bluuebunny/crossref_metadata_2025 huggingface dataset:
Imprecision and real-time clinical performance of a whole blood high sensitivity point of care troponin i: ready for prime time?
Authors: Hatherley J , Dakshi A , Collinson P , Miller G , Davies S , Bailey L , Fearon H , Phillips S , Lambert A , Sekulska K , Khand A
Published: October 2024

Introduction

High sensitivity troponin (hs-cTn) measurement is central to rapid diagnostic algorithms in acute coronary syndrome (ACS). Point of care (POC) testing reduces turnaround time when compared to central lab (CL) testing. Currently there is very little data on the performance of POC hs-cTn assays in a clinical environment with non-expert operators.

Method

In a nested sub-study of a randomised controlled trial (RCT), patients with suspected ACS were randomised to either the ESC 0/1 or 0/3 hour algorithm. They underwent whole blood (WB) sampling for Siemens Atellica VTLi hs-cTnI POC (VTLi POC), CL hs-cTnI and CL hs-cTnT assays. This was for both initial and repeat samples. Assay imprecision of the VTLi POC assay was assessed by 2 runs of 10 tests with whole blood at 9 different troponin levels. 4 devices were used with samples stored at room temperature.Final diagnosis was adjudicated based on all relevant clinical and imaging data together with CL hs-cTnT as the diagnostic biomarker in clinical use (10% coefficient of variation (CV) 3-5 ng/L, 99th percentile 14 ng/L) and using the 4th universal definition of myocardial infarction (MI). Clinical performance was assessed using Receiver Operator Characteristics (ROC) curves.

Results

2144 patients consented and had WB VTLi POC, CL hs-cTnI and CL hs-cTnT available. The index adjudicated type 1 MI rate was 6.1%. Assay imprecision of the VTLi POC assay demonstrated a 10% Coefficient of Variation (CV) at 9.8ng/l. This was >50% lower than the 99th centile of 23ng/l (average for males and females) (Figure 1). Clinical performance of the VTLi POC assay was acceptable and equivalent to CL hs-cTnT: Area Under Curve (AUC) 0.92 (0.89-0.96), 0.98 (0.96-0.99) and 0.93 (0.87-0.98) at presentation (Figure 2), 1 and 3 hours respectively. However, clinical performance was inferior to CL hs-cTnI: AUC 0.96 (0.95-0.98) and 0.96 (0.93-0.98) at presentation (p=0.0007) and 3 hours (p<0.0001) respectively.

Conclusion

The Siemens Altellica VTLi hs-cTnI POC assay has imprecision levels consistent with a high sensitivity troponin assay. It has acceptable clinical performance though inferior to the equivalent CL hs-cTnI. Further validation of this assay, particularly with optimised single sample rule-out, could facilitate its use in routine clinical practice.
High-sensitivity troponin T and risk of stroke in persons with suspected acute coronary syndrome
Authors: Markovic M T , Kragholm K H , Torp-Pedersen C , Pareek M
Published: October 2024

Background

Serial high-sensitivity troponin (hsTn) concentrations are associated with the risk of recurrent ischemic events and death from any cause. Higher hsTn levels may suggest greater infarct size and possibly, a more pronounced risk of non-coronary atherosclerotic events.

Purpose

To examine the association between single and serial hsTnT levels and the risk of incident stroke in individuals presenting with suspected acute coronary syndrome.

Methods

In this Danish nationwide registry-based study, we identified individuals without a history of stroke who presented for myocardial infarction, unstable angina, suspected myocardial infarction, or chest pain from 2013 through 2019, and who underwent serial hsTnT (Roche Diagnostics, Rotkreuz, Switzerland; 99th percentile upper reference limit: 13.5 ng/l) measurements 1-7 hours apart. Subjects were stratified according to their hsTnT level pattern from first to second measurement (main groups: normal, rising, persistently elevated, or falling) and the magnitude of hsTnT level change (secondary groups: <20%, >20 to 50%, or >50% in either direction). Additionally, they were grouped into quartiles based on the initial hsTnT measurement (<=9 ng/l, 10-16 ng/l, 17-68 ng/l, >=69 ng/l). The standardized risk of stroke was computed using multivariable logistic regression with average treatment effect modeling.

Results

The final study sample consisted of 26867 persons, of whom 10407 (38.7%) were diagnosed with myocardial infarction, 1404 (5.2%) with unstable angina, and 15056 (56.0%) with suspected myocardial infarction or chest pain. Median age was 64.3 years, and 40.1% were women. The prevalences of known cardiovascular disease were as follows: coronary artery disease, 20.2%; prior coronary revascularization, 8.4%; heart failure, 6.4%; and atrial fibrillation, 8.9%. At 30 days, 69 individuals had been diagnosed with a stroke, and an additional 185 individuals were diagnosed from days 31 through 365. The standardized risk of stroke at 30 days was <=0.31% in all main groups and did not meaningfully differ from each other. The risk remained low between days 31-365 (<=0,79%), with no significant between-group difference. The magnitude of hsTnT change within each group did not affect stroke risk, nor did hsTnT quartile based on the first measurement.

Conclusions

Persons with suspected acute coronary syndrome had a very low overall risk of incident stroke. Single or serial hsTnT levels at presentation did not seem helpful in identifying individuals at an increased risk of stroke.
Normal reference values of left atrioventricular coupling index on two-dimensional echocardiography
Authors: Anwar A , Alshammakh M S , Al-Bakri I , Alkathiri A , Ayaz M , Ali M
Published: October 2024

Background

From a physiological background, there is close relationship between left atrial (LA) and left ventricular (LV) expressed as coupling. The assessment of LA/LV coupling may reflect LV dysfunction and differentiate between normal and abnormal LV function.

Aim of study

The study is designed to sample normal subjects to provide the normal reference values of LA/LV coupling index (LACI) according to age and sex using 2-dimensional echocardiography (2DE).

Methods

550 healthy subjects (51.9±17.8 years, 56% males) were included with good 2DE image quality enabled measurement of end-diastolic volumes of both LA and LV. LACI was defined as the ratio between LA to LV end-diastolic volumes.

Results

An off-line analysis of apical 4-chamber and 2-chamber views to obtain the 2DE measurements was performed within short time (1.5± 0.3 min). Measurement of LACI was obtained in all individuals. Subjects were divided into 3 age groups (G I: 18-40 years, G II: 41-65 years, and GIII: >65 years). As shown in table 1, the normal LACI values in the whole population was 0.17±0.08 with significantly higher in females (0.178±0.09) than males (0.15±0.06); P<0.02. The LACI values tends to be higher in females than males in the subdivided 3 age groups but not statistically significant. In both sexes, increasing age was associated with significant reduction of the mean LVEDV (P<0.0001), significant increase of the mean LAEDV (P= 0.004), and significant increase of LACI (P< 0.0001); especially considering the differences between the youngest and oldest age groups.

Conclusions

Measurement of LACI is feasible and easily obtainable using 2DE. Age and sex should be considered when defining normal reference values for LACI. The standardization of normal LACI values will help the future studies to assess the changes of these normal values in various cardiac abnormalities for prognostic risk stratification.
Do patients maintain improvement in physical capacity achieved after hybrid telerehabilitation implemented as part of managed care after acute myocardial infarction program at one-year follow-up?
Authors: Piotrowicz E , Orzechowski P , Kowalik I , Piotrowicz R
Published: October 2024

Background

Managed Care after Acute Myocardial Infarction (MC-AMI) is a one-year comprehensive care program dedicated to patients with acute coronary syndrome introduced in Poland. It includes acute intervention, complex revascularization, implantation of cardiovascular electronic devices (in case of indications), rehabilitation or hybrid rehabilitation (HTR) and scheduled outpatient follow-up. HTR is a unique component of MC-AMI program.

Purpose

The purpose of this study was to evaluate whether the effect of improving physical capacity achieved after 5-week HTR was maintained during one-year follow-up.

Methods

The study enrolled 84 patients (90% males, aged 57.5 ± 10.2 years, LVEF 54,6 ± 6.8%) who underwent a 5-week HTR based on Nordic walking training and completed the entire one-year MC-AMI program. Unless there were contraindications, HTR began no later than 14 days after discharge from the hospital and consisted of an initial phase (1 week) conducted in an outpatient center and 4 weeks of telemonitored exercise training at home, five times weekly. Exercise capacity was assessed by comparing the exercise test results at baseline (before HTR), immediately after HTR and at the end of one-year MC-AMI program.

Results

HTR resulted in significant improvement in workload [METS] and workload duration in exercise test. This valuable effects were maintained after one-year follow-up. All results are presented in Table 1 and Figure 1.

Conclusion

The improvement in physical capacity achieved after 5-week of the hybrid telerehabilitation was maintained in patients who completed MC-AMI program in one-year follow-up.
Angiotensin-II receptor type 1 and endothelin-1 receptor type A agonistic autoantibodies in patients with STEMI: new kids on the block
Authors: Civieri G , Martini M , Masiero G , Schiavon B , Bernava G , Vadori M , Iop L , Perazzolo Marra M , Cecere A , Leoni L , Cozzi E , Iliceto S , Tona F
Published: October 2024

Background

The Prognosis after ST-elevation myocardial infarction (STEMI) remains poor. Angiotensin-II and endothelin-1 contribute to adverse prognosis after STEMI through molecular mechanisms that lead to myocardial inflammation, fibrosis and, ultimately, adverse myocardial remodeling. Functional autoantibodies against angiotensin II type 1 (AT1R-AAs) and endothelin-1 type A (ETAR-AAs) receptors bind to the same receptors as natural ligands, eliciting similar (and amplified) responses. In patients with STEMI, AT1R-AAs and ETAR-AAs have been associated with a higher risk of developing microvascular obstruction and left ventricular remodeling. Both microvascular obstruction and left ventricular remodeling are associated with a poor prognosis.

Purpose

To assess the prognostic role of AT1R-AAs and ETAR-AAs after STEMI.

Methods

Consecutive STEMI patients who underwent primary percutaneous coronary intervention within 12 h after pain onset were enrolled in this prospective study. The levels of AT1R-AAs and ETAR ETAR-AAs at the time of hospital admission were measured using an enzyme-linked immunosorbent assay (ELISA) in all patients. The incidence of major adverse cardiovascular events (MACE, defined as a composite of cardiovascular mortality, myocardial re-infarction, and hospitalizations for heart failure) during follow-up was the primary outcome. Autoantibody seropositivity was defined according to ELISA’s kit manufacturer’s instructions (levels > 10 U/mL).

Results

Two hundred patients with STEMI were enrolled. The baseline characteristics of the patients are shown in Table 1. Of these, 110 (55%) were seronegative for both autoantibodies, 44 (22%) were seropositive for one autoantibody (but not both), and 46 (23%) were seropositive for both autoantibodies. The incidence of MACE over a 14-month median follow-up was higher in patients with double (31%) and single (25%) seropositivity than in seronegative patients (13%, p=0.009 and p=0.06, respectively). Survival free from MACE was significantly different across the different degrees of autoantibody seropositivity (Figure 1). In the multivariable Cox regression analysis, adjusted for the variables that were significant in the univariate analysis (highlighted in bold in Table 1), double seropositivity was independently associated with an increased risk of MACE (hazard ratio 2.386, 95 % CI 1.471-3.864, p<0.001).

Conclusions

The degree of seropositivity for AT1R-AAs and ETAR-AAs is associated with an increased risk of MACE after STEMI. Our findings provide valuable mechanistic insights into the pathophysiology of STEMI and pave the way for future therapies focused on the improvement of long-term prognosis after acute coronary syndromes.
STEMI SHOCK outcomes with SCAI classification
Authors: Leung A , Lo S T H , Xu J , Ediriwerra T , Yang K , Tran T , Dignan R , French J K
Published: October 2024

Background

Patients with ST-elevation myocardial infarction who develop cardiogenic shock (STEMI-SHOCK) face significantly increased risk compared to those without shock. Mechanical circulatory support (MCS) devices are commonly utilized in STEMI-SHOCK patients, but the benefits of MCS remain uncertain. This study aims to apply the Society for Cardiovascular Angiography and Interventions (SCAI) shock classification system to STEMI-SHOCK patients, examining outcomes and identifying subgroups that may benefit from MCS.

Purpose

Our study assessed SHOCK severity in STEMI-SHOCK patients using the updated 2021 SCAI-SHOCK classification system and determined survival at various endpoints (30 days, 1 year, and 3 years), along with other outcomes such as vascular access complications and major adverse cardiac events, based on the severity class.

Methods

Patients with angiograms and indications of STEMI-SHOCK between 2012 and 2021 admitted to Liverpool Hospital Australia, were included after adjudication they had STEMI-SHOCK. Angiograms were eligible for adjudication if they met criteria for both STEMI and SHOCK. Each patient underwent individual adjudication by three researchers to confirm STEMI-SHOCK status. Patients were followed from the time of the first SHOCK diagnosis until censoring at the last follow-up. Data were retrieved from electronic and paper-based patient records. The primary outcome was 30-day survival, and secondary outcomes were 1-year and 3-year survival.

Results

The SCAI stages of 160 (Estimated 220) STEMI-SHOCK patients were determined, with 17 in Stage A, 39 in Stage B, 53 in Stage C, 25 in Stage D, and 26 in Stage E. Worse SCAI stages were associated with significantly lower 30-day, 1-year, and 3-year survival. No difference in survival between the time periods 2013-2015 and 2018-2021 was found. An eGFR < 60 millilitres/minute/1.73 meters^2 (hazard ratio [HR] 3.41; 95% confidence interval [CI] 1.18 – 9.92, p=0.024) and lactate greater than 4.15 millimoles/liter (HR 6.48; 95% CI [2.84 – 51.64], p=0.001) at shock were associated with lower 30-day and 3-year survival. Patients in the SCAI C subgroup treated with an IABP had significantly higher 1-year (p=0.001) and 3-year (p=0.001) survival compared to those not treated with an IABP.

Conclusion

The SCAI classification system successfully predicted short and long-term survival in STEMI-CS patients, with worse stages having progressively worse outcomes. No improvement in survival outcomes was observed in the overall SCAI C-E group of patients treated with mechanical support. However, patients in the SCAI C subgroup of SHOCK treated with mechanical support showed a statistically significant improvement in survival outcomes compared to those treated without mechanical support. Further studies with adequate sample sizes are required to investigate sub-populations of SCAI classes that may benefit from MCS devices.
Cardio-renal syndromes in patients admitted with ST-elevation myocardial infarctions: Incidence and impact on renal and overall outcome
Authors: Schmucker J , Lutz J , Fach A , Osteresch R , Ruehle S , Hambrecht R , Wienbergen H
Published: October 2024

Background

The importance of cardiorenal syndromes (CRS) in patients with heart failure has been shown in many studies. However, there is little data on the impact of a combination of heart failure and renal disease in patients with acute myocardial infarctions. Aim of the present study was to investigate, how often a combination of heart failure (HF) and kidney disease (KD) could be detected in patients with ST-elevation myocardial infarctions and to estimate its impact on outcome.

Methods

All patients from a German heart center, admitted with STEMI between 2006 and 2022 were analysed. CRS was defined as a combination of heart failure (HF: left ventricular ejection fraction (LV-EF<40%), HF) and kidney disease (KD: GFR at admission <60 ml/min). Patients were assigned in a 2x2 model: HF-/KD-, HF-/KD+, HF+/KD-, HF+/KD+. Outcome analysis was adjusted by confounders in a multivariate Cox-regression-model. Acute kidney injury (AKI) was calculated by AKIN-criteria (KDIGO)

Results

Of a total of 8276 STEMI-patients included in the study 5696(69%) had a preserved LV-EF and no KD (HF-/KD-), 1354 (16%) a preserved LV-EF and KD (HF-/KD+), 743 (9%) a reduced LV-EF and no KD (HF+/KD-) and 483 (6%) both a reduced LV-EF and KD (HF+/KD+, CRS-Group). In the CRS-group patients were on average older (74.2±12 yrs. vs. 60.8±13 yrs., p<0.01), more likely to be female (36.9% vs. 23.1% in the control group, p<0.01) and more likely to be diabetics (31.0% vs. 16.8% in the control group, p<0.01). CRS was associated with higher rates of cardiogenic shock (41.5% vs. 8.7% in the control group) and higher rates of subsequent AKI with a 18x higher risk to develop AKIN-3 with or without the need for renal replacement therapy (RRT), (table, upper part). In patients with CRS in 11% of patients a temporal RRT was necessary vs. 0.5% in controls. Furthermore, in CRS-patients in-hospital and 1 year-mortality-rates were markedly higher (table, lower part). When adjusting outcomes for confounders (age, gender, CS, diabetes, anterior STEMI, 3 VD) the detrimental effect of CRS on outcome remained: AKIN-3/RRT: OR 16.5, 95% CI 7.5-30.0, p<0.01, In-hospital-mortality: OR 14.2, 95% CI 7.8-21, p<0.01, 1-year-mortality: HR 10.5, 95% CI 7.5-14.1, p<0.01.

Conclusions

In this analysis of registry data, cardiorenal disease could be detected in 6% of STEMI-patients, with higher rates in women and in diabetics. Patients with cardiorenal disease showed a more than 18-fold higher risk of suffering severe renal failure during the index event and a 24-fold higher risk of in-hospital death. Patients with either heart failure or renal disease were situated between the CRS and control group with regard to outcome. These results underline the additive effects of cardiac and renal disease.Table:Event rates by HF and KD group
Association between left ventricular outflow tract velocity time integral, ejection fraction, clinical characteristics, and mortality in an undifferentiated cohort of hospitalised patients
Authors: Eng-Frost J , Medan K , Juneja N , Ravikulan R , George K , Joseph M , De Pasquale C
Published: October 2024

Background

Left ventricular ejection fraction (LVEF) is commonly used to predict mortality in heart failure patients. However, LVEF is dependent on factors including preload, afterload, contractility, heart rate and measurement accuracy. Recently, left ventricular outflow tract velocity time integral (LVOT VTI) has been shown to confer additional prognostic value in both patients with advanced heart failure and patients hospitalised with heart failure with preserved ejection fraction.

Purpose

We evaluated the association between LVOT VTI, LVEF, clinical characteristics and mortality in an undifferentiated cohort of hospitalised patients.

Methods

All hospitalised patients who underwent echocardiogram between January – March 2021 were identified from a single-centre tertiary hospital database. Baseline characteristics, echocardiographic parameters, biomarkers, and mortality at 24 months were collected. Patients were categorised into LVOT VTI tertiles (> 19cm, 13.1 – 18.9cm, < 13cm) and LVEF tertiles (> 50%, 40-50%, < 40%) for analysis; p<0.05 was considered significant.

Results

Altogether, 653 patients comprising 370 (57%) with LVOT VTI > 19cm, 228 (35%) with 13.1 - 18.9cm, and 55 (8%) with < 13cm were included. There were 183 (28%) deaths. Mortality was associated with increased age (75.6 + 13.5 years vs 64.9 + 16.8 years, p<.0001), high-risk echocardiographic features including increased left atrial size (45.4 + 22.7ml/m² vs 35.8 + 14.9 ml/m², p<.001), E/e’ (14.8 + 8.7 vs 10.4 + 4.3, p<.001), reduced LVEF (51.7 + 15% vs 55.9 + 12%, p=.005) and tricuspid annular plane systolic excursion (TAPSE; 2 + 0.5cm vs 2.1 + 0.7cm, p=.001), and biomarkers including haemoglobin (99 + 45g/L vs 117 + 46g/L, p<.001), albumin 28 + 10g/L vs 32 + 10g/L, p<.001), elevated N-terminal pro brain natriuretic peptide (5126 + 5997ng/L vs 2035 + 3569ng/L, p<.0001), troponin (191 + 1301ng/L vs 102 + 306ng/L, p=.008) and creatinine (152 + 165µmol vs 86 + 99µmol, p<.001) levels on admission. Whilst there was no significant difference between LVOT VTI and mortality (z=-1.73, p=0.083) there was a significant positive relationship between LVOT VTI and LVEF (r [651] =0.49, p<.001). Further, there was a significant association between death and both LVEF tertiles (X2 [2, N=653] = 19.63, p<.0001), and LVOT VTI tertiles (X2 [2, N=653] = 9.05, p=.011). However, small subset analyses revealed similar mortality rates for the lowest LVEF LVOT VTI tertile (46%, n=55), lowest LVEF tertile (46%, n=87), and when combined (50%, n=32).

Conclusion

In an undifferentiated cohort of hospitalised patients, reduced LVOT VTI and LVEF are both associated with increased mortality. However, LVOT VTI does not appear to outperform LVEF in being associated with mortality.
Corrected timi frame count : time to replace the TIMI flow?
Authors: Farissa I , Pradipta L D , Nugroho D G , Herry Y , Rifqi S , Praha L B A , Trisnawan M H , Herminingsih S , Uddin I , Cahyadi M H , Safir S
Published: October 2024

Background

Thrombolysis In Myocardial Infarction (TIMI) flow grade had been widely accepted method for evaluating coronary artery perfusion following Percutaneous Coronary Intervention (PCI). Besides, TIMI flow used to predicts outcome in ST Elevation Acute Coronary Syndrome (STEACS) underwent Primary PCI (PPCI). However, its subjective nature has led to the exploration of more objective measures such as the Corrected TIMI Frame Count (CTFC), which quantifies coronary flow by counting the number of cine frames required for contrast to reach distal coronary landmarks.

Purpose

This study aims to assess the predictive value of CTFC in comparison with TIMI flow grades for clinical outcomes in STEACS undergoing PPCI, and whether CTFC could serve as a superior prognostic tool.

Methods

We retrospectively analyzed data from electronic medical record, involving STEACS patients underwent PPCI. Post-procedure, patient with TIMI flow grades 3, CTFC was measured. Patients were followed up during hospitalization for major adverse cardiac events (MACE), including death, myocardial infarction, and revascularization. Statistical analyses were performed to correlate CTFC with clinical outcomes.

Result

A total of 263 patients with TIMI flow 3 were analyzed, 54.5% patient with CTFC ≤27 and >27 respectively. MACE was 5.3% and 21% in the CTFC ≤27 and >27In the regression model analysis indicates a significant relationship between CTFC and MACE was found. The correlation coefficient (R) was observed at 0.417, with the model explaining 17.4% of the variance in MACE occurrence (R Square = .174), and an Adjusted R Square of .171, indicating a modest but significant predictive power. The ANOVA confirmed the model's statistical significance with an F value of 55.067 (p < .001). This suggests that CTFC is a significant predictor of MACE in patients post-PPCI with TIMI 3 flow, underscoring its potential utility in clinical prognostication.

Conclusion

CTFC appears to be a promising tool in assessing coronary flow post-PCI and may be considered as a additional for TIMI flow grading in predicting clinical outcomes in ACS patients. Further large-scale studies are warranted to validate these findings and to explore the integration of CTFC into clinical practice
Chronic stress is gradually accumulated and peaks prior the occurrence of Takotsubo Syndrome: preliminary results based on hair cortisol concentration
Authors: Iordanidis D , Simitsis P , Kosmas N , Papathanasiou K , Rallidis S , Armylagos S , Rallidis L
Published: October 2024

Background

Takotsubo syndrome (TTS) is frequently triggered by stressful events suggesting that increased sympathetic activity has a role in its pathophysiology. Hair cortisol concentration (HCC) is a promising biomarker of excess chronic stress by measuring cortisol secreted into hairs over several weeks.

Purpose

We explored whether premorbid ongoing stress over several weeks assessed by HCC at 2 weeks intervals is associated with the occurrence of TTS.

Methods

A case-control prospective study was performed by recruiting 18 consecutive TTS patients and 36 age- and sex-matched individuals free from cardiovascular or psychiatric disease. Hair samples were collected from participants vertex. Provided that 1 cm of hair represents cortisol levels over ~1 month period, 2.5 cm of hair samples, with many strands each, were cut in equal parts of 0.5 cm, representing cortisol levels in time intervals of 0-15, 15-30, 30-45, 45-60 and 60-75 days prior to hair collection.

Results

All TTS patients were women with a mean age of 71.8±11.2 years. HCC was significantly higher in TTS group versus controls starting from 45 days prior to the event (Figure 1A). Based on the linear mixed effects model, HCC was higher in the TTS group compared to controls at any time point and increased over time starting from 75 days prior to the event, while the rate of increase was significantly higher in TTS versus controls (beta of interaction = 0.48; 95%CI: 0.36 – 0.60; p < 0.001). The model explained a high percentage of the variance (conditional R2 = 0.885). The plot of the predicted HCC over time by diagnosis group is shown in Figure 1B.

Conclusions

Our preliminary data suggest that accumulation of chronic stressful events may cause hypothalamic-pituitary-adrenal axis dysregulation and hyperactivity leading to HCC increase, and this might be implicated in the pathophysiology of TTS.Figure 1.Plot of observed and predicted HCC
Higher blood glucose within the first 72 hours after prolonged cardiac arrest predict poor prognosis: a post-hoc analysis of Prague OHCA trial
Authors: Malik J , Malik J , Valerianova A , Janota T , Buryskova Salajova K , Kubinova N , Rob D , Belohlavek J
Published: October 2024

Background and purpose

Both low and higher glucose levels and their tight control were associated with worse prognosis of critically ill patients. We performed a post-hoc analysis of treated Prague OHCA trial population of patients subjected to extracorporeal cardiopulmonary resuscitation (ECPR) vs. standard approach for refractory cardiac arrest, aimed to assess relationship of glucose levels in the first 72 hours after admission to the neurological outcome.

Methods

Prague OHCA trial enrolled adults with a witnessed refractory OHCA of presumed cardiac origin. In this post-hoc analysis, the effects blood glucose on the best cerebral performance category (CPC) within 180 days was examined. Blood samples for glycemia evaluation were drawn at admission and then every 3 hours within the first 3 days. Fischer exact test was used to analyze the impact on the prognosis (CPC 1-2 = good and CPC 3-5 = poor prognosis).

Results

Patients with CPC 1-2 did not differ in blood glucose on admission from patients with CPC 3-5. However, patients with type 2 diabetes mellitus had significantly worse prognosis (83 vs. 60% of diabetics vs. non-diabetics had poor prognosis, p = 0.007). Glycemia on admission was slightly but significantly related to the amount of given epinephrine and to the serum triglycerides. Patients having at least 3 glucose levels >10 mmol/L within the first 72 hours had worse neurological prognosis: CPC 1-2 was reached in 61.4% of patients with less than 3 levels >10 mmol/L, but only in 24% of patients that fulfilled this criterion (p=0.000004).

Conclusions

Repeatedly higher blood glucose within the first 72 hours after admission for prolonged cardiac arrest are related to worse prognosis.
Improving prehospital risk stratification using deep learning ECG interpretation in suspected acute coronary syndrome
Authors: Demandt J P A , Mast T P , Van Beek K A J , Koks A , Bastiaansen M , Tonino P A L , Van T Veer M , Zimmermann F , Vlaar P J
Published: October 2024

Introduction

Most patients presenting with chest pain in the Emergency Medical Services (EMS) setting are suspected of non-ST-elevation acute coronary syndrome (NSTE-ACS). Distinguishing true NSTE-ACS from non-cardiac chest pain based solely on the electrocardiogram (ECG) is challenging. Recent advances in artificial intelligence (AI) models for ECG interpretation show promising results.

Purpose

The aim of this study is to develop and validate a Convolutional Neural Network (CNN)-based model to diagnose NSTE-ACS within the prehospital ECG and to compare it to current prehospital available diagnostic tools.

Methods

For this study, a training/internal validation cohort (n= 4891) and external validation cohort (n= 754) were used, both consisting of suspected NSTE-ACS patients, and the first prehospital standard 12-lead ECG at presentation was extracted. A CNN (ECG-AI) was trained and validated to detect NSTE-ACS. The training/internal validation cohort was extracted from suspected NSTE-ACS patients presenting to the emergency department. The external validation cohort was extracted from a prehospital, prospective cohort study in which subjects were assessed by EMS paramedics. A validated prehospital clinical risk score (preHEART) was calculated, which includes manual on-site ECG analyses by EMS paramedic (ECG-EMS) and a point-of-care (POC) troponin assessment, and compared to ECG-AI in diagnosing NSTE-ACS.

Results

In the external validation cohort, 202 (27%) subjects were diagnosed with NSTE-ACS. ECG-AI had a better diagnostic performance than ECG-EMS (AUC 0.70 (0.66–0.74) vs. AUC 0.65 (0.61–0.70), p=0.045) for diagnosing NSTE-ACS. The overall diagnostic accuracy of preHEART was AUC 0.78 (0.74–0.82) and superior compared to ECG-AI (p= 0.001). Incorporating ECG-AI instead of ECG-EMS into preHEART led to a significant improvement in diagnostic performance (AUC 0.83 (0.79–0.86,p < 0.001)).

Conclusion

Integrating AI in prehospital ECG interpretation improves NSTE-ACS diagnosis. However, clinical risk scores still yield the best diagnostic performance in the prehospital setting and their accuracy could be further enhanced through AI.ROC prehospital diagnostic toolsROC preheart and preheart-AI
Echocardiographic predictors of mortality in cardiac intensive care unit patients with pulmonary hypertension
Authors: Tabi M , Padkins M , Ilan Bushari L , Jentzer J C
Published: October 2024

Background

Pulmonary Hypertension (PH) is a diverse condition associated with elevated mortality. We sought to determine the association of Transthoracic Echocardiography (TTE) parameters with in-hospital mortality in patients with PH admitted to Cardiac Intensive Care Unit (CICU).

Methods

We included 1 Clinic CICU admissions from 2007 to 2018, with available TTE parameters within the first day of CICU admission who had PH defined as an estimated right ventricular systolic pressure (RVSP) ≥36 mmHg. The primary outcome was in-hospital mortality, evaluated using logistic regression.

Results

We included 3085 unique CICU patients with PH, predominantly WHO group 2 and 3. Median age was 73.7 (63.8, 82.4) years, and 1343 (43.5%) were females. Heart failure (65.6%) and respiratory failure (34.0%) were the most common admission diagnoses. The median RVSP was 47 (41, 56) mmHg, and 1314 (42.6%) had RVSP ≥50 mmHg. A total of 337 (10.9%) patients died during hospitalization. In-hospital deaths had higher RVSP (51 versus 47 mmHg, p <0.001), reflecting higher right atrial (RA) pressure (14 versus 10 mmHg, p <0.001) (Figure). In-hospital mortality increased with worse TTE parameters reflecting Right Ventricle-Pulmonary Artery (RV-PA) coupling, such as Tricuspid Annular Plane Systolic Excursion/ Right Ventricular Systolic Pressure (RVSP), Tricuspid Annular Systolic Velocity (TASV)/RVSP and TASV/ Tricuspid Regurgitation velocity ratios.

Conclusion

In CICU patients with PH, we have identified the specific Doppler TTE parameters with strong associations with outcomes. Specifically, RA pressure and parameters of RV-PA coupling had the highest discrimination for in-hospital mortality. Comprehensive Doppler TTE is valuable for identification of high-risk PH patients to facilitate further investigation plans, management, and prognostication.

Figure: In-hospital mortality in association with right ventricular (RV) function and right atrial pressure (RAP).In-hospital mortality in association wit
Biomarkers of cardiohepatic syndrome in the cardiac intensive care unit
Authors: Butt A , Padkins M , Crespo-Diaz R , Hillerson D , Katz J , Kamath P , Miller E , Rosenbaum A , Samsky M , Kashani K , Jentzer J
Published: October 2024

Introduction

Non-cardiovascular end-organ dysfunction is an important determinant of outcomes in cardiac intensive care unit (CICU) patients. We examined the association between in-hospital mortality with the severity and extent of admission liver function test (LFT) abnormalities in a heterogeneous CICU population.

Purpose

We hypothesized that a greater severity or extent of LFT abnormalities would be associated with higher in-hospital mortality.

Methods

We included consecutive unique adult CICU patients with available data for one or more of the admission LFT values of interest. Admission laboratory values were defined as those closest to CICU admission. We used the NIH Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 to categorize the severity of each LFT abnormality from Grade 0 (normal) to Grade 4 (life-threatening). We defined the extent of LFT abnormality as the number of individual LFTs meeting criteria for CTCAE Grade 1 or greater. The primary outcome of interest was all-cause in-hospital mortality. Odds ratio (OR) and 95% confidence interval (CI) values for in-hospital mortality were estimated using logistic regression, before and after multivariable adjustment.

Results

Of 12,428 unique CICU patients, 5,144 were excluded due to a lack of available data for any admission LFT values. The remaining 7,284 patients comprised the final study population. Among patients with available data for each individual LFT, abnormal values were present in: AST, 2,743/5,733 (47.8%); ALT 1,576/5,512 (28.6%); ALK 611/3,684 (16.6%); and TB 898/5,155 (17.4%). A total of 864 (11.9%) patients died during hospitalization. In-hospital mortality was higher for patients with one or more LFTs meeting criteria for CTCAE Grade 1 or greater (17.9% vs. 6.4%, adjusted OR 1.54 [1.27-1.86], p <0.001). A stepwise increase in in-hospital mortality was observed with increasing CTCAE grade, both overall (adjusted OR 1.25 per each higher CTCAE grade [1.16-1.34], p <0.001); (Figure 1A), and for each individual LFT (Figure 1B).

Conclusion

Cardiohepatic syndrome is an important predictor of prognosis in CICU patients, as the extent and severity of LFT abnormalities are strongly associated with in-hospital mortality. This is the first large-scale study to examine the association between the magnitude of hepatic biomarker derangement with in-hospital mortality in unselected CICU patients. Patients with markedly elevated LFT values exhibited the highest risk of in-hospital mortality. This analysis advocates for the inclusion of commonly obtained LFTs in future risk-prediction tools for enhanced prognostication.
Clinical impact of helicopter transport with a physician in cardiogenic shock complicating acute coronary syndrome
Authors: Singh Y , Ogita M , Suwa S , Onozato T , Abe K , Yatsu S , Shitara J , Endo H , Wada H , Miyauchi K , Minamino T , Yanagawa Y
Published: October 2024

Introduction

Cardiogenic shock (CS) remains the leading cause of death in patients with acute coronary syndrome (ACS). Helicopter transport with a physician may improve the prognosis through reduction of the ischemic time and an early critical care. However, the impact of transfer of a physician-staffed helicopter and outcomes of CS complicating ACS is uncertain.

Purpose

The aim of the present study was to evaluate compare the clinical characteristics and long-term outcome between helicopter transport with a physician and ground transport in CS complicating ACS patients.

Methods

We retrospectively investigated 2324 consecutive patients with ACS who underwent primary percutaneous coronary intervention (pPCI) in our institution from January 2004 to December 2017. The primary outcome was cardiovascular (CV) death.

Results

Among the 2324 eligible patients, 273 ACS patients (11.7%) were complicated by CS. Of 273 CS complicating ACS, a total of 81 (29.7%) patients were transported by helicopter, 166 (60.8%) patients were transported by ambulance, and 26 (9.5%) patients did not use emergency medical service. The mean age was 71 years, 75% of patients were male, STEMI was seen in 87%, and mechanical circulatory support was used in 64%. Kaplan-Meier analysis showed that CV mortality up to 30 days was significantly lower with helicopter transport group compared those with ground transport (P = 0.0407). The rate of long-term CV death was comparable between groups (P = 0.19). Multivariate Cox regression analysis showed helicopter transport was significantly associated with lower 30-day CV mortality (adjusted HR 0.56, 95%CI 0.32-0.99, P = 0.0447).

Conclusions

Helicopter transport with a physician may improve cardiovascular outcomes of CS complicating ACS.Figure 1.Figure 2.
Timing of inopressor initiation in patients with acute myocardial infarction complicated by cardiogenic shock
Authors: Ten Berg S , Peters E J , Bogerd M , Timmermans M J C , Otterspoor L C , Engstrom A E , Vlaar A P J , Henriques J P S
Published: October 2024

Introduction

Inotropes and vasopressors (inopressors) are commonly used in the treatment of acute myocardial infarction complicated by cardiogenic shock (AMICS). The characteristics of patients subjected to early or late initiation of inopressors are not yet described, and the impact of timing on outcomes remains uncertain.

Purpose

This retrospective real-world data study aims to identify patient-, treatment-, and outcome characteristics of AMICS patients treated with early- or late initiated inopressors.

Methods

The Netherlands Heart Registration (NHR) prospectively records baseline, procedural, and outcome data for PCI patients. Between 2017-2021, additional retrospective data on CS patients were collected by fourteen Dutch hospitals. Patients were categorized based on the timing of inopressor initiation, either early (pre PCI) or solely late (at the cathlab or within 24 hours after PCI). Patients presenting with an out of hospital cardiac arrest were excluded. Missing data were imputed through multiple imputation (30x). Multivariable logistic regression analysis was performed to evaluate the association between the timing of inopressor initiation and 30-day mortality, adjusting for univariate significant confounders among variables known at admission.

Results

A total of 956 consecutive CS patients were included of whom 418 (43.7%) and 538 (57.3%) patients were subjected to early and late initiation of inopressors respectively. The most frequently used drug in both groups was noradrenaline. At baseline, patients in the early initiation group were younger (67.4 vs. 70.0 years, p <0.001), presented with a lower mean arterial pressure (MAP) (72.5 vs. 76.3, p = 0.048) and higher lactate (4.2 vs. 3.6, p = 0.012), and presented with a NSTEMI more often (36.0% vs. 14.2%, p <0.001). They also had a higher prevalence of previous myocardial infarction (33.9% vs. 22.9%, p <0.001) and previous CABG (14.3% vs. 6.2%, p <0.001). Moreover, 30-day mortality rates were higher in the early initiated group (48.6% vs. 37.6%, pLogrank <0.001). After multivariate adjustment for age, admission MAP and lactate, early inopressor initiation remained independently associated with 30-day mortality (OR 1.44, 95%-CI 1.08-1.98) compared to late initiation.

Conclusion

In this Dutch cohort of CS patients undergoing PCI, baseline- treatment- and outcome characteristics differed between patient categories receiving either early or late initiated inopressors. Patients who were subjected to early initiated inopressors were younger, presented with worse hemodynamics, had a more extensive cardiovascular medical history and higher 30-day mortality rates. The results of this study reemphasize the importance of identifying patients who benefit from inopressors.30-day mortality late vs. earlyTable patient characteristics
Mild hypercapnia versus normocapnia in resuscitated out-of-hospital cardiac arrest patients: a systematic review and meta-analysis
Authors: Abusuilik H , Mohamed Taha A , Abuelazm M , Soliman Y , Abu Salah M A I , Abusuilik M , Abouzid M , Abdelazeem B
Published: October 2024

Introduction

After out-of-hospital cardiac arrest (OHCA) resuscitation, current guidelines recommend normocapnia. However, mild hypercapnia may confer several physiological benefits that could enhance post-OHCA outcomes.

purpose

To assess the effects of moderate hypercapnia versus normocapnia on clinical outcomes after OHCA resuscitation.

Methods

A systematic review and meta-analysis synthesizing randomized controlled trials (RCTs) and observational studies were retrieved by systematically searching PubMed, Web of Science, SCOPUS, and Cochrane through August 15th, 2023. Dichotomous outcomes were pooled using risk ratio (RR) and continuous data using mean difference (MD), with a 95% confidence interval (CI).

Results

We included five studies with a total of 42,076 patients. There was no difference between both groups in all-cause mortality (RR: 1.15, 95% CI [0.89 to 1.49], p=0.29), good neurological recovery (RR: 0.95, 95% CI [0.81 to 1.12], p = 0.56), mechanical ventilation duration (MD: 1.00, 95% CI [-5.41 to7.41], p= 0.76), ICU length of stay (MD: 0.01, 95% CI [-0.28 to 0.30], p= 0.96), neuron-specific enolase level (MD: -20.92, 95% CI [-69.53 to 27.69], p= 0.40), and the incidence of any serious adverse events (RR: 1.55, 95% CI [0.06 to 42.92], p= 0.80). However, length of hospitalization was lower in the mild hypercapnia group (MD: 0.99, 95% CI [-1.85 to -0.14], p= 0.02).

Conclusion

Mild hypercapnia did not decrease all-cause mortality or improve neurological recovery after OHCA resuscitation compared to normocapnia. However, mild hypercapnia significantly reduced the length of hospital stay.Main outcome
The clinical outcome reflects the heart rhythm profile after defibrillation for shockable rhythm in refractory out-of-hospital cardiac arrest
Authors: Havranek S , Neuhofer J , Vesela M , Kavalkova P , Fingrova Z , Rob D , Dusik M , Pudil J , Smalcova J , Belohlavek J
Published: October 2024

Background

The prognosis of refractory out-of-hospital cardiac arrest (OHCA) is generally poor. A recent Prague OHCA study has demonstrated that an invasive approach (including extracorporeal cardiopulmonary resuscitation, ECPR) is a feasible treatment strategy in refractory OHCA. Post-hoc analysis of Prague OHCA showed that patients with initial ventricular fibrillation (VF) had manifested better clinical outcomes than those with non-shockable rhythms irrespective of cardiopulmonary resuscitation (CPR) strategy. However, initial shockable rhythm could deteriorate to a non-shockable rhythm during CPR, mainly after defibrillation. The study aimed to stratify the prognosis of patients according to rhythm profile after initial VF in refractory OHCA during pre-hospital and early hospital periods.

Methods

The analysis enrolled patients with a witnessed OHCA of presumed cardiac cause, with initial VF, and without early recovery of spontaneous circulation. The primary outcome was a composite of survival with Cerebral Performance in Category (CPC) 1 or 2 at 180 days.

Results

155 (median age 56y, 10 % females) patients with initial VF were enrolled. The median (IQR) duration of resuscitation was 54 (33-69) minutes. Overall survival with CPC 1 or 2 was 40.4 %. 71 patients were randomized to invasive CPR arm and 84 subjects were treated with conventional CPR. Out of all invasively treated patients, ECPR (veno-arterial extracorporeal membrane oxygenation, VA ECMO) was used in 56 cases without stable recovery of spontaneous circulation and 8 patients primary allocated in conventional group. A proportion of survival with CPC 1 or 2 varied by rhythm course: ongoing VF (9 / 28; 32 %), recovery of organized rhythm (43 / 63; 68 %), documentation of pulseless electrical activity (7 / 30; 23%), and progression to asystole (4 / 34; 12 %); P < 0.05. Tables 1 and 2 show differences in primary endpoint according to rhythm profile between invasive and conventional study arms.

Conclusion

Deterioration of initial shockable rhythm to asystole bears a poor prognosis in refractory OHCA even when ECPR is readily available. An invasive approach (including VA ECMO) seems to be beneficial in patients with ongoing VF and with regular electrical activity regardless of effective pulsation.
Therapeutic hypothermia after out-of-hospital cardiac arrest in comatose patients with acute myocardial infarction
Authors: Lee O H , Heo S J , Kim M H , Park J W , Bae S , Kim M , Roh J W , Kim Y , Im E , Jung I H , Cho D K
Published: October 2024

Background

Comatous survivors of out-of-hospital cardiac arrest (OHCA) have a high risk of death or poor neurological outcome. Therapeutic hypothermia is recommended for these patients after OHCA. However, there is a lack of data regarding outcomes of therapeutic hypothermia after OHCA in comatose patients with acute myocardial infarction (AMI).

Purpose

This study aimed to investigate the impact of therapeutic hypothermia on clinical outcomes in comatose patients who underwent primary percutaneous coronary intervention (PCI) for AMI after OHCA.

Methods

Using a prospective nationwide registry from 2016 to 2021, we examined 2,925 consecutive comatose patients experiencing OHCA in patients with AMI. These patients were categorized into groups receiving hypothermia treatment (n=624) and those without hypothermia treatment (n=2,301). The primary endpoint was the mortality rate upon discharge. The secondary endpoints were mortality rates at 6 or 24 hours, and neurological outcomes at hospital discharge.

Results

Overall, 624 (21.3%) patients were classified into the hypothermia group. This group showed a notably reduced mortality rate (hazard ratio [HR]: 0.68, 95% confidence interval [CI]: 0.58-0.78, p<0.001) after IPTW analysis (Figure 1). While the worse neurological outcome (as indicated by cerebral performance category [CPC] category 3-5) at hospital discharge was not significantly different between groups after IPTW analysis (odds ratio [OR]: 1.04, 95% CI: 0.93-1.15, p=0.499), early hypothermia within 180 minutes after hospital arrival showed significantly lower mortality rates (HR: 0.64, 95% CI: 0.44-0.95, p=0.027) and reduced occurrence of worse neurological outcome (OR: 0.75, 95% CI: 0.59-0.96, p=0.021) after IPTW analysis (Figure 2). Detailed hypothermia protocol including a targeted temperature of 33°C vs. 36°C or hypothermia duration of 48 hours vs. 24 hours did not significantly reduce the rate of death or poor neurological outcome at discharge.

Conclusions

Therapeutic hypothermia in OHCA patients complicating AMI was associated with lower mortality rates and comparable neurologic outcomes. However, early hypothermia within 180 minutes after hospital arrival showed significantly improved the mortality and neurological outcomes.all-cause deathAll-cause death and neurological outcome