bluuebunny/crossref_metadata_2025 huggingface dataset:
Initially elevated troponin I in rapid atrial fibrillation should lead to coronary angiography
Authors: Esteves AF , Parreira L , Marinheiro R , Fonseca M , Farinha JM , Pinheiro A , Ferreira J , Mesquita D , Amador P , Fonseca N , Santos R , Seixo F , Costa C , Caria R
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Background

In patients admitted to the emergency department (ED) with rapid atrial fibrillation (AF), the decision to undergo coronary angiography is usually due to elevated cardiac biomarkers. However, a study evaluating the rentability of this approach has never been done.

Purpose

Evaluate the predictors of a positive coronary angiography performed in patients with rapid AF and elevated cardiac biomarkers.

Methods

We retrospectively studied patients admitted to the ED between January 2016 and December 2018 with rapid AF who have undergone coronary angiography. We analysed symptoms, risk factors, initial value, peak value and curve of troponin I (TnI) and ST-T segment abnormalities. We evaluated the presence of significant coronary artery stenosis with the need of revascularization at coronary angiography and we used logistic regression to assess the predictors of a positive result.

Results

From 2265 patients admitted to the ED with rapid AF, 46 patients, 60.9% (28) male, median age 73 (IQR 14.75) years, were submitted to coronary angiography. Significant coronary artery stenosis was present in 24 (52.2%) patients. Regarding cardiovascular risk factors, 39 (85.6%) patients had hypertension, 15 (32.6%) had type 2 diabetes mellitus, 36 (78.3%) had dyslipidaemia, 25 (54.3%) were obese or overweight and 12 (26.1%) had a previous history of CAD. Twenty-eight (60.9%) patients presented with chest pain and 27 (58.7%) had ST-T segment abnormalities. Of note, in 17 (37.0%) cases high-sensitivity TnI was measured.

In univariable analysis, ST-T segment abnormalities, the presence of typical TnI curve and an elevated initial TnI predicted the presence of significant CAD in coronary angiography.

In multivariable analysis, an initial TnI value above the upper reference limit (URL) was the only independent predictor of significant CAD in coronary angiography.

Conclusion

In this group of patients with rapid AF an initial elevated TnI was the only independent predictor of the presence of significant CAD. Therefore, maybe it would be advisable to perform coronary angiography in these patients. Without CADWith CADUnivariate analysisOR (95% CI), p-valueMultivariate analysisOR (95% CI), p-valueAge in years, median (IQR)69 (15)77.5 (17)1.045 (0.988-1.106), 0.1270.967 (0.882-1.062), 0.484Type 2 diabetes mellitus, n (%)5 (23.8)10 (41.7)2.286 (0.629-8.313), 0.2095.865 (0.566-60.806), 0.138ST-T segment abnormalities, n (%)8 (36.4)19 (79.2%)6.650 (1.788-24.730), 0.0055.338 (0.491-58.063), 0.169Typical TnI curve, n (%)10 (52.6)20 (90.9)9.000 (1.628-49.756), 0.01217.900 (0.475-674.480), 0.119Elevated initial TnI, n (%)10 (45.5)18 (75.0)3.600 (1.033-12.542), 0.04415.167 (1.363-168.778), 0.027Peak TnI elevation >2 times URL, n (%)11 (50.0)18 (75.0)3.000 (0.863-10.428), 0.0840.169 (0.005-5.298), 0.312
The c- reactive protein to troponin ratio enhances the differentiation of perimyocarditis from acute myocardial infarction
Authors: Kobo O , Meisel SR , Hamuda N , Natour R , Saada M , Abu Fanne R , Amsalem N , Levin C , Frimerman A , Levi Y , Shotan A , Roguin A , Kleiner Shochat M
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Differentiating perimyocarditis from acute myocardial infarction (AMI) is frequently difficult . Perimyocarditis is primarily an inflammatory disease associated with high C-reactive protein (CRP) and relatively low elevated troponin concentrations, while AMI is characterized by the opposite. We surmised that the CRP/troponin ratio on presentation could improve the differentiation between these two clinical entities.

We evaluated the CRP/troponin ratio on presentation among patients consecutively included in a large hospital registry that included 1898 consecutive patients comprising 1025 ST-elevation myocardial infarction (STEMI) patients, 518 Non-STEMI (NSTEMI) patients, and 355 patients diagnosed as perimyocarditis. CRP and troponin were sampled on admission and their ratio was assessed against discharge diagnosis. ROC analysis of the CRP/troponin ratios evaluated the diagnostic accuracy of perimyocarditis against STEMI with or without NSTEMI.

Median admission CRP/troponin ratios were 84, 65, and 436 mg × ml/liter × ng in STEMI, NSTEMI and perimyocarditis groups, respectively (p < 0.001) demonstrating good differentiating capability. The ROC of admission CRP/troponin ratio for diagnosis of perimyocarditis against STEMI with or without NSTEMI yielded a similar AUC of 0.74 and 0.73, respectively. CRP/troponin ratio > 500 resulted in specificity exceeding 85%.

The CRP/troponin ratio is an effective tool that enhances the differentiation between perimyocarditis and AMI.
Women and elderly: do we delay treatment even after identifying ST-segment elevation?
Authors: Araujo Leite Medeiros P , Martins J , Campos I , Oliveira C , Pires C , Flores R , Mane F , Silva R , Ferreira A , Quina C , Costa J , Braga C , Marques J
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

It is known that some subgroups (e.g. women or elderly) may experience a delay in diagnosis of acute myocardial infarction (AMI). This may be due to atypical symptoms that don’t trigger further evaluation as promptly as typical symptoms or due to underestimation of patient’s complaints. However, we don’t know if there is any delay in treatment after the diagnostic electrocardiogram (ECG).

Aim

To evaluate the association between patients’ gender and age and reperfusion (by percutaneous coronary intervention - PCI) time after ECG.

Methods

Single-center retrospective study of individuals that underwent primary PCI between June 2011 and December 2017. We included patients aged ≥ 18, with time registry of the first ECG with ST segment elevation (or equivalent) and time of PCI. No patients were excluded. We defined the time between the first ECG and reperfusion as the ECG-PCI time.

Results

A total of 1679 patients were included; 78% male (n = 1317) and 22% female (n = 362); 59% were younger than 65 (n = 985) and 41% were 65 or older (n = 694). Median ECG-PCI time was higher in females [104 minutes (IQR = 68)] than in males [94 minutes (IQR = 61)]; this association was statistically significant (U = 269124, p < 0.001). Median ECG-PCI time was also higher in older (≥ 65 years) patients [101 minutes (IQR = 68)] than in younger patients [93 minutes (IQR = 55)], with statistical significance (U = 381141, p < 0.001). After stratifying patients’ gender by age, we observed that, in male patients, median ECG-PCI time was lower in younger patients [91 minutes (IQR = 55)] than in older patients [100 minutes (IQR = 69)]; this association was also significant (U = 220025, p < 0.001). On the other hand, the same analysis in female patients found no significant association between younger and older patients (U = 13799, p = 0.522).

Conclusion

Despite a median ECG-PCI time difference of only 9 minutes between males and females, this difference was found to be significant. Factors delaying evaluation after onset of symptoms in women may also delay PCI after diagnostic ECG; borderline ECG criteria may be devalued in women. Older patients may take longer to PCI due to the higher incidence of comorbidities, specially diabetes mellitus, which can mask typical AMI symptoms. Survival impact of these differences should be further studied. Abstract Figure. ECG-PCI time according to gender and age
Nutritional status in older patients with acute coronary syndrome and comorbidity
Authors: Efremova E , Shutov AM , Menzorov MV , Mashina TV
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Older patients with acute coronary syndrome (ACS) require a special management, taking into account comorbidity and gerontological syndromes. Obesity paradox and nutritional status as a factor of poor prognosis need further study. The aim of this study was to investigate nutritional statusin older patients with ACS and comorbidity.

Materials and methods

90 older patients (51 males and 39 females, mean age was 67.0 ± 6.2 years) admitted to hospital with ACS were studied. ACS with ST-segment elevation (STE-ACS) and without ST segment elevation (NSTE-ACS) were diagnosed according to ESC Guidelines (2017 and 2015, respectively). STE-ACS was diagnosed in 17 (18.9%) patients, NSTE-ACS - in 73(81.1%) patients. All patients had cardiovascular pathology before hospitalization: 86 (95.6%) patients had arterial hypertension, 71 (78.9%) - coronary artery disease, 37 (41.1%) patients - myocardial infarction in history. Charlson comorbidity index (CCI) was estimated. Comorbidity was regarded as high at index ≥ 6 scores. Nutritional status was assessed: the presence of obesity, type of obesity, body composition, including percentage of lean and fat tissue. Quality of life, frailty syndromeand personal characteristics were evaluated.

Results

The CCI was 5.9 ± 1.9 scores. 50 (55.6%) older patients with ACS had high comorbidity. Half of patients (43; 47.8%) had frailty syndrome.Obesity was observed in33 (36.7%) patients, 52 (57.8%)hadoverweight,62 (68.9%)- abdominal obesity. 85 (94.4%) - had a higher percentage of fat tissue.Patients with ACS and high comorbidityhad lowertotal water volume (37.9 ± 5.1and40,8 ± 5.8 liters resp., p = 0,01) and lean body mass (51.9 ± 7.0and55,9 ± 7.5 kg resp., p = 0,01)and higherthe percentage of body fat(40.9 ± 8.9and35,8 ± 6.7 % resp., p = 0,01)compared to patients with low comorbidity. Olderpatientswith ACS andfrailty syndrome had higherthe percentage of body fat(43.9 ± 9.4and31,9 ± 6.3 % resp., p = 0,002)andlowerthe percentage of leanbody(62.9 ± 6.4and71,3 ± 4.9 % resp., p = 0,00008)compared to patients without frailty syndrome. There was a direct relationship between the level of anxiety and depression and the percentage of body fat( r = 0.45, p < 0.0001; r = 0.36, p = 0.001 resp.) and negative relationship with physical functioning (r=-0.46, p < 0.0001).

Conclusions

Older patients withACS are characterized byhigh comorbidity and frailty. Body composition is dependent on comorbidity: patients with ACS and high comorbidityhadlowertotal water volume, lean body massandhigher percentage of body fat(sarcopenic obesity)compared to patients with low comorbidity.
Inferior acute myocardial infarction caused by left anterior descending coronary artery, worse prognosis? experience in our center
Authors: Martinez Primoy IR , Carmona Carmona J , Seoane Garcia T , Martinez Nunez R , Arroyo Monino DF , Garcia Rubira JC
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

I

Key diagnostic test in acute myocardial infarction with ST segment elevation(STEMI)is 12-lead electrocardiogram, which guides initial treatment and informs about area at necrosis risk, necrosis extension, and culprit coronary artery. ST elevation in leads II, III, aVF is related to obstruction of right coronary artery(RCA)or circumflex artery. Inferior STEMI with occlusion of left anterior descending artery(LAD)has been described. Our goal is to analyse incidence and characteristics of inferior STEMI due to LAD occlusion.

M

Observational retrospective study, of patients admitted to our Coronary Care Unit due to inferior STEMI, between08/2011-12/2020. We analysed all patients whose culprit artery was LAD and a random sample of138patients among those with RCA as culprit. Chi-square, Student-t or Mann-Whitney tests were used.

R

there were a total of2498acute coronay syndromes, 1541were STEMI. 47.7%of them(n:735)were from inferior wall. From inferior STEMI, 12were caused by LAD occlusion(1.6%, 95%confidence interval0.8-2.8%), representing0.8%of all STEMI. There were21.3%women(n:32)and a mean age of61.6 ± 12.5years, without differences by culprit artery. STEMI related with RCA presented a 28.3% of  either right ventricular dysfunction or atrioventricular block, versus none of those related to LAD(p0.037). There was difference in dominance: STEMI caused by LAD presented right dominance in72.7%of cases, while caused by RCA in94.4%(p0.034). All inferior LAD STEMIs had normal left ventricular ejection fraction(LVEF) at admission. There was no statistically significant difference in LVEF at discharge(RCA54.3 ± 7.6vsLAD50.5 ± 13.6), but there was in maximum troponin, which was higher in those STEMI related to RCA(2208 ± 1756mg/dl vs 4095 ± 3833mg/dl, p0.040). Complementary comparisons in Table.

Conclusion

we found that1.6%of inferior STEMI are caused by LAD occlusion instead of RCA or circumflex coronary artery. These STEMI do not cause more severe affectation of left ventricle and run without typical complications of inferior STEMI. RCALADSite of occlusion-nProximal65(47.1%)5(41.7%)Medium41(29.7%)5(41.7%)Distal32(23.2%)2(16.7%)Worst Killip-Kimbal-nI112(81.2%)10(83.3%)II11(8.0%)1(8.3%)III2(1.4%)1(8.3%)IV13(9.4%)0
Inflammation and neurohormonal activation is increased at hospital admission in patients with ST-elevation myocardial infarction with diabetes compared to non-diabetic patients
Authors: Kunkel JB , Hassager C , Moeller JE , Holmvang L , Jensen LO , Frydland M
Published: April 2021

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Rigshospitalets Forskningsfond. The Lundbeck Foundation.

Background

Patients with diabetes have an increased risk of coronary artery disease (CAD). In patients with myocardial infarction (MI), diabetes is associated with a poor outcome. Inflammation and neurohormonal activation have previously been shown to be associated with poor outcomes in patients with ST-elevation MI (STEMI). We therefore sought to assess whether STEMI-patients with diabetes (DM) had increased levels of inflammation and neurohormonal activation upon hospital admission.

Methods

In 1892 consecutive STEMI-patients from two danish tertiary heart centres, biomarkers reflecting neurohormonal activation (pro-atrial natriuretic peptide (proANP) and mid-regional pro-adrenomedullin (MRproADM)) and inflammation (soluble suppression of tumorigenicity 2 (sST2) and C-reactive peptide (CRP)) were measured upon admission before angiography. Patients were stratified according to DM or not.

Results

In total, 245 (13%) patients had DM. DM patients were older (mean (SD) 66 (11) vs 63 (13) years old, p = 0.0002), had more comorbidities (hypertension, previous stroke/TIA, ischemic heart disease (IHD), chronic kidney dysfunction (CKD)), and higher body mass index (BMI). In addition, DM patients had a longer time from symptom debut to angiography and more often multivessel disease (MVD). We found no difference in admission troponin plasma concentrations.

Upon hospital admission, DM patients had higher concentrations of MRproADM (median (IQR) 0.88 (0.64-1.20) vs. 0.71 (0.58-0.90) nmol/L, p < 0.0001), sST2 (41 (64-31) vs. 39 (55-28) ng/ml, p = 0.01), and CRP (4.5 (1.9-12.1) vs. 3.4 (1.4-8.3) mg/L, p = 0.001) but not proANP (figure). When adjusted for age, BMI, CKD, IHD, time from symptom debut to angiography, and MVD, DM remained associated with increased MRproADM (OR (95% CI) 1.35 (1.05; 1.74), p = 0.02) and sST2 (1.20 (1.02; 1.41), p = 0.03), but no longer with CRP. Patients with DM had a higher one-year all-cause mortality rate (12% vs. 9.4%, p = 0.03).

Conclusion

STEMI patients with diabetes have increased neurohormonal activation and inflammation at hospital admission compared to patients without diabetes. This may play a role in the increased mortality in STEMI patients with diabetes. Abstract Figure.
Effects of daily mindfulness practice on fatigue, kinesiophobia, and quality of life in patients with acute myocardial infarction: a randomized controlled trial
Authors: Karadas C , Oksul M , Ozer N , Ozdemir L
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Background and Aim

Mindfulness meditation (MM) leads to controlled blood pressure and positive improvements in other symptoms which may trigger acute coronary diseases. The present randomized controlled study was aimed to investigate the effect of the MM on fatigue, kinesiophobia, and the quality of life (QoL) in patients with acute MI.

Method

The study was carried out with 56 MI patients. Participants were randomly assigned to meditation group (MG; n = 28) or control group (CG; n = 28).  The MG patients received a 15 min MM session comprising sitting and breathing for a total of eight weeks, while the CG patients received only a single-time attention-matched education. Piper Fatigue Intervention, Tampa Scale for Kinesiophobia-Heart and MacNew Quality of Life scales were utilized for data collection.

Results

After completion of the 8-week MM, any significant difference was not found in the fatigue scores of the patients (p > 0.05). On the other hand, kinesiophobia scores in the MG were significantly lower in the 4th, 8th and 12th weeks (p < 0.05). Similarly, the QoL scores were significantly higher in the MG in 8th week (p < 0.05). Significant change in the emotional function sub-dimension of QoL continued in the follow-up assessment at 12th week (p < 0.05).

Conclusion

The MM can significantly improve the QoL and decrease kinesiophobia in patients with MI. Beneficial effect of MM is maintained particularly in the emotional aspect. Based on the results of the study, MM may be recommended as a mind-body based complementary approaches within the scope of secondary protection after MI. Comparison of the study groupsGroupBaseline(Mean ± SD)4th week(Mean ± SD)8th week(Mean ± SD)12th week(Mean ± SD)PFSMM2.08 ± 1.870.90 ± 0.990.47 ± 0.780.44 ± 0.76CG1.56 ± 2.011.12 ± 1.590.98 ± 1.520.76 ± 1.33tp1.004 0.32-0.6210.54-1.5840.12-1.0850.28TSK-HMM40.25 ± 5.0436.18 ± 4.4934.39 ± 4.6134.96 ± 4.71CG41.71 ± 7.2841.89 ± 6.7441.82 ± 5.8441.00 ± 5.54tp-0.8750.39-3.7340.001-5.279 0.000-4.3900.00MacNewMM5.04 ± 0.715.53 ± 0.455.76 ± 0.475.77 ± 0.47CG5.17 ± 0.855.32 ± 0.605.37 ± 0.525.53 ± 0.46t; p-0.640; 0.531.436; 0.162.933; 0.0051.964; 0.06(Mean ± SD): Mean ± Standard Deviation; PFS: Piper Fatigue Scores; TSK-H: Tampa Scale for Kinesiophobia-Heart; MacNew: MacNew Quality of life Scale; EFS: emotional functioning sub-dimension; PFS: physical functioning sub-dimension; SFS: social functioning sub-dimension; t= Student T Test value; p< 0.05
The interplay between myocardial bridging and coronary spasm in patients with myocardial infarction and non-obstructive coronary arteries: pathogenic and prognostic implications
Authors: Montone RA , Gurgoglione F , Del Buono MG , Meucci MC , Iannaccone G , La Vecchia G , Camilli M , Trani C , Niccoli G , Crea F
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Myocardial bridging (MB) is associated with endothelial dysfunction and may represent a cause of angina in patients with non-obstructive coronary artery disease (NOCAD).

Purpose

 Herein, we assessed the interplay between MB and coronary vasomotor disorders, evaluating also their prognostic relevance in patients with myocardial infarction and non-obstructive coronary arteries (MINOCA) or stable NOCAD.

Methods

We prospectively enrolled consecutive NOCAD patients undergoing intracoronary acetylcholine provocative test to assess the presence of epicardial or microvascular spasm in patients with suspected angina or MINOCA. Myocardial bridging was diagnosed by coronary angiography. The incidence of major adverse cardiac events (MACE), defined as the composite of cardiac death, non-fatal MI and rehospitalisation for unstable angina, was assessed at follow-up. We also assessed angina status using Seattle Angina Questionnaires (SAQ).

Results

We enrolled 310 patients (mean age 60.6 ± 11.9; 136 [43.9%] men; 169 [54.5%] stable NOCAD and 141 [45.5%] MINOCA). MB was found in 53 (17.1%) patients. MB was an independent predictor of spasm and MINOCA (p < 0.05). At follow-up (median 22 months, interquartile range [13-32]), patients with MB had a higher rate of MACE and a lower SAQ score (all p < 0.001) compared with patients without MB. The rate of MACE was considerably higher in patients with both spasm and MB than in the remaining patients (12/42 [28.6%] vs. 13/268 [4.8%], p < 0.001).

Conclusion

Among patients with NOCAD coronary spasm associated with MB predicts a worse clinical presentation with MINOCA and a worse clinical outcome at medium-long term follow-up, thus identifying a high-risk subset of patients with MB with relevant therapeutic implications. MB and clinical outcomesCharacteristicsOverall population(n= 310)Presence of Myocardial bridging(n= 53)Absence of Myocardial bridging(n = 257)p valueMACE [n, (%)]25 (8.1)12 (22.6)13 (5.1)<0.001CV Death [n, (%)]1 (0.3)0 (0.0)1 (0.4)0.649MI occurrence [n, (%)]6 (1.9)2 (3.8)4 (1.6)0.286Hospitalization for unstable angina [n, (%)]18 (5.8)10 (18.9)8 (3.1)< 0.001Recurrent angina [n, (%)]70 (22.6)20 (37.7)50 (19.4)0.004SAQ [median (IQR)]82 [78; 88]78 [68; 84]84 [78; 88]< 0.001Follow-up time [months, median (IQR)]22 [15;32]20 [15; 28]23 [15; 34]0.10CV Cardiovascular; MI: Myocardial Infarction; IQR: InterQuartile Range; MACE: Major Adverse Cardiovascular Event; SAQ: Seattle Angina Questionnaire.Abstract Figure Outcomes
Long-term clinical outcome of cardiogenic shock patients undergoing Impella CP treatment vs. standard of care
Authors: Scherer C , Luesebrink E , Massberg S , Orban M
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Background

The number of patients treated with the mechanical circulatory support device Impella Cardiac Power (CP) for cardiogenic shock is steadily increasing. The aim of this study was to investigate long-term survival and complications related to this modality.

Methods

Patients undergoing Impella CP treatment for cardiogenic shock were retrospectively enrolled and matched with cardiogenic shock patients not treated with mechanical circulatory support between 2010 and 2020. Data were collected from the cardiogenic shock registry of our university hospital.

Results

68 patients with refractory cardiogenic shock without mechanical circulatory support were matched with 68 patients treated with Impella CP. At presentation, the mean age was 67 ± 14 years with 82% being male in the group without support and 68 ± 14 years (p = 0.65) with 77% being male (p = 0.52) in the group with Impella. There was no significant difference in the rate of cardiac arrest (57% vs. 54%, p = 0.86) and myocardial infarction was the predominant cause of cardiogenic shock in both groups (66% vs. 74%, p = 0.34). A total of 46% of patients without cardiocirculatory support and 54% of patients with Impella support died during the first month (p = 0.32). After one year, mortality rates were similar in both groups (53% in conventional vs. 59% in Impella CP group, p = 0.51) as was mortality rate at long-term 5-years follow-up (73% in conventional vs. 72% in Impella CP group, p = 0.50). The rate of clinically significant bleedings during ICU stay was much lower in the conventional group than in the Impella support group (25% vs. 42%, p = 0.03).

Conclusion

In this small observational and non-randomized analysis no difference in long-term outcome between patients treated with Impella CP vs. guideline directed cardiogenic shock therapy without mechanical circulatory support could be detected. Care must be taken regarding the high rate of bleeding and vascular complications when using Impella CP. Large, adequately powered studies are urgently needed to investigate the efficacy and safety of Impella CP in cardiogenic shock.
Higher CICU mechanical ventilation volumes are associated with lower in-hospital mortality
Authors: Nandiwada S , Islam S , Jentzer J , Miller PE , Fordyce CB , Lawler P , Alviar CL , Sun L , Dover D , Kaul P , Van Diepen S
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Background

 The incidence of respiratory failure and the provision of invasive and non-invasive mechanical ventilation (MV) in patients admitted to cardiac intensive care units (CICU) are increasing. While institutional MV volumes are associated with reduced mortality in medical and surgical ICUs, this relationship has not been characterized in the CICU population.

Purpose

 By describing the relationship between institutional MV volume and outcomes in the CICUs, we hope to shed light on minimum volume benchmarks for providing MV.

Methods

 National Canadian population-based data from 2005 to 2015 was used to identify patients admitted to CICUs requiring MV. CICUs were categorized into low (≤100), intermediate (101-300), and high (>300) volume centers based on spline knots identified in the association between annual MV volume and mortality (Figure). Outcomes of interests included all-cause in-hospital mortality, the proportion of patients requiring prolonged MV (>96 hours) and CICU length of stay (LOS).

Results

 Among the 47,173 CICU admissions that required MV, 89.5% (42,200) required invasive mechanical ventilation. The median annual CICU MV volume was 127 (range 1-490). In-hospital mortality was lower in intermediate (29.2%, adjusted odds ratio [aOR] 0.84, 95% CI 0.72-0.97, p = 0.019) and high-volume (18.2%; aOR 0.82, 95% CI 0.66-1.02, p = 0.076) centers, compared to low volume centers (35.9%). The proportion of patients requiring prolonged MV was higher in low-volume (29.2%) compared to high-volume (14.8%, OR 0.70, 95% 0.55-0.89, p = 0.003) centers. Point estimates for mortality and prolonged MV were lower in PCI-capable and academic centers (Table). Significantly (p <0.01) lower CICU LOS was observed only in the subgroup of PCI-capable intermediate- and high-volume hospitals.

Conclusions

 In a national dataset, we observed that higher CICU MV hospital volumes were associated with lower in-hospital mortality, CICU LOS, and fewer episodes of prolonged MV. Pending further validation, these data suggest minimum MV volume benchmarks for CICUs caring for patients with respiratory failure. Further research is warranted to explore these associations in more detail. Unadjusted volume-outcome relationshipsOutcomesGroup 1 Annual Volume ≤100Group 2 Annual Volume 101-300Group 3 Annual Volume >300Totalp-valueTotal N1770224351512047173In-hospital mortality6357 (35.0%)7122 (29.2%)933 (18.2%)14412 (30.6%)p < 0.0001Median CICU LOS(hours)85796679p < 0.0001Episodes of prolonged MV5161 (29.2%)5608 (23.0%)758 (14.8%)11527 (24.4%)p < 0.0001Abbreviations OR (odds ratio), RD (risk difference), CI (confidence interval), PCI (percutaneous coronary intervention), LOS (length of stay)Abstract Figure. Annual CICU MV volume and mortality
The clinical significance of blood lactate levels in evaluation of adult patients with Veno-Arterial Extracorporeal Membrane Oxygenation
Authors: Laimoud M , Alanazi M
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Veno-Arterial ECMO is  a life  supporting procedure that can be done to the patients with cardiogenic shock which is associated with hyperlactatemia . The objective of this study was to detect the validity of serial measurements of arterial lactate level in differentiating hospital mortality and neurological outcome  after VA-ECMO support. Results : This retrospective study included 106 patients between 2015 and 2019 with a mean age of  40.2 ± 14.4 years and mostly males (69.8%) . The in-hospital mortality occurred in 56.6% and acute strokes occurred in 25.5% of the patients . The non-survivors and the patients with acute strokes  had significantly higher arterial  lactate levels at pre-ECMO initiation , post-ECMO peak and after 24 hours of ECMO support compared to the survivors and those without strokes respectively.  The peak arterial lactate  ≥ 14.65 mmol/L measured  after  ECMO support  had 81.7 % sensitivity and 89.1 % specificity for predicting hospital mortality  [AUROC: 0.889 , p <0.001 ] while the arterial lactate level ≥ 3.25 mmol/L after 24 hours of ECMO support had  88.3% sensitivity and 97.8% specificity for predicting hospital mortality  [AUROC: 0.93 , p <0.001 ]. The peak lactate  ≥ 15.15 mmol/L  measured  after  ECMO support  had 70.8 % sensitivity and 69 % specificity for predicting cerebral strokes [AUROC: 0.717 , p <0.001 ] while the lactate level ≥ 3.25 mmol/L after 24 hours of ECMO support had  79.2% sensitivity and 72.4% specificity for predicting cerebral strokes [AUROC: 0.779, p <0.001 ]. Progressive hyperlactatemia (OR = 1.427  , 95% CI : 1.048 – 1.944 , p = 0.024 ) and increasing  SOFA score after 48 hours  (OR = 1.819 , 95% CI : 1.374 – 2.409 , p < 0.001) were significantly associated with in-hospital mortality after VA-ECMO support. Conclusion : Progressive hyperlactatemia after VA-ECMO initiation for adult patients with cardiogenic shock is a sensitive and specific predictor of hospital mortality and acute cerebrovascular strokes  . According to our results , we could recommend early VA-ECMO initiation to achieve adequate circulatory support and better outcome. Predictors of hospital mortality.Studied variablesP valueOR95% CI for ORLactate peak0.0241.4271.048 - 1.944Hemodialysis0.3154.1260.344 - 51.669Atrial fibrillation0.073.2680.786 - 31.26Cardiac surgeries0.2173.4820.480 - 25.152Δ SOFA<0.0011.8191.374 - 2.409Central VA-ECMO0.123.9310.482 - 24.16Abstract Figure. ROC of lactate differentiating mortality
Severe aortic stenosis in octogenarian: is surgical aortic valve replacement a good option?
Authors: Menezes Fernandes R , Costa HA , Bispo JS , Mota TF , Bento D , Marques N , Jesus I
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Aortic stenosis (AS) is the most prevalent valvular heart disease among the elderly, reaching 8,1% in 85 years-old patients. Symptomatic severe AS entails a high risk of morbidity and mortality without valve replacement, and increasing age is associated with higher surgical risk.

Purpose

To determine the prognostic impact of advanced age in patients with severe AS referred to surgical valve replacement.

Methods

We conducted a retrospective study encompassing patients referred to surgical aortic valve replacement due to severe AS, from January 2016 to December 2018. Clinical characteristics, diagnostic studies and follow-up were analysed. Patients were divided in two groups according to the age: <80 and ≥80 years old. Independent predictors of mortality and/or re-hospitalization were identified through a binary logistic regression analysis, considering p = 0,05.

Results

A total of 222 patients were included, with a 64,4% male predominance and a median age of 75 years old. 27,5% had concomitant surgical coronary artery disease and 87,4% waited in an out-patient setting. Median delay until surgery was 87 days and median follow-up after surgical referral was 517 days. 59 patients (26,8%) had ≥ 80 years old. Male gender (69,6% vs 50,8%; p = 0,01), smoking habits (14,3% vs 1,7%; p = 0,024), higher glomerular filtration rate (75,5 vs 63,2 ml/min; p = 0,001) and lower Euroscore II values (2,89% vs 4,64%; p = 0,003) were more common in younger patients. Global mortality rate (27,1% vs 15,5%; p = 0,05) and the composite of mortality or re-hospitalization (52,5% vs 36,6%; p = 0,034) were more frequent in older patients. Despite re-hospitalizations were also more common (37,3% vs 29,2%), they did not reach statistical significance (p = 0,252). After multivariate analysis, advanced age was not an independent predictor of mortality and/or re-hospitalization. In this population, only the presence of extracardiac arteriopathy (p = 0,007; p = 0,006) and pulmonary hypertension (p = 0,004; p = 0,002) were both independent predictors of mortality and the composite of mortality or re-hospitalization.

Conclusion

Older patients with AS have higher mortality, but advanced age was not an independent predictor of mortality and/or re-hospitalization. The decision to perform aortic valve replacement should be discussed in the Heart Team, considering patient’s comorbidities and performing a comprehensive geriatric evaluation, not just focusing on age itself.
Contemporary in-hospital mortality of pulmonary embolism
Authors: Kleissner M , Vojtickova L , Kettner J , Kautzner J , Sramko M
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Recent data on mortality of hospitalised patients with pulmonary embolism (PE) are scarce.

Purpose

To compare in-hospital mortality between a contemporary and a historical cohort of patients treated for PE.

Methods

We retrospectively analysed clinical and imaging data of 372 consecutive patients who were admitted to our department for PE between February 2010 and November 2020. Patients in whom PE presented as an out-of-hospital cardiac arrest without sustained return of spontaneous circulation (n = 12) were not included. In-hospital mortality was compared between patients admitted before and after January 2016 (n = 178 and n = 194, respectively). The patients were classified as low, intermediate and high clinical risk, according to the 2019 European Society of Cardiology guidelines.

Results

The diagnosis of PE was based on computed tomography angiography (85%), ventilation/perfusion lung scan (7%), echocardiography (7%), and autopsy (1%). The majority of patients presented with intermediate-risk (288 [77%]), followed by low-risk (46 [12%]) and high-risk PE (38 [10%]). The risk profile did not differ between the contemporary vs. historical cohort (78% vs. 77%, 13% vs. 11%, and 9% vs. 12%, respectively, all p >0.05). Eleven patients (3%) died of PE during the index hospitalization: eight with high-risk PE (21%), three (1%) with intermediate-risk and zero (0%) with low-risk PE (p < 0.0001). The in-hospital mortality did not differ between the contemporary vs. historical cohort (5 [3%] vs. 6 [3%], p = 0.76). In the multivariate regression analysis, the initial manifestation of cardiogenic shock, presence of provoking factors for PE, and a history of stroke were associated with higher in-hospital mortality.

Conclusion

The mortality of hospitalised patients with intermediate and low-risk PE is lower than previously reported and did not change over the last decade. High-risk PE is associated with in-hospital mortality of 21%. Abstract Figure.
Different D-dimer algorithms to rule out pulmonary embolism in patients with cancer: a comparative study
Authors: Silva BV , Mendonca C , Cunha N , Silverio Antonio P , Rodrigues T , Brito J , Morais P , Rigueira J , Alves Da Silva P , Pereira S , Pinto FJ
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary embolism (PE) is more prevalent in patients with cancer. D-dimers are a less useful test in such patients due to less specificity. Several algorithms have been developed as an alternative to the fixed d-dimer cutoff,  aiming to avoid the excessive use of computed tomography pulmonary angiography (CTPA), but it is not clear which is the most accurate algorithm in PE patients with cancer.

Objective

To compare the efficacy of 4 algorithms to rule out pulmonary embolism (fixed Ddimer cutoff, age-adjusted, YEARS and PEGed) in patients with active cancer.

Methods

Retrospective study of consecutive outpatients who presented to the emergency department and underwent CTPA for PE suspicion from April 2019 to February 2020. The clinical-decision algorithms were retrospectively applied. In fixed and age-adjusted cutoffs, high probability patients are directly selected for CTPA and the others perform CTPA if DDimer ≥500µg/L or age x10 µg/L within patients over 50 years, respectively. YEARS includes 3 items (signs of deep vein thrombosis, haemoptysis and whether PE is the most likely diagnosis): patients without any YEARS items and Ddimer ≥1000ng/mL or with ≥1 items and Ddimer 500ng/mL perform CTPA. In the PEGeD, patients with high clinical probability or with intermediate and Ddimer >500µg/L or low probability and Ddimer >1000 µg/L are selected for CTPA.

Results

Of 409 patients with suspected PE, 87 patients (21,3%) had cancer. The prevalence of PE was 38% in cancer patients and 35% in patients without cancer (p > 0.05). Age-adjusted cut-off, compared to the conventional cutoff, had an AUC significantly higher (0.68 vs 0.61, p = 0.005). Despite both having 100% sensitivity, age-adjusted cutoff had a significant higher specificity compared to conventional cut-off (44% vs 35%, p < 0.05). Both YEARS and PEGED algorithms had significantly lower sensitivity (p = 0.003 and p = 0.002, respectively) and higher specificity (p < 0.001, for both) compared to conventional cutoff in patients with active cancer. The AUC of these two algorithms was not significantly different compared to conventional cutoff (p = 0.08 and p = 0.78, respectively).

Conclusion

Considering our results, age-adjusted cut-off seems to be the most accurate algorithm to rule out pulmonary embolism in active cancer patients. Sen(%)Spec(%)Conventional10022Age-adjusted10035YEARS9144PEGED9130Abstract Figure. AUC of four algorithms
Safety and efficacy of direct oral anticoagulants (DOACs) vs low molecular weight heparin (LMWH) in malignancy induced venous thromboembolism-a systematic review and meta analysis
Authors: Abdul Razzack A , Hussain N , Adeel Hassan S , Mandava S , Yasmin F , Pothuru S , Panday P , Kumar Ochani R , Shariq Usman M , Sattar Y
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Background- Low molecular weight heparin (LMWH) and direct oral anticoagulants (DOACs) have been proven to be more effective in the management of venous thromboembolism (MVTE). The efficacy and safety of LMWH or DOACs in treatment of recurrent or malignancy induced VTE is not studied in literature.

Objective

To compare the efficacy and safety of LMWH and  DOACs in the management of malignancy induced  VTE

Methods- Electronic databases ( PubMed, Embase, Scopus, Cochrane) were searched from inception to November  28th, 2020. Dichotomous data was extracted for prevention of VTE and risk of major bleeding in patients taking either LMWH or DOACs. Unadjusted odds ratios (OR) were calculated from dichotomous data using Mantel Haenszel (M-H) random-effects with statistical significance to be considered if the confidence interval excludes 1 and p < 0.05. 

Results- Three studies with 2607 patients (DOACs n = 1301 ; LMWH n = 1306) were included in analysis. All the study population had active cancer of any kind diagnosed within the past 6 months. Average follow-up period for each trial was 6 months. Patients receiving DOACs have a lower odds of recurrence of MVTE as compared to LMWH( OR 1.56; 95% CI 1.17-2.09; P = 0.003, I2 = 0). There was no significant difference in major bleeding among patients receiving LMWH or DOACs  (OR-0.71, 95%CI 0.46-1.10, P = 0.13, I2 = 22%) (Figure 1). We had no publication bias in our results (Egger’s regression p > 0.05).

Conclusion-

DOACs are superior to LMWH in prevention of MVTE and have similar major bleeding risk as that of LMWH. Abstract Figure. A)VTE Recurrence B)Major Bleeding events
Long-term 5-year outcome of the randomized IMPRESS in severe shock trial: percutaneous mechanical circulatory support versus intra-aortic balloon pump in severe cardiogenic shock
Authors: Karami M , Eriksen E , Ouweneel DM , Lagrand WK , Henriques JPS
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Background

The role of percutaneous mechanical circulatory support (pMCS) in cardiogenic shock (CS) is still a subject of debate. The IMPRESS in Severe Shock trial is still the largest RCT on the effectiveness of pMCS in CS patients. We performed a follow-up at 5-years of the IMPRESS in Severe Shock trial to assess differences in long-term clinical outcome and functional status between pMCS and intra-aortic balloon pump (IABP) treated patients.

Methods

The IMPRESS in Severe Shock trial (NTR3450) is an investigator-initiated, multicentre, randomized, open-label trial. Between June 2012 and September 2015, a total of 48 patients with severe CS from AMI with ST-segment elevation undergoing immediate revascularisation were randomized to pMCS with the Impella CP (n = 24) or IABP (n = 24). The trial design and primary end-point results (30-day all-cause mortality) have been previously published. For the 5-year assessment, all-cause mortality and the occurrence of major adverse cardiovascular and cerebrovascular events (MACCE) were evaluated. MACCE consisted of death, myocardial re-infarction, repeat PCI, CABG and stroke. In survivors, a structured interview was conducted and follow-up echocardiography was obtained. Data were analysed according to the intention-to-treat principle.

Results

Long-term follow-up was performed 5.5 years (IQR 5.3-6.5) after initial randomization and completed for all patients regarding mortality status. Five-year mortality was 50% (n = 12/24) in the pMCS group and 63% (n = 15/24) in the IABP group (RR 0.87, 95% CI 0.47-1.59, p = 0.65). After 6 months, only 3 additional deaths occurred, all in the IABP group. MACCE occurred in 12/24 (50%) of the pMCS patients versus 19/24 (79%) of the IABP patients (p = 0.07) (Figure 1). Myocardial re-infarction occurred in 1 pMCS patient and in 2 IABP patients, repeat PCI in 3 IABP patients, CABG in 1 IABP patient and stroke in 2 pMCS patients and in 2 IABP patients. Among 5-year survivors, follow-up interview was successfully conducted in 11/12 (92%) pMCS and 7/9 (78%) IABP patients. All patients except for one were in NYHA class I or II (pMCS n = 10 [91%] and IABP n = 7 [100%], p = 1.00) and none of the patients had residual angina complaints. Echocardiography was obtained in 10/12 (83%) pMCS and 6/9 (67%) IABP patients. There were no differences in LVEF between the two groups (pMCS 52 ±11% vs. IABP 48 ±10%, p = 0.53).

Conclusions

In this randomized trial of patients with CS after AMI, there was no difference in long-term 5-year mortality between pMCS (by Impella CP) and IABP treated patients, supporting previously published 30-day and 6-month data. Interestingly, we did observe a not significantly different (p = 0.07) higher occurrence of MACCE in the IABP group. Abstract Figure. Kaplan Meier Impella vs. IABP: MACCE
Sleep inadequacy and incident cardiovascular disease among adults in Greece
Authors: Fountoulakis PN , Terzoudi A , Tsiptsios D , Triantafyllis AS , Matziridis A , Leontidou E , Manolis A , Tsamakis K , Ouranidis A , Steiropoulos P , Vorvolakos T , Tripsianis G
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Sleep disorders are an emerging and modifiable risk factor for cardiovascular disease (CVD).

Purpose

The aim of our study was to investigate potential associations between sleep insufficiency and incident CVD.

Methods

In this cross-sectional study, 957 participants, (mean age 49.62 ± 14.79) from the region of Thrace, Greece were enrolled and classified into three groups [short (<6 h), normal (6-8 h) and long (>8 h) sleep duration]. CVD was assessed by a positive response to the following questions: "Have you been told by a doctor that you have had a heart attack or angina (chest pain or exertion that is relieved by medication)?" or "Have you been told by a doctor that you have had a stroke?". Participants’ sleep quality was estimated with the Epworth Sleepiness Scale, Athens Insomnia Scale, Pittsburgh Sleep Quality Index, and Berlin Questionnaire.

Results

The overall prevalence of CVD was 9.5%. The population with CVD exhibited reduced sleep duration and efficiency reduced by 33 min and 10%, respectively. After adjusting for all possible cofounders, short sleep duration was 3.07-times more frequent in patients with CVD and sleep duration of less than 5:33 hours could be a potential risk factor for CVD, especially among females. Additionally, CVD was significantly associated with excessive increased daytime sleepiness, insomnia, poor sleep quality and increased risk of obstructive sleep apnea.

Conclusion(s): Our study depicts a strong correlation of sleep insufficiency with CVD and promotes early pharmacological or cognitive behavioral interventions in order to protect cardiovascular health. Abstract Figure. Results
Metabolic outcome analysis of patients with and without diabetes mellitus undergoing cardiac rehabilitation for ischaemic heart disease
Authors: Mannion J , Nagle N , Spelman D , Brassill MJ
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients with T2DM have reduced benefit from cardiac rehabilitation compared to non-diabetics. Additionally, diabetics are less likely to follow up after rehab completion. The European Society of Cardiology (ESC) recommend the use of SGLT2 inhibitors and GLP-1 analogues for T2DM with coronary artery disease. Both classes reduce all-cause mortality, improve HbA1C and obesity.

Purpose

We analysed our cardiac rehab population, comparing outcomes of patients with T2DM to those without; additionally, we appraised outcomes of new agents compared to prior standard care.

Methods

180 patients were analysed, 90 diabetics and 90 non-diabetics. Data from 2016-2020 was reviewed. Sub-analysis was performed on those treated with SGLT2 inhibitors or GLP-1 analogues.

Statistics performed on IBM SPSS v.26.

Results

Data points are displayed in Table 1.

Patients on GLP-1/SGLT2 therapy comprised 14.44% (n = 13) of diabetics. Prescription of these agents increased from 0% in 2016 to 45% in 2020. Mean BMI loss in this group was comparable to non-diabetics, at 0.3615 kg/m2.

Conclusions

HTN and obesity was higher in diabetics, with lower total cholesterol - possibly explained by earlier recognition and treatment. BMI loss for non-diabetics was 2.13 times that of diabetics (0.362 kg/m2 vs 0.171 kg/m2, p = 0.2), but comparable to those on SGLT2 or GLP-1 therapy (0.3615 kg/m2). Use of these agents increased significantly as robust data became available. Table 1CategoryNon-Diabetics (Mean)Diabetics (Mean)P-ValueAge (Years)66.1 (SD +/- 8.73)67.73 (SD +/- 8.88)0.21Sex (Male)58%54%0.41Smoker or Ex25%27.7%0.52PCI (% of total)78%82%0.48CABG (% of total)22%18%0.74Cholesterol (mmol/L)4.21 (SD +/- 1.29)3.57 (SD +/- 0.9)<0.001BMI (kg/m2)- Prior27.56 (SD +/- 3.11)31.76 (SD +/- 5.89)<0.001BMI (kg/m2)- Post27.19 (SD +/- 3.13)30.98 (SD +/- 6.16)<0.001Change in BMI0.363 (SD +/- 0.525)0.171 (SD +/- 1.33)0.21Resting Heart Rate - Prior73.32 (SD +/- 10.75)76.94 (SD +/- 13.22)0.059Resting Heart Rate - Post69.46 (SD +/- 10.01)75.29 (SD +/- 11.21)<0.001Systolic BP (mmHg) - Prior141.9 (SD +/- 18.89)150.5 (SD +/- 18.87)0.0026Systolic BP (mmHG) - Post135.2 (SD +/- 17.65)140 (SD +/- 19.26)0.07Comparison of baseline demographics and metabolic data of those with diabetes mellitus to those without.