bluuebunny/crossref_metadata_2025 huggingface dataset:
Reduction of perivascular inflammation following long-term statin treatment - a coronary CT follow-up study using Fat Attenuation Index
Authors: Matyas B , Benedek I , Rosca A , Stanescu A , Blindu E , Gerculy R , Benedek T
Published: November 2023

Background

Perivascular fat attenuation index (FAI) assessed by coronary computed tomography (CCTA) has been demonstrated to represent a reliable marker of coronary inflammation. Several studies have explored the potential anti-inflammatory effects of statins in reducing the risk of plaque rupture and subsequent cardiovascular events. However, the effect of statin therapy on FAI has not been clearly demonstrated so far.

Purpose

Our objective was to investigate the changes in perivascular FAI at the level of coronary lesions, as measured by coronary computed tomography (CCTA), following long-term high-dose statin therapy.

Methods

This study includes 23 patients who presented with typical chest pain, had a low to intermediate likelihood of coronary artery disease, and underwent a CCTA examination which revealed the existence of at least one coronary atheromatous plaque. Statin therapy was initiated in all patients according to guidelines. The CCTA was repeated after a time interval ranging from 1.5 to 3 years. Lesion-specific perivascular FAI, together with different plaque characteristics, were measured at both baseline and follow-up using a new AI-powered medical device called CaRi-Heart®.

Results

The mean age of the participants was 61.72 ± 8.86 at the time of the first scan, and 65.21% (n = 15) of them were male. At baseline, the CT density of the adipose tissue (ranging from -190 to -30 HU), was not significantly different between the two groups. A significant decrease in serum lipids following statin therapy was recorded during follow-up: from 193.4 ± 47.09 to 145.2 ± 34.7, p = 0.04 for total cholesterol, and from 101.77 ± 25.20 to 86.41 ± 21.09, p = 0.02 for LDL cholesterol. The FAI-score consistently decreased from baseline to follow-up, especially in the left anterior descending artery: from 15.87 ± 9.32 vs. 12.40 ± 7.55, p = 0.04, while there was no significant decrease in coronary inflammation at the level of left circumflex artery (13.98 ± 6.16 vs. 13.10 ± 6.59, p = ns), or right coronary artery (20.53 ± 13.74 vs. 19.96 ± 16.24, p = ns). Similarly, the FAI-Score Centile values were lower during the second scan, specifically for LAD (0.51 ± 0.28 vs. 0.69 ± 0.29, p = 0.04), while there were no significant differences of FAI score centile in the LCX (0.72 ± 0.28 vs. 0.74 ± 0.26, p = ns) and RCA (0.71 ± 0.32 vs. 0.78 ± 0.21, p = ns).

Conclusion

CaRi-Heart® mapping technology revealed a significant decrease of coronary inflammation, as expressed by the FAI-score, as a result of high-dose statin treatment especially at the level of the LAD. This indicates a potential role of local factors related to coronary circulation in the complex process of plaque inflammation. The perivascular FAI-score and FAI-score centile may serve as promising imaging biomarkers for monitoring the anti-inflammatory response to statin treatments.Color-coded FAI MappingPVAT-FAI Score of Coronary Inflammation
Time to coronary catheterization in patients with NST-ACS and high GRACE score
Authors: Bar O , Elias A , Halhal B , Marcusohn E
Published: November 2023

Introduction

Current European guidelines recommend early (<24 hours) invasive coronary angiography (ICA) strategy in certain high-risk non-ST segment elevation acute coronary syndrome (NSTE-ACS) patients, including those with GRACE score over 140. The evidence for this recommendation is based on older trials using pre high-sensitive troponin (HsTn) biomarkers and non-contemporary therapy.

Purpose

To assess the association between GRACE score over 140, timing of ICA and their interaction on clinical outcomes in patients with ACS with no ST elevation, using (HsTn) as part of the calculated GRACE risk score.

Methods and results

Between February 1st 2016 and July 31th 2021, 1767 patients with a primary diagnosis of NSTE-ACS without indication for urgent ICA, underwent ICA during index hospitalization. 655 (37%) patients underwent early-invasive ICA (within 24 hours) and 1112 (63%) underwent late ICA (between 24 hours and 1 week). 107 patients had a GRACE risk score of 140 or above and 1660 had a GRACE risk score under 140. The primary composite outcome was all-cause mortality, stroke, and recurrent MI. The median time from admission to ICA was 13.3 hours (IQR 6.0,20.6) for the early group and 59.9 hours for the late group (IQR 23.5,96.3). The vast majority of patients had re-vascularization (75.1%) performed, mostly by PCI (69.4%). There was no difference between the early and late ICA groups in the primary composite outcome (late Catheterization >24h HR 1.196, 95% CI 0.969-1.475, P-value 0.096). Using a multivariable cox regression model for the composite outcome revealed no difference between the early and late ICA groups (late Catheterization >24h HR 1.0735, 95% CI 0.862-1.327, P-value 0.512) with no effect for performing early ICA in patients with GRACE score over 140 (HR 1.291 95% CI 0.910-1.831, p-0.151).

Conclusion

Early ICA strategy in patients with NSTE-ACS patients and GRACE risk score over 140, compared with late ICA, was not associated with improved composite outcome of death, myocardial infarction, and stroke at 1 year.
Pretreatment with P2Y12 inhibitors and relationship with clinical outcomes in NSTEMI: Analysis of 2 Argentinian registries
Authors: Sigal A , Rivero M , Mezza M , Kersten S , Boissonnet C , Filippa G , Procopio G , Abud C M , Ahuad Calvelo S A , Nani S , Perez G E , Odone M , Guardiani F , Duronto E , Costabel J P
Published: November 2023

Introduction

Pretreatment with P2Y12 inhibitors has been widely studied in the context of NSTEMI patients, with varying results. General consensus is that this strategy should be avoided, unless a long wait time is expected before angiography can be performed. However, it is unclear whether this strategy is associated with a reduction in clinical outcomes, or an increase in bleeding events.

Purpose

To analyze frequency of pretreatment in NSTEMI in our medium, and association with clinical outcomes.

Methods

We analyzed the results of two Argentinian acute coronary syndrome registries from 2017 and 2022. We explored incidence of pretreatment, and drug used. We evaluated first through univariate analysis the relationship between pretreatment use and a clinical composite outcome of in hospital events: Myocardial infarction + Mortality + In stent thrombosis + post MI angina + Stroke/TIA. We also explored the relationship of pretreatment with bleeding events (BARC 2 or higher). We later conducted a logistic regression with other clinical variables: Age, gender, diabetes, previous bleeding events, previous MI, aspirin use, anticoagulation, killip-kimball scale and ejection fraction.

Results

1297 patients were included in the analysis, after excluding STEMI patients, patients with current use of P2Y12 inhibitors at time of event, and patients who did not undergo angiography. 75.6% were men, 25.6% diabetic, 27,1% smokers, 70.3% hypertensive, and 23.1% had a previous acute coronary syndrome. Mean age was 55.3 years old. Mean GRACE score was 113,5 and CRUSADE 23,8. 44% of patients recieved pretreatment, mostly with clopidogrel (93.5%). Patients that recieved pretreatment were more frequently hypertensive (73.8% vs 67%, p=0.01) and had a higher incidence of previous MI (27% vs 19%, p=0.002). GRACE score was significantly lower in patients that were pretreated (111,5 vs 115, p=0.04). Pretreatment use was significantly associated with a higher incidence of the composite clinical outcome, occuring in 10.1% of patients pretreated and in 6.9% of patients not pretreated (OR 1.56 (1.06-2.3) p=0.02. Bleeding events were numerically more frequent with pretreatment (8.7% vs 5.9%), though did not reach statistical significance (OR 1.51 (0.99-2.3) p=0.054).

In multivariate analysis, after adjusting for multiple clinical variables, pretreatment was no longer associated with a higher incidence of clinical outcomes, though also not with a lower incidence (OR 1.4 (0.89-2.3) p=0.13).

Discussion

Pretreatment, mostly with clopidogrel, did not show a relationship with either benefit or harm with regard to ischemic and bleeding outcomes in NSTEMI patients.
Poor prognosis of total culprit artery occlusion in patients presenting with NSTEMI
Authors: Herman R , Smith S W , Meyers H P , Bertolone D T , Leone A , Bermpeis K , Viscusi M , Martonak M , Bahyl J , Demolder A , Perl L , Wojakowski W , Bartunek J , Barbato E
Published: November 2023

Background

The prognosis of STEMI and NSTEMI patients stratified according to invasive angiographic findings of an occluded culprit coronary, i.e., occlusion myocardial infarction (OMI), remains unclear.

Purpose

This retrospective single-center study aimed to compare the clinical presentation, management, and all-cause mortality of STEMI, NSTEMI-OMI, and NSTEMI-Non-OMI (NSTEMI-NOMI).

Methods

Demographics, clinical and procedural data were pooled for all patients with an index ACS event between January 2011 and May 2021. Patients were classified according to the presence of OMI determined by angiography and troponin. All-cause mortality was compared by Kaplan Meier analysis at 1-year and landmark analysis up to 5 years after the ACS event.

Results

A total of 9,943 patients [64.1 ± 14.2 years, 62.2% males] were included and classified into STEMI (n=507), NSTEMI-OMI (n=685), NSTEMI-NOMI (n=1,535) and MI ruled-out (n=7,216). Median time to coronary angiography (CAG) was 1.4 hours for STEMI compared to 16.3 and 45.8 hours for NSTEMI-OMI and NSTEMI-NOMI, respectively (p<0.001) [Figure 1]. At one year, all-cause mortality occurred in 9.9% of STEMI patients vs. 18.1% of NSTEMI-OMI patients (hazard ratio, 1.84; 95% CI, 1.32 to 2.55; p<0.001) and 7.9% of NSTEMI-NOMI patients (hazard ratio, 0.79; 95% CI, 0.56 to 1.09; p=0.150) [Figure 2]. An unfavorable mortality outcome for NSTEMI-OMI compared to STEMI was maintained in the age and gender-adjusted analyses and landmark analysis beyond 1-year (hazard ratio, 2.59; 95% CI, 1.75 to 3.82; p<0.001).

Conclusions

Despite similar baseline demographics and angiographic findings, patients with NSTEMI-OMI have increased delays to reperfusion and unfavorable short and long-term all-cause mortality compared to STEMI. These findings support the need for more accurate and timely identification of NSTEMI-OMI.Time to Coronary Angiography (CAG)All-cause 1-year Mortality
Machine learning versus guideline recommended pathways for the diagnosis of myocardial infarction
Authors: Boeddinghaus J , Duodesis D , Lopez-Ayala P , Lee K K , Koechlin L , Nestelberger T , Rubini Gimenez M , Wildi K , Mills N L , Mueller C
Published: November 2023

Background

CoDE-ACS (Collaboration for the Diagnosis and Evaluation of Acute Coronary Syndrome) is a validated clinical decision-support tool that uses machine learning to calculate the probability of myocardial infarction (MI) for an individual patient. Current European guidelines recommend the use of 0/1h- and 0/2h-algorithms optimised to rule-out or rule-in MI and the High-STEACS pathway, which enables rapid discharge or admission in patients with suspected MI. However, it is unknown how CoDE-ACS performs against these guideline recommended pathways.

Methods

We enrolled adult patients presenting with suspected acute coronary syndromes at 12 sites in 5 European countries. Patients with ST-elevation MI and those with missing high-sensitivity (hs)-cTnI concentrations at 0h, 1h or 2h were excluded. Final diagnoses were adjudicated by two independent cardiologists according to current guidelines and the 4th universal definition of MI using all information including serial hs-cTnI measurements and imaging. We compare the diagnostic performance and effectiveness of CoDE-ACS with the 0/1h- and 0/2h-algorithms and the High-STEACS pathway.

Results

In 4,105 patients (median age 61 [IQR 50-74], 32% women), the prevalence of type 1 MI was 14%. At presentation, CoDE-ACS identified 56% (2,280/4,105) of patients as low-probability, with a 99.7% (99.5-99.9%) negative predictive value (NPV) and 99.0% (98.6-99.2%) sensitivity, which ruled out twice as many patients as other pathways. CoDE-ACS incorporating 1h hs-cTnI measurements identified 65% (2,671/4,105) patients as low-probability with a 99.7% (99.5-99.8%) NPV and 98.6% (98.2-98.9%) sensitivity and 19% (770/4,105) patients as high-probability with a 64.9% (63.5-66.4%) PPV and 92.4% (91.5-93.1%) specificity, with 16% classified as intermediate probability. In comparison, the 0/1h-algorithm identified 49% (2,014/4,105) patients as low-risk with a 100% (99.9-100%) NPV and 100% (99.9-100%) sensitivity and 20% (829/4,105) patients as high-risk with a 61.5% (60.0-63.0%) PPV and 91.0% (90.0-91.8%) specificity, with 31% triaged to the observe zone. Findings for CoDE-ACS incorporating hs-cTnI measurements at 2h, the 0/2h-algorithm and the High-STEACS pathway were comparable (Table).

Conclusion

All guideline recommended clinical pathways provide excellent performance for the diagnosis of MI. CoDE-ACS provides comparable diagnostic performance, but identifies twice as many patients as low-probability at presentation and fewer patients require further observation following serial hs-cTnI measurements. Implementation studies are warranted to determine whether CoDE-ACS can further improve the early diagnosis of MI.
Temporal trends in intra-aortic balloon pump use
Authors: Cohen B , Kalmanovich E K , Perl L P , Greenberg G G , Samara A S , Beigel R B , Ovdat T O , Kornowski R K , Orvin K O
Published: November 2023

Background

Intra-aortic balloon pump (IABP) is still the most accessible and available mechanical support solution in acute myocardial infarction patients, especially in cardiogenic shock. Although studies from the last decade failed to prove benefit for routine IABP use in this indication, the benefit of IABP utilization in selected cases is still unknown.

Purpose

To follow temporal trends in IABP use in a large-scale, real-world cohort of ACS patients.

Methods

We evaluated IABP utilization and patient’s outcome form the ACS Israel Survey (ACSIS) between 2000-2021. Temporal trends and compared rates of mortality and MACE (comprising death, myocardial infarction, stroke, target vessel revascularization and/or coronary bypass surgery) with IABP at 2 time periods were set: early (2000-2010) and late (2013-2021). Subgroup analysis for cardiogenic shock patients was performed as well.

Results

Out of 18,662 admitted ACS patients, 692 (3.7%) patients were treated with IABP. The rate of IABP use stood at about 4.5% (511 patients) in the early period and decreased to ∼2.5% (181 patients) in the late period. Patients treated with IABP in the early period had more frequently moderately and severely reduced ejection fraction on admission (64.5% vs 53.2%, p<0.01) and were mostly STEMI patients (71.0% vs 62.4%, p=0.04). On admission and in hospital cardiogenic shock (Killip 4) were presented equally in both periods (14.6% vs. 17.1%, p= 0.66 and 42.8% vs. 41.9%, p=0.90, respectively). 30-day mortality and MACE were comparable between time periods (28% vs 30.7%, p=0.547 and 43.6%vs. 44.1%, p=0.978, respectively) however major bleeding complication was significantly higher in the later period (4.8% vs 11.2%, p=0.04). These observations were consistent also in patients with baseline Killip class 3/4.

Conclusions

Our real-world data based prospective study demonstrated poor prognosis with IABP during all time periods, suggesting poor outcome in routine as well as selective use.
Association of myocardial infarction with nonobstructive coronary arteries with long-term outcomes
Authors: Miller A , Tao M , Price J , Dhaliwal S , Masson R , Henriques M D , Kim P M , Rahman T , Bench T J , Pyo R
Published: November 2023

Background

Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA) is a disease classification that is not uncommonly encountered yet poorly characterized. The association of MINOCA with long-term cardiovascular (CV) outcomes has been inconsistently assessed with studies reporting conflicting results. The purpose of this meta-analysis is to evaluate the association of MINOCA with long-term cardiovascular outcomes.

Methods

A literature search was conducted for studies reporting on the association of MINOCA with clinical endpoints as compared to obstructive coronary artery disease (OCAD). The primary end-point was all-cause mortality. Secondary endpoints included CV mortality, need for revascularization, recurrence of acute coronary syndrome (ACS), CV rehospitalization, persistent angina after discharge, and major adverse cardiac events (MACE). Databases searched included Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar. The search was not restricted to time or publication status.

Results

A total of 29 studies with 893134 patients with acute myocardial infarction (AMI) (48425 with MINOCA, 844709 with OCAD) met inclusion criteria. Mean follow-up was 39 months, mean age was 62, 66% were male. MINOCA was associated with significantly lower risk of all-cause mortality compared to OCAD (OR 0.69, 95% CI 0.60-0.78; p<0.01). The overall effect size was large (z=5.72). MINOCA was associated with significantly lower risk of CV mortality, need for revascularization, recurrent ACS, and persistent angina after discharge (OR 0.49, 95% CI 0.36-0.67; p<0.01; OR 0.09, 95% CI 0.03-0.31; p<0.01; OR 0.57, 95% CI 0.37-0.89; p=0.01; OR 0.23, 95% CI 0.11-0.51; p<0.01). MINOCA was not associated with a significant difference in risk of CV rehospitalization (OR 0.74, 95% 0.46-1.19; p=0.21).

Conclusions

In patients with AMI, MINOCA is associated with lower risk of all-cause mortality, CV mortality, need for revascularization, recurrent ACS, and persistent angina on long-term follow-up compared to OCAD. However, MINOCA is associated with similar risk of rehospitalization for CV events. Further studies are needed to determine the association between different medical therapies and clinical outcomes in patients with MINOCA.
Coronary microvascular dysfunction in takotsubo syndrome: an analysis using angiography-derived index of microcirculatory resistance
Authors: Schweiger V , Gilhofer T , Fang R , Wuerdinger M , Candreva A , Di Vece D , Koleva I , Rajman K , Ghadri J R , Cammann V L , Templin C
Published: November 2023

Background

Coronary microvascular dysfunction (CMD) has been proposed to be a major contributing factor in the pathophysiology of Takotsubo syndrome (TTS). To asses CMD, the angiography-derived index of microcirculatory resistance (caIMR) has been developed as a wire-free alternative to the conventional hyperemic wire-based index (IMR). This study aimed at evaluating the extent and transience of CMD and its implications on in-hospital outcome in TTS using caIMR.

Methods

Microcirculatory function of the three main coronary arteries of 96 TTS patients (48 with apical- and 48 with midventricular type) was assessed using caIMR. Measurements were compared with those of non-culprit vessels of 96 matched patients with ST-elevation myocardial infarction, as non-culprit vessels have previously been demonstrated to have an intact microcirculatory function [1]. In ten patients, follow-up caIMR was determined from angiographies without any cardiac event and was compared with event-caIMR. The prognostic role of caIMR on the in-hospital combined endpoint of death, cardiac arrest, ventricular arrhythmia, and vasopressor dependency was assessed via a binomial logistic regression analysis.

Results

CMD was present in all patients with TTS in at least one coronary vessel (caIMR>25), most frequently observed in the LCX (86 of 88 measurable LCXs [98%]). CaIMR in all three coronary arteries was significantly higher compared to the respective vessels of the control group. No significant difference in caIMR was observed comparing the apical and midventricular type of TTS. We could demonstrate normalization of caIMR in patients with follow-up angiographies performed at a median of 22 months (median [IQR] caIMR during event vs. follow-up: LCX 39.5 [33.9-52.0] vs. 25.1 [20.5-31.3]; LAD 34.2 [29.4-38.3] vs. 17.2 [15.9-23.9]; RCA: 31.7 [25.0-39.1] vs. 19.6 [17.1-24.0], Figure 1). The in-hospital combined endpoint correlated with the extent of CMD (p=0.036, Figure 2).

Conclusion

CMD was present during the acute TTS event and normalized during follow-up, suggesting that CMD is only a phenomenon of the acute phase of TTS and IMR values recover to normal dimensions. In addition, LAD caIMR was associated with the in-hospital end point of death, cardiac arrest, ventricular arrhythmia, and vasopressor dependence, however prospective validation will be necessary to further substantiate these findings.
Veno-arterial extracorporeal membrane oxygenation for cardiogenic shock: one-year outcomes from a cardiac intensive care unit led shock team program
Authors: Bello A , Presume J , Gomes D , Albuquerque F , Lopes P , Brizido C , Strong C , Ferreira J , Tralhao A , Neves J P , Brandao H
Published: November 2023

Background

Mechanical circulatory support (MCS) with peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used for severe cardiogenic shock (CS).

Purpose

To describe the initial experience with peripheral VA-ECMO within a cardiac intensivist team led program.

Methods

Retrospective analysis of a short-term MCS prospective registry, from 1 September 2021 to 1 December 2022. Clinical and device related variables were reviewed and reported. We assessed both patient outcomes as well as ECMO-related complications.

Results

A total of 21 patients were included in this analysis (50 ± 13 years-old, 80% male), ranging from SCAI-C (n = 8) to E (n = 5) and with a median predicted mortality by SAVE score of -4 points [IQ -6 - 0] (corresponding to 30% in-hospital survival). All cannulations were done percutaneously, mostly by trained cardiac intensivists and while at the CICU (n = 12). A femoro-femoral configuration was used for all patients. One patient was cannulated at the referring hospital and retrieved to our unit for further care. Three patients were cannulated during intra-hospital cardiac arrest and one patient was cannulated while breathing spontaneously (awake-ECMO). Mean venous and arterial cannula sizes were 22 ± 1.9 Fr and 17 ± 1.6 Fr, respectively. A 7 French (Fr) arterial limb reperfusion cannula was used in 85% of cases. The most frequent etiology was acute decompensation of chronic heart failure (n = 7), followed by acute myocardial infarction related CS (n = 5), fulminant myocarditis (n = 2) and massive pulmonary thromboembolism (n = 2). A left ventricle venting device was used in 70% of patients [intra-aortic balloon pump (n = 10); percutaneous microaxial pump ( n = 2)] and upgrade to a veno-arterio-venous configuration was necessary in one patient due to differential hypoxemia. Mean ECMO-run duration was 8.4 ± 4.8 days while mean CICU length of stay was 22 ± 17.9 In-hospital mortality was 40%. In survivors, decannulation was surgical in all but one patient. The most frequent strategy was bridge to recovery (n = 14). One patient was bridged directly to heart transplant, one to a temporary centrifugal left ventricular assist device (LVAD) and one to a durable magnetically levitated LVAD. Complications were common and included bleeding from cannula insertion sites (n = 19), renal replacement therapy requirement (n= 10), Harlequin syndrome (n = 2), cardiac tamponade (n = 2), intestinal ischemia (n = 3) and limb ischemia (n = 2).

Conclusion

VA-ECMO performed by cardiac intensivists is a feasible MCS strategy for severe cardiogenic shock patients in whom mortality, while high, was similar to large international published series. Further experience will allow for improvement in patient selection and minimization of device related complications.ECMO VA 1 year single-center experience
Validation of SAVE score and the value of serum lactate in patients admitted for cardiogenic shock treated with VA-ECMO
Authors: Presume J , Gomes D A , Albuquerque F , Lopes P , Bello A R , Brizido C , Strong C , Ferreira J , Mendes M , Neves J P , Tralhao A
Published: November 2023

Introduction

Veno-Arterial extracorporeal membrane oxygenation (VA-ECMO) is a treatment option to provide circulatory and pulmonary support to patients with cardiogenic shock. However, a risk profile assessment is essential for an adequate selection of patients for this type of therapy.

The aim of this study was to 1) validate the SAVE score in a Portuguese cohort of patients treated with VA-ECMO due to cardiogenic shock; 2) evaluate the prognostic impact of the maximum serum lactate level pre-VA-ECMO implantation; 3) assess the ability of lactate to improve risk stratification by the SAVE score.

Methods

We conducted a single-center retrospective analysis of patients treated with VA-ECMO due to cardiogenic shock from 2017 until 2022. Variable assessments were considered before VA-ECMO implantation. The primary outcome analyzed was in-hospital mortality.

Results

A total of 61 patients were included (52±12 years, 74% male, 40% with acute myocardial infarction, 54% with an ejection fraction <20%, and 74% in SCAI stage D pre-implantation). Overall, 38 (62%) died during hospitalization. The mean SAVE score was -1.7±7.2 points, and the median maximum serum lactate before ECMO implantation was 5.8 [2.7; 11.8] mmol/L.

SAVE score showed a statistically significant association (1±5 vs. -4±7; OR 0.872 [0.789; 0.964] per each point increase; p=0.008) and good discriminative power (AUC 0.710; p=0.006) to predict in-hospital mortality. When grouping patients according to this score, 25 (41%) were classified as SAVE risk class I or II, and 36 (59%) as SAVE class III, IV, or V.

Maximum serum lactate before VA-ECMO implantation also showed a significant association (4.5±3.1 vs. 9.6±6.6; OR 1.264 [1.066;1.498] per each 1mmol/l increase; p=0.007) and good discriminative power (AUC 0.771; p=0.001) to predict the primary outcome. The best lactate cut-off to identify high mortality risk was 5 mmol/l with a sensitivity of 74% and a specificity of 76%. Additionally, taking into account this threshold, lactate significantly enhanced the SAVE score group stratification, with a net reclassification improvement of 36.7% (p=0.021).

Conclusion

In this cohort of patients, the SAVE score was significantly associated with in-hospital mortality. Maximum serum lactate before VA-ECMO implantation was a strong predictor of in-hospital mortality and significantly improved SAVE score risk stratification.
Impact of age and body mass index (BMI) on the short-term prognosis of Impella in patients with cardiogenic shock
Authors: Nakayama T , Unoki T , Tsurusaki Y , Toyofuku T , Konami Y , Suzuyama H , Inoue M , Horio E , Taguchi E , Sawamura T , Sakamoto T , Nakao K , Koyama J
Published: November 2023

Introduction

The percutaneous transcatheter left ventricular assist device, Impella, has been recently introduced in Japan for patients with drug refractory acute heart failure including cardiogenic shock (CGS). Despite its potential benefits, Impella is associated with certain limitations, including a large device size and an increased risk of complications such as bleeding, hemolysis, and renal failure. These factors may present challenges for the use of Impella in elderly patients and those with smaller body size. For elderly patients with various comorbidities, the clinical impact of invasive hemodynamic support with impella remains unclear.

Objective

To assess the impact of age and body mass index (BMI) on the survival of patients with CGS treated with Impella.

Methods

We retrospectively reviewed 133 consecutive patients, who received Impella for cardiogenic shock, including cardiac arrest, between September 2018 and January 2023 at our institute. Patients were divided into two distinct age groups: younger group (<75 years of age; n=59) and elderly group (≥75 years; n=74). We assessed rate of successful Impella weaning and the 30-day survival. Multivariate cox regression analysis was used to identify risk factors for 30-day all-cause mortality.

Results

Baseline patient characteristics demonstrated a mean age of 70 ±13 years with 71% male ratio. Acute coronary syndrome was diagnosed in 72% of patients, while 63% received concomitant venoarterial extracorporeal membrane oxygenation (VA-ECMO), called ECPELLA, and 41% underwent extracorporeal cardiopulmonary resuscitation (E-CPR). The elderly group exhibited a lower BMI and higher rates of comorbidities, such as hypertension and chronic kidney disease. Notably, the incidence of cardiac arrest, E-CPR, and concomitant use of VA-ECMO were significantly lower in the elderly group compared with the younger group. There were no significant differences in Impella weaning, support duration, and length of hospital stay among two groups. Kaplan-Meier analysis revealed that the 30-day survival was also similar between two groups. Univariable Cox regression analysis revealed that BMI was significantly associated with 30-day mortality along with E-CPR and the combined use of VA-ECMO. Multivariable Cox regression analysis including the age, male, BMI, E-CPR, and combined use of VA-ECMO showed that the predictive values of independent determinants for 30-day mortality were age (hazard ratio [HR] 1.05, 95% confidence interval [CI], 1.02-1.07, P<0.0001), BMI (HR 1.14, 95%CI, 1.06-1.21, P=0.0001), and VA-ECMO (HR 4.27, 95% CI, 1.92-9.50, P=0.0004).

Conclusion

Results suggest that age and BMI were significantly associated with increased 30-day mortality risk, indicating a counterintuitive relationship between BMI and mortality in this population.OutcomesMultivariate Cox Regression
Metabolism in resuscitated out-of-hospital cardiac arrest and the effect of Tozilizumab
Authors: Paulin Beske R , Meyer M , Obling L , Moeller J , Kjaergaard J , Johansson P , Hassager C
Published: November 2023

Background

Out-of-Hospital Cardiac Arrest (OHCA) is a leading cause of death. The mortality and morbidity for initially comatose patients remain high even after successful resuscitation. The conquest of attenuating the damage caused by ischemia and reperfusion is ongoing. In a double-blinded clinical trial, comatose resuscitated OHCA patients (n=80) were randomized 1:1 to receive tocilizumab (interleukin-6 receptor antagonist) or placebo at arrival to the intensive care unit to reduce systematic inflammation (Figure 1). Tocilizumab markedly reduced the immunological response invested by high-sensitive C-reactive-protein and white blood count and further significantly lowered both troponin and NT-pro-BNP levels.

Aim

To describe circulating metabolites in out-of-hospital cardiac arrest patients and how tocilizumab affects the metabolism.

Methods

Accordingly, using ultra-performance-liquid-mass-spectrometry, we detected more than 3000 plasma metabolites in samples from arrival at the hospital (before tocilizumab infusion) and 48 hours later. We had prespecified 61 metabolites for quantification.

Results

The level of poly-unsaturated free fatty acids was associated with activated partial thromboplastin time (rho=0.77), while metabolites from the tricarboxylic acid cycle were associated with time to return of spontaneous circulation (rho=0.32) and interleukin-6 levels (rho=0.37) upon arrival. Furthermore, medium- and long-chain acylcarnitines were associated with increasing age (rho=0.32), eGFR (rho=-0.46), and NT-pro-BNP level (rho=0.47) Tocilizumab treatment increased the levels of several amino acids and free fatty acids more than 1.5 times (Figure 2). A possible interpretation would suggest a downregulated systemic protein synthesis in the tocilizumab group, possibly due to reduced systemic inflammation.

Conclusion

In this study, we have described the alterations in metabolites following OHCA and, for the first time, described the effect of tocilizumab on metabolism in critically ill patients.IMICA TrialVolcano Plot - Effect of tocilizumab
Impact of extracorporeal circulation support systems on blood product resources during the course of intensive care unit treatment
Authors: Haertel F , Fritzenwanger M , Pfeifer R , Gecks T , Moebius-Winkler S , Schulze P C
Published: November 2023

Background

Extracorporeal circulatory support systems necessitate careful blood product management due to the large cannulas and exposure of blood components to artificial surfaces in the circuits. Blood component derangements can occur during implantation and the operational period of these systems, posing a significant complication. To enhance patient safety and bolster the body's own blood reserves, accurate characterization of the extent of necessary blood product substitution is imperative.

Methods

We analyzed data from consecutive patients who received extracorporeal circulatory support systems (Impella, veno-arterial extracorporeal membrane oxygenation (VA-ECMO), or ECMella) over a 5-year period (2016-2021). We obtained information on blood product usage, costs, and various clinical parameters. We assessed the vascular access site according to the Bleeding Academic Research Consortium (BARC) and Global Utilization of Streptokinase and tPA for Occluded Coronary Arteries (GUSTO) criteria, and hemolysis was evaluated using serum free hemoglobin (fHb).

Results

We studied 370 patients (Table 1) who received extracorporeal circulatory support systems (Impella, VA-ECMO, and ECMella) from 2016 to 2021. The median number of RBC transfusions was 7 (3 - 12) for the entire cohort, with ECMella patients requiring the highest amount (12.5 (6.7 - 27.5)) and VA-ECMO patients requiring the most within the first 24 hours (57%, p < 0.05). Hemolysis was present in all groups, with Impella patients having the highest levels (49.8 µmol / L (21.3 – 113.1), p < 0.01). ECMella patients required the highest overall blood product substitution (Figure 1) and incurred the highest associated costs (1642.4 EUR (1079.1 – 3660.3), p < 0.01). Bleeding complications in the groin area were moderate in 45% of patients, with VA-ECMO patients having the highest incidence (58%, p < 0.05). Type 3a bleeding according to the BARC criteria was most common (31.7%).

Conclusion

Although extracorporeal circulatory support systems have made technical advances, significant resources are still required during the operational period to maintain coagulation homeostasis, particularly in ECMella patients. Complications at the insertion site are also common, with bleeding being expected, especially in emergency situations when a VA-ECMO is used. To ensure patient safety, interdisciplinary teams should establish standardized follow-up protocols to detect peripheral complications early.
Utilisation of artificial intelligence to predict early readmission to the cardiac intensive care unit in critically ill patients
Authors: Thevathasan T , Krause F J , Paul J , Boie S D , Knie W , Girke G , Wurster T H , Landmesser U , Balzer F , Skurk C
Published: November 2023

Background

The need for cardiac intensive care unit (ICU) beds remains high in order to treat patients with severe cardiovascular diseases. Therefore, safe and timely discharge policies from the cardiac ICU to normal wards are crucial to meet the continuously increasing demand for cardiac ICU beds. ICU readmission after ICU discharge has been shown to increase mortality, hospital length of stay and costs. Artificial intelligence may provide a timely and accurate discharge decision support system for intensivists based on comprehensive, multi-dimensional ICU data.

Purpose

This is the first study to develop and validate a neuronal network, called Feedforward Neural Network (FNN), to safely discharge patients from the cardiac ICU and predict ICU readmission within 72 hours.

Methods

Adult patients who were admitted to the cardiac ICU due to a primary cardio-pulmonary admission diagnosis (such as acute myocardial infarction, cardiogenic shock or cardiac arrest) at a German tertiary care center between 2003 and 2021 were included. The dataset was split into a training and test dataset. The FNN was trained with 127 variables, including patient demographics, co-morbidities, medical diagnoses, disease acuity levels, laboratory values, vital parameters, ICU procedures and administered ICU medications. FNN was compared to the predictability of a classic logistic regression model and the Stability and Workload Index for Transfer (SWIFT) score, which is a clinical score to predict ICU readmission.

Results

2,498 adult patients in the cardiac ICU met the inclusion criteria, out of which the FNN was trained in 1,998 (80.0%) patients and tested in 500 (20.0%) patients. The FNN had a 97.9% sensitivity, 86.9% specificity, 99.4% precision and 97.4% accuracy. FNN showed a better predictability of early ICU readmission than the logistic regression model and the SWIFT score: areas under the receiver operating characteristic (AUC ROC) curves were 90.78% vs. 71.34% vs. 71.13% (P <0.001) (Figure), respectively.

Conclusions

ICU transfer to the normal ward is considered to be a high-risk event and the vast amount of daily clinical, physiologic, laboratory and monitoring data may overwhelm critical care providers in making well informed decisions on patient discharge readiness. Artificial intelligence might be used as a sensitive, specific and accurate decision support system to help with patient discharge management and reduce ICU readmission rates.
Sex-based differences in short-term survival following out-of-hospital cardiac arrest
Authors: Zylyftari N , Gnesin F , Lykkemark Moeller A , Mills E H A , Moeller S G , Jensen B , Gislason G H , Torp Pedersen C , Lee C J Y
Published: November 2023

Background

Survival among OHCA patients remains low, thus it is important to understand the difference in short-term survival according to sex to identify subgroups of OHCA that could benefit from future preventive strategies.

Purpose

To examine sex differences in patient characteristics and the 30-day survival in patients with OHCA during 20 years of follow-up.

Methods

The study was observational and register-based, using information from the Danish Cardiac Arrest Registry (2001-2020) and linking at an individual level to other Danish national registers. Patients between 18-100 years old, with a presumed cardiac cause of OHCA, and not witnessed by emergency medical services (EMS) during their OHCA were identified. Baseline characteristics were expressed as medians (interquartile range [IQR]) or frequencies (percentages), and temporal trend analyses of 30-day survival were performed according to sex.

Results

We included 50,270 OHCA patients between 2001-2020 (17,179 [34%] women). Compared to men, women were older, with a median age of 76 years (Q1-Q3: [66-84]), had a higher proportion with a basic education level, and low-income. They also had a higher burden of comorbidities such as respiratory (38% vs. 32%; p<0,001), especially chronic obstructive pulmonary disease (COPD,19% vs. 14%; p<0,001), and a higher burden of psychiatric disease (13% vs. 8%; p<0,001). Related to medication 180 days before OHCA, women compared to men had more prescriptions of antibiotics (47.5% vs. 34.9%; p<0,001), steroids (18% vs. 13%; p<0,001), and QT-prolonging drugs (17% vs. 11%; p<0,001). By contrast, men had more cardiac-related comorbidities, especially ischemic heart disease (24% vs. 17%; p<0,001), and accordingly a higher prescription of anticoagulant drugs (17% vs. 13%; p<0,001), and statins (32% vs. 25%; p<0,001). Concerning cardiac arrest-related factors, women had more OHCA in a private home, less witnessed, were less likely to receive cardio-resuscitation and defibrillation and had less shockable rhythm. Figure 1 shows the temporal trend of OHCA incidence and 30-day survival by sex during 2001-2020. Although there has been an increase in survival for both sexes, women had lower 30-day survival compared to men throughout the period study. The average 30-day survival by sex during 2001-2010 vs. 2011-2020 was, for women 4.7% vs 8.2% and for men 8.1% vs 15.4%.

Conclusions

From 2001 to 2020, there was an increase in the 30-day survival in both sexes. However, the survival discrepancies increased between the sexes, where women had less shockable rhythm and lower 30-day survival compared to men.
Left-ventricular unloading with Impella during refractory cardiac arrest treated with veno-arterial extracorporeal membrane oxygenation - A systematic review and meta-analysis
Authors: Thevathasan T , Fuereder L , Mork S R , Schrage B , Gaisendrees C , Unoki T , Axtell A L , Takeda K , Teixeira P G , Lemaire A , Alonso-Fernandez-Gatta M , Lim H S , Garan A R , Landmesser U , Skurk C
Published: November 2023

Background

Extracorporeal cardio-pulmonary resuscitation (ECPR) is the implementation of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) during refractory cardiac arrest. The role of left-ventricular (LV) unloading with Impella in addition to VA-ECMO ("ECMELLA") during ECPR is unlear.

Purpose

This is the first systematic review and meta-analysis to characterise patients receiving LV unloading and to compare in-hospital mortality between ECMELLA and VA-ECMO treatment during ECPR.

Methods

A systematic review and meta-analysis was performed according to the PRISMA checklist on clinical studies with adult patients with refractory cardiac arrest treated with ECMELLA or VA-ECMO as part of ECPR. The meta-analysis was performed by using a random-effects model. Risk of bias was assessed with Cochrane ROBINS-I tool, heterogeneity with Cochrane Q test and publication bias with funnel plots.

Results

Altogether, 13 study records from 32 tertiary care centers with a total of 1,037 adult patients with ECPR were included, out of which 785 patients (75.7%) received VA-ECMO and 252 (24.3%) ECMELLA support. Compared to VA-ECMO, the ECMELLA group was comprised of more male patients (71.4% vs. 57.3%), more patients with initial shockable ECG rhythms (55.2% vs. 40.3%), lower pre-ECPR pH (7.07 vs. 7.11) and higher lactate levels (10.9 vs. 10.1 mmol/L), as well as higher rates of acute myocardial infarction (75.0% vs. 41.9%) and percutaneous coronary interventions (71.8% vs. 35.4%) (Table). Age, rate of out-of-hospital cardiac arrest and low-flow times were similar between both treatment groups. Compared to ECMELLA, VA-ECMO alone was more frequently used in pulmonary embolism (6.4% vs. 0.4%) and miscellaneous causes of cardiac arrest (19.0% vs. 4.4%). ECMELLA support was associated with a 47% reduced mortality risk [95% Confidence Interval 0.31-0.93] compared to VA-ECMO alone: 123 (48.8%) vs. 539 (68.7%) patients (P=0.026). Patients with ECMELLA had a longer hospital length of stay (18.7 days vs. 10.6 days). Results remained robust in sensitivity analyses after exclusion of smaller studies and gray literature.

Conclusions

ECMELLA support was predominantly utilised in patients with acute myocardial infarction and VA-ECMO for pulmonary embolism and miscellaneous causes of cardiac arrest across institutions. Indications and frequency of ECMELLA use varied strongly between institutions. ECMELLA support during ECPR was associated with improved survival across studies and might be considered in well selected patients with refractory cardiac arrest. Further scientific evidence is urgently required to elaborate standardised guidelines for the use of LV unloading during ECPR.
Predictors of long-term outcomes of patients with concomitant moderate aortic and mitral valves diseases: a single tertiary care center experience 2010-2018
Authors: Gaballa A , Hajj Ali A , El Dahdah J , Popovic Z , Wang T K M , Reed G W , Rodriguez L , Griffin B , Roselli E E , Gillinov A M , Kapadia S , Svensson L G , Desai M
Published: November 2023

Background

To date, moderate concomitant valvular heart diseases have been scarcely studied. This study aimed to further define predictors of long-term outcomes in patients diagnosed with concomitant moderate aortic and mitral valve disease at a tertiary center.

Methods

In this cohort we included 3257 patients (aged 71.7 ± 12.9 years; 55.2% male; 83.1% white) diagnosed with concomitant moderate aortic and mitral valves diseases who presented to the Cleveland Clinic between 2010 and 2018. The patients’ demographic, clinical and echocardiographic variables were collected. The primary endpoint of the study was the long-term composite outcome defined as heart failure hospitalization or all-cause mortality. We then conducted a univariate and multivariate cox proportional hazard survival analysis for the primary endpoint.

Results

The patients were followed up for 21.8 months. Baseline demographic characteristics are presented in table 1. Multiple demographic, clinical, and echo variables were evaluated. Using a univariate Cox proportional hazard survival analysis, older Age, history of smoking, Diabetes, Hypertension, Chronic Kidney Disease (CKD), Coronary Artery Disease (CAD), Atrial Fibrillation (Afib), Dyslipidemia, higher Right Ventricular Systolic Pressure (RVSP), higher New York Heart Association (NYHA) class, and lower Left Ventricular Ejection Fraction (LVEF) were associated with worse long-term outcomes. Additionally, patients who underwent an aortic (39.1%) or a mitral valve intervention (29.4%) were associated with better long-term outcomes (HR, 0.710, 0.708; respectively). In comparison, on Multivariable Cox analysis, female sex was significantly associated with worse survival (HR of 1.151, p-value=0.019). However, older Age, history of smoking, Diabetes, CKD, higher RVSP, NYHA class 2, 3, and 4, and lower LVEF remained significantly associated with worse long-term (table 2). Aortic valve intervention remained significantly associated with better survival (HR, 0.861, P-value=0.021). Compared to the Aortic Stenosis/ Mitral Stenosis (AS/MS) group, univariate analysis showed that patients in the Aortic Regurgitation/Mitral Regurgitation (AR/MR), and the AR/MS groups were significantly associated with better long term outcomes (HR, 0.738, HR, 0.575; respectively). Conversely, on Multivariate Cox analysis, AR/MR and AS/MR groups were significantly associated with better survival compared to AS/MS group (HR, 0.580, HR, 0.716; respectively).

Conclusion

In patients diagnosed with concomitant moderate aortic and mitral valve diseases, female sex, older age, history of smoking, diabetes, CKD, RVSP, NYHA class, LVEF and aortic valve intervention are independent predictors of the composite endpoint of heart failure hospitalization or all-cause mortality.Table 1Table 2