepsin levels as independent predictors of all-cause deaths when assessed as either continuous variables (relative risk [RR] 3.33 per 10-fold increment; P<0.0001) or variables categorized according to quartiles (RR quartile 4 vs. 1, 3.60; P<0.0001). Quartiles of presepsin levels were significantly (P<0.0001) associated with increased risk of mortality (Figure). Adding presepsin levels to a baseline model that included established risk factors, BNP, and hsCRP further enhanced reclassification (P=0.009) and discrimination (P=0.0008) beyond that of the baseline model alone.

Conclusions

Circulating concentration of presepsin on admission may be a potent and independent predictor of mortality, and it may improve the risk stratification of patients admitted at medical CICUs.

Presepsin quartiles and mortality

Funding Acknowledgement

Type of funding source: None
Frailty is associated with chronic inflammation and pro-inflammatory monocyte subpopulations
Authors: Cybularz M , Wydra S , Berndt K , Poitz D , Barthel P , Pfluecke C , Linke A
Published: November 2020

Introduction

Patients with frailty represent an increasing patient group in the intensive care medicine. A connection between frailty and inflammation has been suggested. An increased mortality rate in patients with high grade aortic valve stenosis (AS) and frailty, who underwent Transcatheter Aortic Valve Implantation (TAVI) has been observed. A systemic inflammatory reaction in the intensive care unit in the first days after TAVI is a positive predictive factor for an unfavorable outcome. Exact mechanisms are still not fully explained. Monocyte subpopulations are associated with both cardiovascular diseases and a high APACHE II score in critically ill patients.

Purpose

This study investigates the correlation between frailty and cellular and systemic inflammatory mechanisms and mortality after TAVI.

Methods

We examined 120 patients with symptomatic AS who underwent TAVI. Before the implantation, frailty status has been assessed. In all patients a flow cytometry analysis has been performed. Monocyte subpopulations were defined as follows: Mon1 (CD14++CD16–), Mon2 (CD14++CD16+) and Mon3 (CD14+CD16++). Expression of CD11b has been measured as a marker for monocyte activation. Pro-inflammatory cytokines such as interleukin IL-8, as well as CRP have been measured with Cytometric Bead Array or standard laboratory methods.

Results

After 3 months 15 of 120 patients died, primarily without relevant dysfunction of the implanted aortic valve. In 8 of 15 (53%) of the deceased patients and 20 of 100 (19%) of the surviving patients, frailty could be diagnozed before TAVI (p=0.003). Patients with frailty showed prior to TAVI signs of chronic inflammation: elevated CRP (3.7 vs. 5.9 mg/l, p=0.001) and elevated levels of considered as pro-inflammatory Mon2 monocytes (37 vs. 53, p=0.001). Expression of CD11b and IL-8 showed an increasing trend in patients with frailty. Frailty, the monocyte markers, IL-8 and CRP prior to TAVI correlated with increased early mortality after TAVI.

Conclusion

A considerable number of elderly patients with high grade aortic valve stenosis can be described as frail. This syndrome is associated with increased mortality and with signs of chronic systemic inflammation and pro-inflammatory monocytes.

Funding Acknowledgement

Type of funding source: Private hospital(s). Main funding source(s): Heart Center Dresden
Predictive Role of Selvester QRS Score in Patients Undergoing Transcatheter Aortic Valve Replacement
Authors: Bignoto T , Le Bihan D , Barretto R.B.M , Ramos A.I.O , Moreira D.A.R , Simonato M , Siqueira D.A.A , Pinto I.M.F , Santos T.S.G , Sousa A.G.M.R , Abizaid A
Published: November 2020

Introduction

Few data exist regarding the late clinical impact of the Selvester score prediction of myocardial fibrosis after transcatheter aortic valve replacement (TAVR). This study evaluated the predictive power of the Selvester score on survival in patients with aortic stenosis (AS) undergoing TAVR.

Methods and results

Patients with severe AS who had preoperative electrocardiograms were included. Clinical follow-up was obtained retrospectively. The primary endpoint was all-cause mortality. Secondary endpoints were cardiovascular death and major adverse cardiac events (MACE). Two hundred twenty-eight patients were included (mean age, 81.5±7.4 years; women, 58.3%). Deceased patients had a higher mean score (4.6±3.2 vs. 1.4±1.3; p<0.001). At a mean follow-up of 36.2±21.2 months, the Selvester score was independently associated with all-cause mortality (hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.48–1.84; p<0.001), cardiovascular death (HR, 1.59; 95% CI, 1.38–1.74; p<0.001), and MACE (HR, 1.55; 95% CI, 1.30–1.68; p<0.001). After 5 years, the mortality risk was incrementally related to the Selvester score. The involvement of the inferior wall of the left ventricle was a lower mortality risk (HR, 0.42; 95% CI, 0.18 to 0.98; p=0.046). For a Selvester score of 3, the area under the curve showed 0.92, 0.94, and 0.86 (p<0.001), respectively, for 1, 2, and 3 years.

Conclusions

Elevated Selvester scores increase the risk of poor outcomes in patients with AS undergoing TAVR. The involvement of the anterior or lateral wall presents worse prognosis.

Kaplain Meier and ROC Curve

Funding Acknowledgement

Type of funding source: None
Post-surgical outcomes in infective endocarditis patients with liver disease: nationwide propensity-match analysis
Authors: Ludhwani D.L , Vemireddy L.V , Patel R.P , Jhaveri K.J , Zaidi A.Z
Published: November 2020

Introduction

Surgery remains the definitive treatment for persistent infective endocarditis (IE). Age, renal dysfunction and diabetes mellitus are few amongst the many associated with increased post-surgical mortality. Liver dysfunction is a common entity seen in patients with IE. Data on post-surgical sequelae in patients with IE and liver disease is lacking.

Method

We performed a retrospective cross-sectional analysis of all adult (age>18 years) admissions with a discharge diagnosis of acute or sub-acute IE using the 2016 National Inpatient Sample (NIS). IE patients undergoing valve replacement or repair were identified and divided into two groups based on the presence or absence of liver disease. Propensity score matching was performed to control for confounders such as diabetes, age, smoking among others. Odds of in-hospital mortality, cardiogenic shock, and acute kidney injury were calculated using multivariate logistic regression analysis. IE patients without liver disease undergoing valve surgery were selected as the reference population.

Results

We identified a total of 9,822 IE related admissions in the 2016 NIS. Amongst all IE admissions, 11.7% (n=1,158) had either valve replacement or repair surgery performed. After using propensity scores for 1 to 1 matching 16.8% of patients (n=195) who had concomitant liver disease were compared with 195 patients without liver disease. In-hospital mortality was significantly higher in patients with hepatic impairment (14.3% vs 0.51%, p=0.004). Patients with liver disease also had higher odds of concurrent cardiogenic shock (OR=9.35, 95% CI=3.01–29.15, p=0.001), acute kidney injury (OR=2.13, 95% CI=1.15–3.93, p=0.01), and thrombocytopenia (OR=2.29, 95% CI=1.13–4.61, p=0.02).

Discussion

The presence of liver disease in the setting of IE, in patients undergoing valvular surgery significantly increases the morbidity and mortality post-operatively. Functional status of the liver should be considered in addition to the commonly used tools for cardiac operative risk evaluation.

Funding Acknowledgement

Type of funding source: None
Early safety outcome in patients requiring conversion to general anesthesia during transfemoral transcatheter aortic valve replacement
Authors: Mayr P , Pellegrini C , Rheude T , Trenkwalder T , Alvarez-Covarrubias H , Xhepa E , Wiesner G , Schunkert H , Tassani-Prell P , Joner M
Published: November 2020

Background

Transfemoral TAVR (tf-TAVR) has become an established therapy. Conscious sedation (CS) is a alternative to general anesthesia (GA). So far, the outcome of patients undergoing unplanned conversion from CS to GA has not been investigated.

Methods

All patients undergoing tf-TAVR in CS between 2014 and 2019 were included. Primary endpoint was early safety at 30 days according to VARC-2 criteria. The reasons for conversion and length of ICU-/ hospital-stay were further analyzed.

Results

Of 1058 patients 35 (3.3%) required a conversion. Baseline characteristics were similar among groups. The combined VARC-2 endpoint was documented in 13 (37%) of the converted and 110 (11%) of non-converted patients (p<0.001). Four major sub-groups were underlying causes: unrest in 11/35, procedural complications in 10/35, respiratory distress in 8/35 and cardiovascular decompensation in 6/35 patients. An univariable analysis was performed to identify risk factors for unplanned conversion due to respiratory distress or cardiovascular decompensation (Table). Compared to the group without conversion (Median [IQR], 4 [4–5] days), length of hospital stay was longest in the group with procedural complications (6 [1–11] days) followed by cardiovascular decompensation (5 [4–7] days).

Conclusions

The conversion rate to general anesthesia was overall low but associated with a higher observation of the composite endpoint. Hospital stay was longer dependent on the reason for conversion. A thorough understanding of the frequency, causal factors and clinical significance of unplanned conversion to general anesthesia is of utmost clinical relevance taking a general trend towards a minimalist approach into consideration.

Funding Acknowledgement

Type of funding source: None
Anatomical changes in tricuspid annulus and tricuspid regurgitation reduction after Cardioband implantation
Authors: Garcia Martin A , Fernandez-Golfin C , Sanchez Recalde A , Salido-Tahoces L , Lorente Ros A , Hinojar Baydes R , Gonzalez-Gomez A , Jimenez Nacher J.J , Zamorano J.L
Published: November 2020

Introduction

Isolated tricuspid regurgitation (TR) is an entity of high prevalence and associated with poor prognosis. Traditionally, treatment options have been limited because high surgery mortality. In this context, new percutaneous therapeutic options have appeared. The objective of this study is to describe the anatomical changes in tricuspid annulus (TA) and the immediate response in the TR severity after implantation of the Cardioband tricuspid system as well as the safety of the procedure.

Methods

Patients undergoing Cardioband implantation in our center where included. The diameter and area of the TA were measured by 2D and 3D transesophageal echocardiography (TEE) before and immediate after the implantation. TR severity was evaluated by the vena contracta width (VC) in 0 and 90 degrees by 2D TEE.

Results

Six patients (81.3 (79–85) years, 66.3% females) were included. The etiology of TR was dilatation of the ring in two cases, secondary to left valvulopathy in three cases and secondary to type III pulmonary hypertension in other case. Four patients presented basal severe TR, and two patients massive TR.

A significant reduction in TA diameters (reduction TA diameter 0°: 10.6 mm; 90°: 12.2 mm) and 3D TA area (4.5 mm2) was observed immediately after the procedure as well as a reduction in the VC width (reduction VC 0°: 4.8 mm; 90°: 3.9 mm). Table 1 shows the measurements before and after the procedure.

The success of the procedure was 84% (Five patients reduced one-degree TR severity, and one reduced two degrees TR severity). One patient was partial success because the complete implant of all anchors could not be performed. There was 0% intraprocedural mortality or major complications. There were two minor complications, one related to vascular access and the other related to an intra-atrial thrombus, both resolved.

Conclusions

The new percutaneous techniques to treat TR are a reality, and preliminary results seem to indicate that they are a safe and effective alternative, reducing the size of the ring and the severity of valvulopathy. Further studies and longer clinical follow-up will lead to the generalization of these new techniques.

Funding Acknowledgement

Type of funding source: None
Meta-analysis and meta-regression of early aortic valve replacement versus watchful waiting in asymptomatic severe aortic stenosis: a 2020 boost of evidence
Authors: Costa G , Oliveiros B , Goncalves L , Teixeira R
Published: November 2020

Background

Current guidelines recommend aortic-valve replacement (AVR) as the only effective therapy for severe symptomatic aortic stenosis (AS) patients. Nevertheless, management and timing of intervention in asymptomatic AS remains a controversial topic, with sparse evidence to support the recommendations (level C).

Purpose

To assess an early-AVR strategy in asymptomatic severe AS, comparing it with a watchful waiting (WW) strategy

Methods

We systematically searched PubMed, Embase and Cochrane databases, in February 2020, for both interventional or observational studies comparing early-AVR with WW in the treatment of asymptomatic severe AS. Random-effects meta-analysis for early-AVR and WW were performed. Meta-regression was used to assess the influence of study characteristics on the outcome.

Results

Eight studies were included (seven registry-based or unrandomized studies and one randomized clinical trial) providing a total of 3985 patients, and 1232 pooled all-cause deaths (172 in early-AVR and 1060 in watchful waiting). Meta-analysis showed a significantly lower all-cause mortality for the early-AVR compared with WW group (pooled OR 0.24 [0.17, 0.32], P<0.01) although with a moderate amount of heterogeneity between studies in the magnitude of effect (I2=57%, P=0.02). The early-AVR patients also displayed a lower cardiovascular mortality (pooled OR 0.27 [0.15, 0.48], P<0.01) plus a lower heart failure hospitalization rate (pooled OR 0.27 [0.06, 0.65], P<0.007). No difference in clinical thromboembolic event rate (stroke or myocardial infarction) was noted.

The meta-regression for all cause mortality based on possible confounders such as time of follow-up, age, gender, diabetes mellitus, coronary artery disease, left ventricular ejection fraction, and mean peak aortic jet velocity showed that effect sizes reported by the individual studies seem to be independent from the covariates considered (P>0.05).

Conclusions

Our 2020 pooled data reinforces the previous evidence suggesting the benefit of early-AVR in asymptomatic patients with severe AS.

Early AVR vs WW, All-cause death

Funding Acknowledgement

Type of funding source: None