bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical practice and outcomes in elderly STEMI patients undergoing PCI with new generation DES – data from a large worldwide registry
Authors: Roguin A
Published: November 2020

Background

The best treatment option for elderly patients with acute myocardial infarction (MI) remains unclear.

Purpose

We aimed to determine clinical practice and outcomes of PCI with a new generation DES in patients with ST-elevated MI (STEMI), aged ≥80 years included in a one of the largest real-world PCI registries.

Methods

e-Ultimaster is a prospective, world-wide, multi-centre registry that enrolled 36,671 patients with coronary artery disease, treated with a thin strut sirolimus-eluting stent with abluminal bioresorbable polymer coating, across 50 countries. 34,538 patients who completed 1-year follow-up or who died were included in the analysis. The primary endpoint was 1-year target lesion failure (TLF: cardiac death, target vessel (TV) MI, clinically driven (CD) target lesion revascularization (TLR)). An Clinical Event Committee adjudicated all endpoint-related adverse events.

Results

6863 presented with STEMI at baseline (19.9%). Mean age of STEMI patients was 61.0±11.7 years, with 78.8% males. Diabetes was present in 20.9% and hypertension in 52.4%.

Of 6863 STEMI patients, 430 patients (6.2%) were aged ≥80 years, with 46.5% females compared to 19.5% females in the younger group. Patients in the older group had more comorbidities (hypertension and renal impairment) and more often took oral anticoagulant medication (9.2% vs 3.9%; p<0.001). At discharge 94.9% of older STEMI patients were on dual antiplatelet therapy (DAPT) as compared to 97.6% of younger STEMI patients (p=0.002). Older STEMI patients more often took clopidogrel as second antiplatelet agent (54.7% vs 39.8%; p<0.001) and were less often on prasurgrel (2.3%vs 10.9%; p<0.001) and ticagrelor (41.2% vs 48.1%; p=0.005).

STEMI patients in the older group more often had multivessel disease (52.1 vs 45.8%; p=0.01), treatment of the left main artery (4.7 vs 1.4%; p<0.001) and more calcified lesions (18.8 vs 11.2%; p<0.001). Other lesion characteristics were similar between the two groups. Preferred access approach was radial and was alike in the two groups (87.0 vs 84.0%; p=0.10)

In-hospital mortality was more frequent in older STEMI patients (2.3% vs 0.8%; p=0.003). More bleedings were observed in older vs younger STEMI patients at discharge.

One-year TLF was significantly higher in older age group (7.0% vs 3.0%; p<0.01), mainly driven by increased rates of cardiac death. All-cause mortality and bleedings were also more frequent in older STEMI patients. No differences were observed in revascularization or ST rates (1.4 vs 1.1%; p=0.48).

Conclusions

In elderly patients with STEMI, in-hospital mortality rates as well as bleeding rates were higher as compared to younger patients, while 1-year rates of revascularization and ST did not differ between the groups.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Terumo Europe
Effect of transradial ECG guided immediate intervention on culprit lesion with a single guiding catheter on door to balloon time
Authors: Guo G.J.C , Wang W.G.Z , Liu L.Z.J , Li L.H.D , Niu N.D , Gan G.S.J
Published: November 2020

Objective

There is limited literature on procedure of primary PCI in catheterization laboratory. This study was designed to assess the impact of electrocardiogram-guided immediate intervention on culprit lesion with a single guiding catheter in ST-elevation myocardial infarction (STEMI) patients on door-to-balloon (D2B) time and clinical outcomes.

Methods

In this prospective, randomized single center study, 560 patients with STEMI who underwent primary PCI from February 2017 to July 2019 were randomized into two groups. In single catheter group, a single guiding catheter (MAC3.5 or JL 3.5 guiding catheter) was used to perform angiogram and PCI of culprit vessel, followed by contralateral angiography (n=280). In contral group, 280 patients underwent primary PCI after complete diagnostic angiography. The primary evaluation was D2B time and second endpoint include catheterization laboratory-to-balloon (C2B) time, major adverse cardiac events (MACE) at 30 days. This trial was registered with ClinicalTrials.gov, NCT03272451.

Results

Baseline characteristics were not different between the two groups. The median D2B time (54.83 [IQR 40.00–68.0] min versus 58.32 [IQR 44.12–78.40] min, P=0.007), C2B time (16.91 [IQR 13.88–21.42] min versus 23.80 [IQR 18.92–28.52] min, P<0.001), total procedural time (45.17 [34.06–59.48] min versus 48.51 [37.04–64.60] min, P=0.012) and fluoroscopy time (9.70 [6.50–14.15] min versus 11.26 [8.01–14.27] min, P=0.025)were significantly shorter in single catheter group Compared with control group. The proportion of patients achieving D2B time within 60 minutes increased significantly in the single catheter group (61.79% vs. 52.14%, P=0.021). The rate of radial perforation was significantly reduced in single catheter group (0.71% vs. 3.21%, P=0.033). The total number of catheters was significantly less in single catheter group (1.18±0.54 vs. 2.23±0.60, p<0.001). There was no significant difference in the MACE at 30 days (2.5% vs. 4.64%, P=0.172) between the 2 groups.

Conclusion

ECG-guided immediate intervention on culprit lesion with a single guiding catheter in STEMI patients can reduce D2B time, C2B time, procedural time and fluoroscopy time.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Capital's Funds for Health Improvement and Research
The importance of early and late ventricular arrhythmias detection and prediction in acute myocardial infarction
Authors: Krljanac G , Trifunovic D , Asanin M , Savic L , Vratonjic J , Zlatic N , Viduljevic M , Arnautovic N , Sulovic V , Aleksandric S , Mrdovic I
Published: November 2020

Background

Malignant arrhythmias, ventricular tachycardia or ventricular fibrillation (VT/VF) in acute myocardial infarction (AIM) carry ominous prognosis including sudden cardiac death (SCD). It is not clear whether the timing of VT/VF occurrence always affects the poor prognosis of patients with AMI.

Aim

To investigate the prognosis of patients who undergoing primary percutaneous coronary intervention (PCI) in accordance with timing of VT/VF and to find the power predictors of their occurrence.

Methods

307 consecutive patients in PREDICT-VT study (NCT03263949), 57.9±10.6 year old, 72.3% males were analysed. Of these patients, 27.7% had VT/VF from the symptoms onset, within 48 hours of AIM (early VT/VF group). 8.1% of patients had VT/VF after 48h, during one year follow up (late VT/VF group).

Results

The frequency of VT/VF occurrence was high between symptoms onset and the end of 2nd month and during 5th and 6th month of AIM. The parameters of conventional echocardiography were significantly impaired in late VT/VF group, as well as parameters of longitudinal strain (LS) (table). Moreover, the MACE (cardiovascular mortality, SCD, new infarction, emergency revascularisation, and hospitalized heart failure) was the highest in late VT/VF group (p=0.000). The most significant predictor of late VT/VF was systolic LS (cut off −12.72%, ROC 0.680, Sen 71%, Sp 64%, p=0.006).

Conclusions

Although late VT/VF occurrence after primary PCI were less frequent than early VT/VF occurrence, patients with late VT/VF had a very poor prognosis. The most power predictor of late VT/VF were systolic longitudinal strain.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Clinical Center of Serbia
Prognostic impact of active mechanical circulatory support in cardiogenic shock complicating acute myocardial infarction: results from the CULPRIT-SHOCK trial
Authors: Feistritzer H , Desch S , Freund A , Poess J , Zeymer U , Ouarrak T , Schneider S , De Waha-Thiele S , Fuernau G , Eitel I , Noc M , Stepinska J , Huber K , Thiele H
Published: November 2020

Background

Active mechanical circulatory support (MCS) devices are increasingly used in patients with cardiogenic shock (CS) complicating acute myocardial infarction (AMI). However, data derived from randomized controlled trials on the efficacy and safety of these devices are still limited.

Purpose

To analyze the prognostic impact of active MCS devices in a large prospective contemporary cohort of patients with CS complicating AMI.

Methods

This is a predefined subanalysis of the Culprit Lesion Only PCI versus Multivessel PCI in Cardiogenic Shock (CULPRIT-SHOCK) randomized trial and prospective registry. Patients with CS, AMI and multivessel coronary artery disease were categorized in two groups; (1) use of at least one active MCS device, vs. (2) no active MCS or use of intra-aortic balloon pump (IABP) only. The primary endpoint was a composite of all-cause death or need of renal replacement therapy at 30 days.

Results

Two hundred of 1055 (19%) patients received at least one active MCS device (n=112 Impella®; n=95 extracorporeal membrane oxygenation [ECMO]; n=6 other devices). The primary endpoint occurred significantly more often in patients treated with active MCS devices compared to those without active MCS devices (142 of 197, 72% vs. 374 of 827, 45%; p<0.001). All-cause mortality at 30 days and 1 year as well as bleeding rates were significantly higher in the active MCS group (all p<0.001). After multivariable adjustment the use of active MCS was significantly associated with the primary endpoint (odds ratio [OR] 4.0, 95% confidence interval [CI] 2.7–5.9; p<0.001).

Conclusion

In the CULPRIT-SHOCK randomized trial and prospective registry approximately one fifth of patients was treated with active MCS devices. Compared to patients without active MCS, patients treated with active MCS devices showed worse outcome at 30 days and 1 year.

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): Supported by a grant (FP7/2007-2013) from the European Union 7th Framework Program and by the German Heart Research Foundation and the German Cardiac Society.
Coronary angiographic manifestations of fibromuscular dysplasia and clinical outcomes in patients with spontaneous coronary artery dissection
Authors: Inohara T , Alfadhel M , Choi D , Starovoytov A , Saw J
Published: November 2020

Background

Fibromuscular dysplasia (FMD) is a common predisposing condition for spontaneous coronary artery dissection (SCAD), which is an important cause of myocardial infarction (MI) in young to middle-aged women. However, its impact on clinical presentation, coronary anatomies, and outcomes have not been reported.

Purpose

To evaluate coronary angiographic characteristics and clinical outcomes in SCAD patients with or without underlying extracoronary FMD.

Methods

We retrospectively analyzed patients enrolled in our Vancouver SCAD registries who were screened for extracoronary FMD. Extracoronary FMD was defined as the presence of multifocal FMD on catheter or noninvasive angiography (computed tomographic or magnetic resonance imaging) in ≥1 extracoronary vascular beds. We reviewed coronary angiograms for manifestations of coronary FMD that were previously described (i.e. irregular stenosis, smooth stenosis, dilatation/ectasia, and tortuosity). Severe tortuosity was defined as ≥2 consecutive bends ≥180° at any cardiac cycle or 360° loop in ≥1 epicardial artery that was ≥2 mm in diameter. Clinical outcomes of major adverse cardiovascular event (MACE), a composite of all-cause death, MI, and stroke, were evaluated.

Results

We included 346 SCAD patients, 250 (72.3%) had extracoronary FMD. Patients with FMD were older (54.6±9.5 vs. 51.7±9.8 years) and more likely to have prior history of MI (7.2% vs. 1.0%, p=0.047) and stroke (4.4% vs. 0%, p=0.081) compared with non-FMD patients. The proportion of multivessel SCAD and TIMI flow was not different between groups, but type 3 SCAD was more commonly observed in FMD group (11.6% vs. 3.1%, p=0.026). On coronary angiography, severe tortuosity was more prevalent in patients with extracoronary FMD (58.4% vs. 36.5%, p<0.001), whereas rates of irregular stenosis, smooth stenosis, and dilatation/ectasia were not significantly different (Figure). Percutaneous coronary intervention was performed in 13.2% of FMD and 15.6% of non-FMD group, with similar success rates (75.8% vs. 69.2%, p=0.65). In-hospital and long-term MACE rate at median follow-up of 1032 (IQR 453–1096) days were not different between FMD and non-FMD groups (in-hospital: 5.6% vs. 8.3%, p=0.492; long-term: 19.6% vs. 15.6%, p=0.185).

Conclusion

In SCAD patients, severe coronary tortuosity was more prevalent in patients with FMD than those without. Despite the complex coronary anatomy, FMD was not associated with worse outcomes.

Differences in coronary manifestations

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Canadian Institutes of Health Research
Long-term clinical outcomes of troponin-positive chest pain and unobstructed coronary arteries assessed by cardiovascular magnetic resonance imaging
Authors: Ananthakrishna R , Woodman R , Grover S , Bridgman C , Selvanayagam J
Published: November 2020

Background and introduction

Troponin-positive chest pain with unobstructed coronary arteries is a distinct entity with different pathophysiological causes. We have previously reported on the incremental diagnostic capability of cardiovascular magnetic resonance (CMR) in this cohort. However, there is paucity of literature on the long-term clinical outcomes of these patients assessed with CMR.

Objectives

Using the unique cohort of patients previously studied, we sought to assess the long-term clinical outcomes in patients with troponin-positive chest pain and unobstructed coronary arteries, as graded by their acute CMR presentation.

Methods

A total of 122 consecutive patients with troponin-positive chest pain and unobstructed coronary arteries undergoing CMR assessment during the acute admission (2010–2014) were studied. The primary endpoint was major adverse cardiac event (MACE), defined as a composite of all-cause mortality and cardiovascular readmissions (heart failure, acute myocardial infarction [AMI], atrial or ventricular arrhythmia and stroke). Patients were grouped into 4 categories based on their initial CMR findings: AMI, acute myocarditis, Takotsubo cardiomyopathy and normal CMR.

Results

The mean age of the study cohort was 55.6±16.5 years and 56.5% were women. CMR (performed at a median of 6 days from presentation) provided a diagnosis in 87% of the patients (38% myocarditis, 28% Takotsubo cardiomyopathy and 21% AMI). Patients with a diagnosis of AMI were prescribed guideline recommended medical therapy. Over a median follow-up of 2524 days (6.9 years), 32 (26.2%) patients experienced a MACE. The all-cause mortality was 2.5%. The most common indication for cardiovascular readmissions in this cohort was heart failure (12.3%) and AMI (9%). In multivariate analysis, a CMR diagnosis of AMI (hazard ratio = 2.6; 95% confidence interval = 1.2, 5.7; p=0.019) and peak troponin (hazard ratio = 1.0003; 95% confidence interval = 1.00003, 1.0006; p=0.028) were significantly associated with MACE after adjusting for age and gender. In addition, CMR diagnosis of AMI was significantly associated with a lower event-free survival rate compared with a diagnosis of non-AMI (adjusted hazard ratio = 2.57, p=0.019) (Figure).

Conclusions

The long-term prognosis of patients with troponin-positive chest pain and unobstructed coronary arteries is not benign. CMR diagnosis of AMI is a significant predictor of MACE even in the absence of significant coronary artery obstruction and despite guideline recommended post AMI therapy.

Figure 1

Funding Acknowledgement

Type of funding source: None
Triggers of stress cardiomyopathy and their association with clinical outcomes
Authors: Chiu S , Nayak R , Duan L , Shen A , Lee M
Published: November 2020

Background

Stress cardiomyopathy can be a result of physical stress, emotional stress, or both. Whether the type of trigger affects clinical outcomes is not well studied.

Purpose

The objectives of this study were to identify the prevalence of emotional and physical stressors and to assess differences in patient characteristics and mortality based on the type of trigger.

Methods

We conducted a retrospective review of 523 consecutive patients who presented to our institution from 2006 to 2016. All patients presented with acute coronary syndrome. Triggers for stress cardiomyopathy were abstracted from reviewing patients' medical records. Patients were categorized into those with 1) physical trigger, 2) emotional trigger, 3) both physical and emotional trigger, or 4) no known trigger. Baseline characteristics and clinical outcomes were reported.

Results

Among 523 patients with stress cardiomyopathy, 151 (28.9%) had a physical trigger, 189 (36.1%) had an emotional trigger, 30 (5.7%) had both physical and emotional triggers, and 153 (29.3%) had no known triggers identified. Men comprised the higher proportion of patients with physical triggers. Comorbidities including diabetes, pulmonary disease, chronic kidney disease and hypothyroidism were more prevalent among patients with physical triggers. Compared to patients with no obvious triggers, patients with a physical trigger had a much higher mortality rate (hazard ratio 2.0, 95% CI 1.2–3.3, p=0.007), whereas patients with an emotional trigger had significantly lower mortality (hazard ratio 0.40, 95% CI 0.21–0.89, p=0.007).

Conclusion

Different triggers for stress cardiomyopathy is associated with different baseline characteristics and clinical outcomes. Overall survival is worst in the group with an identified physical trigger.

Figure 1

Funding Acknowledgement

Type of funding source: None
Impact of east Japan earthquake disaster with massive tsunami for prevalence of Takotsubo syndrome – a multicenter regional registry before and after east Japan earthquake disaster
Authors: Itoh T , Toda N , Osaki T , Maegawa Y , Yoshizawa R , Ishikawa Y , Nishiyama O , Yoshizawa M , Nakajima S , Nakamura M , Morino Y
Published: November 2020

Background

Previous studies demonstrated Takotsubo syndrome (TS) was easy provoked by earthquake disaster. However, a previous other regional report demonstrated TS was not increased after 2011 east Japan earthquake disaster. The purpose of this study was to clarify incidence of TS after the earthquake disaster in Iwate prefecture during long term period.

Method

Consecutive hospitalized TS patients were registered during 8 years between 2009 and 2016 in our medical university and five Iwate prefecture hospitals. Moreover, patients were divided into two groups, i.e., those with the inland and those with tsunami-stricken area groups. Prevalence of TS were calculated by standard incidence ratio (SIR) before and after the earthquake disaster. Moreover, long-term prognosis in the both groups was compared using Kaplan-Meier analysis.

Results

A total of 112 TS (male 25 and female 87) were registered from acute coronary syndrome registry in each hospital (n=4,163). Averaged age was 75.3 year-old. A total number of TS just after the two months of the earthquake (March and April 2011) was nine and significance monthly variation was observed comparing with the other months (p=0.029). SIR before and after the disaster is as following Figure. There were no significant differences for long-term prognosis between the two groups (p=0.20).

Conclusion

Incidence of TS was increased in acute phase after east Japan earthquake disaster. However, significance increases were maintained during long-term period, although number of TS was decreased after acute phase. TS is increased not only acute but also chronic phase after the serious earthquake disaster.

Standard incidence ratio

Funding Acknowledgement

Type of funding source: None
Impact of the cardiopulmonary resuscitation-related injuries on the prognosis after cardiac arrest
Authors: Merino Argos C , Marco Clement I , Rosillo Rodriguez S.O , Martin Polo L , Arbas Redondo E , Tebar Marquez D , Poveda Pinedo D.I , Velez Salas A , Rodriguez Sotelo L , Martinez Marin L.A , Gonzalez Fernandez O , Caro Codon J , Rial Baston V , Lopez-Sendon Hentschel J.L , Lopez De Sa Areses E
Published: November 2020

Background

Cardiopulmonary resuscitation (CPR) manoeuvres involve vigorous compressions with the proper depth and rate in order to keep sufficient perfusion to organs, especially the brain. Accordingly, high incidences of CPR-related injuries (CPR-RI) have been observed in survivors after cardiac arrest (CA).

Purpose

To analyse whether CPR-related injuries have an impact on the survival and neurological outcomes of comatose survivors after CA.

Methods

Observational prospective database of consecutive patients (pts) admitted to the acute cardiac care unit of a tertiary university hospital after in-hospital and out-of-hospital CA (IHCA and OHCA) treated with targeted temperature management (TTM 32–34°) from August 2006 to December 2019. CPR-RI were diagnosed by reviewing medical records and analysing image studies during hospitalization.

Results

A total of 498 pts were included; mean age was 62.7±14.5 years and 393 (78.9%) were men. We found a total of 145 CPR-RI in 109 (21.9%) pts: 79 rib fractures, 20 sternal fractures, 5 hepatic, 5 gastrointestinal, 3 spleen, 1 kidney, 26 lung and 6 heart injuries. Demographic characteristics and cardiovascular risk factors did not differ between the non-CPR-RI group and CPR-RI group. Also, we did not find differences in CA features (Table 1). Survival at discharge was higher in the CPR-RI group [74 (67.8%) vs 188 (48.3%); p<0.001]. Moreover, Cerebral Performance Category (CPC) 1–2 within a 3-month follow-up was significantly higher in the CPR-RI group [(71 (65.1%) vs 168 (43.2%); p<0.001; Figure 1]. Finally, pts who recieved blood transfusions were proportionally higher in the CPR-RI group [34 (32.1%) vs 65 (16.7%)]; p=0.004).

Conclusions

In our cohort, the presence of CPR-RI was associated with higher survival at discharge and better neurological outcomes during follow-up.

Figure 1

Funding Acknowledgement

Type of funding source: None
Refractory cardiac arrrest treated with extracorporeal cardiopulmonary resuscitation, 2-year follow-up
Authors: Kruger A , Ostadal P , Janotka M , Naar J , Vondrakova D , Skalsky I , Neuzil P
Published: November 2020

Introduction

Extracorporeal cardiopulmonary resuscitation (ECPR) has been introduced as a life-saving procedure in refractory cardiac arrest.

Methods

Eligible patients for this analysis had to undergo ECPR after unsuccessful cardiopulmonary resuscitation with a minimum of three defibrillation attempts. For extracorporeal life support (ECLS) was used Cardiohelp system or Levitronix CentriMag blood pump. LUCAS II system was used for chest compressions during cardiac arrest. The relations of blood lactate and pH levels, measured before ECPR insertion and after 24 hours as well as comorbities (diabetes, hypertension, BMI) to the clinical outcomes at 2 years were evaluated.

Results

We analyzed data from 59 patients treated with ECPR for refractory cardiac arrest. The mean age of our patients was 61 years. Out-of-hospital cardiac arrest (OHCA) occurred in 33 patients, 26 patients suffered from in-hospital arrest (IHCA). Baseline value of lactate was 11.57±4.22 mmol/l, initial pH 6.95±0.31. In comparison with survivors, patients who died had significantly higher initial lactate levels (12.05±0.81 vs. 8.01±0.77; P<0.05). Moreover, survivors had significantly lower lactate levels after 24 hours (7.39 vs 2.56) and lower BMI (27.4 vs 31.2; P<0.05). Diabetes or hypertension in our group have no influence on the mortality. The difference of mortality in the group of OHCA or IHCA was also not significant. 32% patients survived one month with good neurological outcome (CPC 1–2), 30% six months, 23% one year and 21% two years.

Conclusions

ECPR give the last chance to survive refractory cardiac arrest. The levels of blood lactate are significantly associated with clinical outcomes of ECPR. Obesity was associated with significantly higher mortality in our group.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): MH CZ DRO (Nemocnice Na Homolce - NNH, 00023884)
Coronary angiography findings in patients with refractory vs. non-refractory ventricular fibrillation cardiac arrest
Authors: Nas J , Thannhauser J , Damen Van Dijk E.G.J.A , Verkroost C , Van Wely M , Van Geuns R.J , Van Royen N , Bonnes J.L , Ten Cate T , Brouwer M.A
Published: November 2020

Introduction

Refractory ventricular fibrillation (VF) is usually defined as the need for >3 shocks and poses a therapeutic challenge during cardiac arrest. For these patients, new treatment strategies such as early invasive management are under active investigation, yet the underlying myocardial substrate has poorly been characterised. In search of potential therapeutic targets, we studied coronary angiography findings in refractory vs. non-refractory VF.

Methods

Out of our prospective cardiac arrest registry (2013–2018), we studied all VF-patients that were transported to our tertiary hospital, and underwent coronary angiography (CAG). CAGs were assessed by interventional cardiologists blinded for clinical outcomes and patient category, being either patients with refractory (>3 shocks) or non-refractory VF (≤3 shocks). CAG images were scored using predefined data-sheets with uniform definitions.

Results

We studied 301 patients, of which the majority was male (82%) and median age was 63 (53–70) years. Of all patients, 105 (35%) had refractory VF and 196 (66%) had non-refractory VF. We found no differences in baseline and arrest characteristics (i.e. arrest location, witnessed arrest, bystander CPR, EMS response time and AED use) between refractory and non-refractory VF. In both groups, significant coronary artery disease (≥1 stenosis >70%) was highly prevalent (78 vs. 77%, p=0.76). Acute coronary occlusions were more prevalent in the refractory VF group (41% in refractory VF vs. 26% in non-refractory VF, p=0.006). Figure 1 demonstrates that the proportion patients with an coronary occlusion increases with an increasing number of shocks (p for trend=0.003). Chronic total occlusions did not differ between both groups (29% vs. 33%, p=0.47). Refractory VF-patients had lower proportions 24-hour survival (75% vs. 93%, p<0.001) and survival to discharge (61% vs. 78%, p=0.002).

Conclusion

In this VF-cardiac arrest study on patients transported to the hospital and undergoing coronary angiography, acute coronary occlusions were more prevalent in refractory compared to non-refractory VF. After confirmation of these findings, further studies on the potential benefit of early treatment of acute coronary occlusions in patients with refractory VF are eagerly awaited.

Figure 1

Funding Acknowledgement

Type of funding source: None
Assessment of the 2015 cardiopulmonary resuscitation guidelines for patients with out-of-hospital cardiac arrest: results from the All-Japan Utstein registry
Authors: Yagi T , Nagao K , Tachibana E , Yonemoto N , Tahara Y , Nonogi H , Ikeda T , Sato N , Tsutsui H
Published: November 2020

Background

The 2015 cardiopulmonary resuscitation (CPR) guidelines have stressed that high-quality CPR improves survival from cardiac arrest (CA). In particular, the guidelines recommended that it is reasonable for rescuers to perform chest compressions at a rate of 100 to 120/min in adult CA patients. However, it is unknown whether the 2015 guidelines contributed to favorable neurological outcome in adult CA patients. The present study aimed to clarify the effects of the 2015 guidelines in adult CA patients, using the data of the All-Japan Utstein Registry, a prospective, nationwide, population-based registry of out-of-hospital CA (OHCA).

Methods

From the data of this registry between 2011 and 2016, we included adult witnessed OHCA patients due to cardiac etiology, who had non-shockable rhythm as an initial rhythm. We excluded patients who received prehospital care in 2015 because it was difficult to distinguish prehospital care based on either 2010 CPR guidelines or 2015 CPR guidelines. We also excluded patients who received bystander CPR by citizens because we cannot assess the quality of bystander CPR in this registry. Study patients were divided into five groups based on different years (figure). The endpoint was the favorable neurological outcome at 30 days after OHCA. Potential confounding factors based on biological plausibility and previous studies were included in the multivariable logistic regression analysis. These variables included the age, sex (male, female), advanced airway or not, the administration of adrenaline or not, the administration of saline or not, instructed by dispatcher or not, and time interval from call EMS to scene.

Results

The figure showed favorable neurological outcomes at 30 days. In the multivariate analysis, the adjusted odds ratio for 30-day favorable neurological outcome in OHCA patients in 2016 as compared to in 2011 was 1.32 (95% CI: 1.04–1.68, p=0.022). On the other hands, there were no significant differences from 2011 to 2014.

Conclusion

In the OHCA patients with non-shockable rhythm, the 2015 guidelines were superior to the 2010 guidelines, in terms of neurological benefits.

Figure 1

Funding Acknowledgement

Type of funding source: None
Rapid recognition of out-of-hospital cardiac arrest by emergency medical dispatchers is associated with improved survival
Authors: Gnesin F , Moeller A.L , Mills E.H.A , Zylyftari N , Jensen B , Boeggild H , Ringgren K.B , Kragholm K , Lippert F , Folke F , Gislason G , Torp-Pedersen C.T
Published: November 2020

Background

Emergency medical dispatchers' (EMD) recognition of out-of-hospital cardiac arrest (OHCA) is an essential part of the first link in the Chain of Survival. However, it is unknown whether the time-to-recognition of OHCA by EMD during an emergency call is associated with survival.

Purpose

To investigate the effect of time-to-recognition on 30-day survival among patients with recognised OHCA.

Methods

We linked data on OHCAs occurring in the Capital Region of Denmark from 2016 through 2017 to records of corresponding emergency calls. We defined recognition as dispatching an ambulance with an appropriate priority level and subsequently defined time-to-recognition as the time from start of the call to the time of dispatching the ambulance. Among patients with recognised OHCA, we performed uni- and multivariate logistic regression to investigate the association of time-to-recognition and 30-day survival and reported odds ratios (OR) with 95% confidence intervals (CI).

Results

Among 2,382 patients with OHCA, 94.2% were recognised, in which median age was 73.6 years, 61.6% were males and median time-to-recognition was 0.8 minutes (interquartile range 0.7 minutes). Patients for whom time-to-recognition was up to (but not including) one minute had more than three-fold higher probability of surviving 30 days (15.5%) compared to patients for whom time-to-recognition was three or more minutes (4.5%) (Figure 1). Time-to-recognition was significantly associated with 30-day survival: OR 0.75 per minute (95% CI 0.62–0.91, P<0.005), and results were similar in the adjusted analysis: OR 0.72 per minute (95% CI 0.58–0.90, P<0.005).

Conclusion

Rapid recognition of OHCA by EMD resulted in improved survival rate of patients. This was particularly evident when time-to-recognition was three or more minutes.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Hjerteforeningen
Countdown to physician-free EKG interpretation
Authors: Mehta S , Avila J , Niklitschek S , Fernandez F , Villagran C , Vera F , Rocuant R , Cardenas G , Frauenfelder A , Vieira D , Quintero S , Vijayan Y , Merchant S , Narvaez-Caicedo C , Sanchez C
Published: November 2020

Background

With the introduction of electronic medical records and other digital platforms, the classification and coding of different medical entities have become a complex, cumbersome task that is prone to diagnostic inconsistencies and errors. By incorporating Artificial Intelligence (AI) to a massive database of EKG records, we have developed an innovative methodology to accurately discriminate an EKG as “normal” or “abnormal”. We firmly believe that this algorithm sets up medicine on a path of complete computer-aided EKG interpretation.

Purpose

To present a viable AI-guided filter that can accurately discriminate between normal and abnormal EKG within a cardiologist-annotated EKG database.

Methods

An observational, retrospective, case-control study. Samples: A total of 140,000 randomly sampled 12-lead ECG of 10-seconds length with a sampling frequency of 500 [Hz] from Brazil (BR) and Colombia (CO) (divided as 70,000 normal and 70,000 abnormal EKG records per country dataset) were derived from the private International Telemedical System (ITMS) database from September 2018 to July 2019. Only de-identified records were used, records with artifacts were excluded. Preprocessing: Only the first 2s of each short lead and 9s of the long lead were considered. This data includes mobile (MOB) and transtelephonic (TTP) EKGs (50/50 ratio). Limb leads I, II and III and precordial leads V1, V2, V3 and V5 were used. The mean was removed from each lead. Training Sets: Four models were trained as depicted in the figure below. Each training dataset has 25,000 Normal and 25,000 Abnormal records, where 10% of the total records were used as a validation set. The test sets included 10,000 normal, and 10,000 abnormal records each. Testing and Class Assigning: An inception convolutional neural network was implemented; Each model was tested with 5,000 normal and 5,000 abnormal records of the corresponding country and transmission type with which they were trained. “Normal” or “Abnormal” labels were assigned to each EKG record and were compared to the cardiologists' reports; performance indicators (accuracy, sensitivity, and specificity) were calculated for each model.

Results

An overall accuracy of 82.4%; sensitivity of 88.7%; and specificity of 76.2% was achieved amongst the 4 testing models (Separate results of each training set are shown below).

Conclusion(s)

AI enables the interpretation of digital EKG records to be exercised in an organized, accurate, and straightforward manner, taking into consideration the multiple potential entities that can be diagnosed through this historical triage tool. By quickly identifying the normal records, the cardiologist is able to invest efforts in treating patients in a timely manner.

Funding Acknowledgement

Type of funding source: None
Presentation characteristics, use of treatments and outcomes in patients with ischaemic vs. non-ischaemic cardiogenic shock
Authors: Schrage B , Dabboura S , Yan I , Hilal R , Weimann J , Becher P.M , Seiffert M , Blankenberg S , Westermann D
Published: November 2020

Aim

Evidence on non-ischaemic cardiogenic shock (CS) is scarce. The aim of this study was to investigate differences in presentation characteristics, use of treatments and outcomes in patients with ischaemic vs. non-ischaemic CS.

Methods

Patients with CS admitted to a tertiary care hospital between October 2009 and October 2017 were identified and stratified as ischaemic CS/non-ischaemic CS based on the presence/absence of acute myocardial infarction. Missing data was handled by chained equation multiple imputation. Logistic and Cox regression models were fitted to investigate the association of non-ischaemic CS with presentation characteristics (adjusted for all baseline variables), and use of treatments as well as30-day in-hospital mortality (adjusted for relevant confounders including age, sex, prior cardiac arrest, haemodynamics, pH and lactate).

Results

A total of 978 patients were enrolled in this study; median age was 70 (interquartile range 58, 79) years and 70% were male. 505 patients (43%) had non-ischaemic CS. Patients with non-ischaemic CS were more likely younger and female; were less likely to be active smokers or to have diabetes, but more likely to have chronic renal disease and history of myocardial infarction; and were more likely to present with unfavourable haemodynamics and with mechanical ventilation. Regarding use of treatments, patients with non-ischaemic CS were more likely to be treated with catecholamines [odds ratio (OR) 1.58, 95% confidence interval (CI) 1.11–2.27, p0.01], but less likely to be treated with extracorporeal membrane oxygenation (OR 0.66, 95% CI 0.48–0.92, p=0.02) or percutaneous left ventricular assist devices (OR 0.51, 0.35–0.74, p<0.01). Unadjusted survival probabilities in patients with non-ischaemic vs. ischaemic CS were 36% (95% CI 32–42%) vs. 39% (95% CI 35–45%). After adjustment for multiple relevant confounders, non-ischaemic CS was associated with a significant increase in the risk of 30-day in-hospital mortality (hazard ratio 1.30, 95% CI 1.09–1.55, p<0.01, Figure 1).

Conclusion

In this large study, non-ischaemic CS accounted for almost 50% of all CS cases. Non-ischaemic CS was not only associated with relevant differences in presentation characteristics and use of treatments, but also with a worse prognosis. These findings highlight the need for effective treatment strategies for patients with non-ischaemic CS.

Figure 1

Funding Acknowledgement

Type of funding source: None
Early Impella support in post-cardiac arrest cardiogenic shock complicating acute myocardial infarction improves short and long term survival
Authors: Hatzis G , Markus B , Luesebrink U , Ahrens H , Divchev D , Syntila S , Schieffer B , Karatolios K
Published: November 2020

Background

Early mechanical circulatory support with Impella may improve survival outcomes in the setting of post-cardiac arrest cardiogenic shock (CS) after out of hospital cardiac arrest (OHCA) complicating acute myocardial infarction (AMI). However, the optimal timing to initiate mechanical circulatory support (MCS) in this particular setting remains unclear.

Purpose

We aimed to compare survival outcomes of patients supported with Impella 2.5 before percutaneous coronary intervention (PCI) (pre-PCI) to those supported after PCI (post-PCI).

Methods

Single center study of patients resuscitated from OHCA due to AMI with post-cardiac arrest CS between September 2014 and June 2018. Survival outcomes were compared between those with Impella support before and after PCI.

Results

A total of 65 consecutive patients with infarct-related post-cardiac arrest shock supported with Impella 2.5 during admission coronary angiogram were included. All patients were in profound CS requiring catecholamines on admission. Overall survival to discharge and at 12-months was 44.6% and 41.5%, respectively. Patients in the pre-PCI group had a higher survival to discharge and at 12-months as compared to patients of the post-PCI group (60.7% versus 32.4%, p=0.03 and 57.1% versus 29.7%, p=0.04, respectively). Moreover, the patients in the early support group demonstrated a greater functional recovery of the left ventricle when Impella support was initiated prior to PCI.

Conclusions

Our results suggest that the early initiation of MCS with Impella 2.5 prior to PCI is associated with improved hospital and 12-month survival in patients with post-cardiac arrest CS complicating AMI.

Figure 1

Funding Acknowledgement

Type of funding source: None
Ejection dynamics and valve kinetics in patients with low-gradient severe aortic stenosis with preserved ejection fraction. Comparison between normal and low-flow
Authors: Migliore R , Adaniya M.E , Barranco M.A , Gonzalez S , Miramont G
Published: November 2020

Background

Studies of ejection dynamics in severe aortic stenosis and prosthetic valve obstruction had demonstrated a delay in aortic valve opening.

Purpose

The aim of this study was to compare and evaluate ejection dynamics and valve kinetics in patients with severe aortic stenosis with preserved ejection fraction with normal and low flow.

Methods

83 patients (age average 68±11 years) with severe aortic stenosis (aortic valve area <1cm2) and preserved ejection fraction (≥50%) were studied with Doppler echocardiography and included prospectively. The ratio of aortic valve area measured at mid-deceleration and mid-acceleration (Md/Ma) were calculated using velocity of left ventricular outflow tract and aortic transvalvular velocity in continuity equation as an index of valvular kinetics. A ratio of Md/Ma >1 indicate delay in opening of aortic valve. Assessment of ejection dynamics was evaluated with acceleration time (AT), ejection time (ET) and the ratio AT/ET estimated from aortic Doppler velocities profiles. Aortic flow was calculated as stroke volume/ET. According to stroke volume index and mean gradient patients were classified in 3 groups: normal-flow, low-gradient (NFLG) 25 patients, low-flow, low-gradient (LFLG) 28 patients and normal-flow, high-gradient (HG) 30 patients. Analysis of the variance and coefficient of correlation “r” were used for statistical evaluation. A p value <0.05 was considered significant.

Results

There was no significant difference among the 3 groups with regard to ratio Md/Ma: NFLG 1.29±0.38, LFLG 1.22±0.26 and HG 1.23±0.45, NS. No difference was found in AT in the 3 groups, but ET was shorter in LFLG (310±30 ms) in comparison with NFLG (345±32 ms) and HG (361±31 ms), p<0.01. Ratio AT/ET occurred in early systole in NFLG (0.27±0.07) compared with LFLG (0.32±0.07) and HG (0.39±0.07), p<0.01. As expected, flow was decreased in LFLG (163±20 ml/s, p<0.001) compared with NFLG (217±13 ml/s) and HG (233±44 ml/s). There was no correlation among AT/ET and aortic flow or stroke volume index.

Conclusions

There were not differences among the groups with regard to kinetic of the valve evaluated by mean of ratio Md/Ma. According to ratio AT/ET, aortic valve takes less time to open in NFLG compared with LFLG and HG independent of aortic flow suggesting a different ejection dynamics pattern in this group.

Funding Acknowledgement

Type of funding source: None
Heritability of aortic valve stenosis and evidence of bicuspid enrichment in families with tricuspid aortic valve stenosis
Authors: Boureau A , Le Souarnec S , Dina C , Karakachoff M , Capoulade R , Piriou N , Cueff C , Probst V , Schott J.J , Le Tourneau T
Published: November 2020

Background

Calcific aortic valve stenosis (CAVS) is the most common valvular heart disease. Although a familial component has been described, the heritability remains unknown. This study aimed to determine the heritability of CAVS and to compare the prevalence of bicuspid aortic valve (BAV) relatives among families with tricuspid and bicuspid aortic valve phenotype and to a control cohort.

Methods

Probands were recruited following aortic valve replacement in three French university hospitals. All relatives who agreed to participate were enrolled in the study. Families were defined as tricuspid aortic valve (TAV) or BAV families based on the aortic valve phenotype observed in the proband. As control group, we used probands diagnosed with mitral valve prolapse and their families. All recruited probands and relatives underwent comprehensive transthoracic echocardiography to determine aortic valve morphology and CAVS status. Additive genetic heritability was performed with SOLAR genetic statistics package. Prevalence of BAV relatives in each sub-group and Prevalence Ratio were calculated.

Results

Within the 2371 relatives coming from 138 CAVS families, the heritability of CAVS was significant (h2=0.49, p<0.001). Furthermore, TAV stenosis heritability was only significant in TAV families (h2=0.20, p=0.013). The prevalence of BAV was significantly higher in TAV families and BAV families than control families (5.96 [95% CI: 4.2–8.3%], [n=32 of 537] vs. 2.49 [95% CI: 1.3–4.7%], [n=9 of 361]; PR 2.64 [95% CI: 1.41–5.91]; p=0.005 and 10.20 [95% CI: 7.0–14.5%], [n=26 of 255] vs. 2.49 [95% CI: 1.3–4.7%], [n=9 of 361]; PR 4.63 [95% CI: 2.35–13.44]; p<0.001; respectively).

Conclusions

The heritability of aortic valve stenosis in this population confirms the genetic effect in determining aortic stenosis for all aortic valve phenotype and for tricuspid aortic valve. The bicuspid enrichment in TAV families suggests common genetic predisposition of aortic valve stenosis in some families. Taking all together, these findings encourage echocardiography screening of relatives of affected individuals.

Funding Acknowledgement

Type of funding source: None
ECG modifications, life-threatening ventricular arrhythmias and relation to mitral valve apparatus phenotype in mitral valve prolapse
Authors: Stevant D , Plessis M , Gourraud J.B , Cueff C , Piriou N , Thollet A , Probst V , Le Tourneau T
Published: November 2020

Background

Mitral valve prolapse (MVP) is a common condition in the general population, which can be associated to non-specific ECG abnormalities described initially as ST segment depression, T waves flattening or inversion, especially in the inferior leads. Lately, this type of ECG abnormalities has been reported in patients with MVP and ventricular arrhythmias (VA) or sudden death (SD). However, the prevalence of ECG abnormalities has never been studied in a large series of patients, and the link between ECG abnormalities, VA and SD to echocardiography examination has never been prospectively assessed.

Objective

To study the prevalence of ECG abnormalities including ventricular arrhythmias in MVP patients and their link with echocardiographic characteristics.

Methods

All patients (n=731, MVP = 486, Controls = 245) were prospectively enrolled and underwent a comprehensive echocardiography and ECG. In MVP patients 81 had minimal systolic displacement (MSD), 92 isolated MVP, 108 mild-moderate MR, and 196 severe MR. A comprehensive qualitative and quantitative analysis of ECG obtained from rest ECG, 24-hours ECG recording or exercise stress tests, was carried out. Mean follow-up was 4.4 years.

Results

The mains ECG abnormalities were an inversion of T wave in the inferior leads found in 12 MVP vs 1 control (2.5 vs 0.4%, P=0.047) or a QRS notch (5.1 vs 2.9%, P=0.13). In bileaflet MVP T wave inversion was more frequent as compared with other MVP patients (3.8 vs 0.8%, P=0.039). In addition there was a progressive prolongation of PR interval, QRS duration and increase QT dispersion associated with worsening of MR and heart chambers remodeling. None of ECG findings were significantly linked with the presence of MVP only. Out of 731 individuals, 27 (3.7%) had an history of VA or SD. In a multivariate analysis, bileaflet prolapse and mitral annulus disjunction were associated with VA or SD, whereas none of ECG criterion was associated with.

Conclusion

In this large prospective series of MVP patients, prevalence of inferior leads ECG abnormalities is very low. Prolongation of atrio-ventricular and ventricular conduction, as well increased QT dispersion is associated with worsening of MR and LV remodeling. Bileaflet prolapse and mitral annulus disjunction are associated with VA or SD.

Funding Acknowledgement

Type of funding source: None