bluuebunny/crossref_metadata_2025 huggingface dataset:
Timing of cardiovascular magnetic resonance imaging and diagnostic yield in patients with acute myocardial infarction with nonobstructive coronary arteries
Authors: Junca Puig G , Teis Soley A , Kasa Yaglici G , Ferrer Sistach E , Lopez Ayerbe J , Vallejo Camazon N , Gual Capllonch F , Bayes Genis A , Delgado Garcia V
Published: October 2022

Background

Accurate diagnosis of the underlying cause of myocardial infarction (MI) without obstructive coronary artery disease (MINOCA) is crucial. Cardiovascular magnetic resonance (CMR) plays an important role in the work up of patients with MINOCA. However, the timing of performance of CMR may impact on the diagnosis yield.

Purpose

To establish the diagnostic yield of CMR in a large cohort of patients admitted with MINOCA based on the timing of referral to CMR.

Methods

All patients referred to CMR from January 2009 to February 2022 with MINOCA were included. Studies were performed on a 1.5 T or 3T scanners. SSFP cines, T2-weighted black-blood fat-sat images and DE-segmented GE IR images 10–15 minutes after iv gadolinium-DTPA administration (0.15mmol/kg) were performed in 3 long-axis and 11–15 parallel short-axis views. All images were reviewed and analyzed off-line with specialized post-processing software.

Results

A total of 203 patients (median age 49 years, 60% men) with MINOCA diagnosis were included. Main ECG alterations were ST-segment elevation (STE) (57%) and T wave inversion (19%). Mean peak high sensitivity (HS)-TnI levels were 3706pg/mL. Median time to CMR was 7 days (5–9 days). Mean LVEF was 58% (range 18–83%) and mean LVEDVi 77 mL/m2 (range 35–210 mL/m2). Regional wall abnormalities were present in 123 patients (62%). High signal in T2w images was detected in 153 cases (75%) and late gadolinium enhancement (LGE) in 143cases (71%). Final CMR diagnosis resulted in myocarditis in 46%, MI in 20%, Takotsubo in 18%, and other cardiomyopathies in 6.4%. CMR was normal in 15 patients and not conclusive in 1. When CMR was performed within 7 days of admission (median: 5 days (4–6 days); n: 116 patients), the distribution of diagnoses was myocarditis in 53%, MI in 20%, Takotsubo in 16%, other cardiomyopathies in 6% and normal CMR in 4%. Whereas, if CMR was performed after 7 days (median: 10 days (8–12 days); n: 87 patients), the diagnoses were as flows: myocarditis in 36%, MI in 22%, Takotsubo 20%, cardiomyopathies in 7%, not conclusive in 1% and normal CMR in 13% (Table 1).

Conclusions

CMR led to the underlying diagnosis of MINOCA in 92% of patients. Myocarditis was the most frequent diagnosis. The final diagnosis of myocarditis was more frequent when CMR was performed within 7 days with a lesser percentage of normal CMR.

Funding Acknowledgement

Type of funding sources: None.
Predictors of late gadolinium enhancement development and extension in myocardial infarction with non-obstructive coronary arteries
Authors: Amicone S , Bergamaschi L , Armillotta M , Sansonetti A , Stefanizzi A , Impellizzeri A , Suma N , Tattilo F P , Angeli F , Paolisso P , Rinaldi A , Foa' A , Casella G , Galie' N , Pizzi C
Published: October 2022

Background

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous clinical entity and in its complex diagnostic approach cardiovascular magnetic resonance (CMR) plays a pivotal role.

Purpose

To characterize the differences of MINOCA patients with and without late gadolinium enhancement (LGE) at CMR and to identify the predictors for ischemic LGE development and extension.

Methods

We assessed 461 MINOCA cases from January 2016 to June 2021. MINOCA were defined according to the current European guidelines criteria. We excluded acute myocarditis, Tako-tsubo syndromes, cardiomyopathies, or non-pathological CMR. According to CMR imaging findings, our cohort was divided into two CMR phenotypes based on regional myocardial necrosis detected throughout LGE (“LGE-positive MINOCA”) or regional ischemic injury without LGE (“LGE-negative MINOCA”). Extended LGE was considered as the presence of >2 segments with transmural LGE. Multivariate logistic regression analysis was used to determine the predictors of LGE and extended LGE.

Results

The final cohort included 175 MINOCA: 121 (69.1%) constituted the LGE-positive group. The mean time delay between acute clinical presentation and CMR was 6±2.9 days. At admission MINOCA LGE-patients more frequently presented angina and ST segment elevation (24% vs 7.4%, p=0.01), compared to LGE negative ones. Furthermore, the LGE positive group had a significantly greater infarct size, measured by peak hs-Troponin I values and left ventricular function (LVEF). The only predictor of LGE was the peak troponin value (OR 1.64, 95% CI 1.18–2.28, p=0.003), while predictors of extended LGE were ST-segment elevation at admission (OR 7.44, 95% CI 1.57–35.22, p=0.01), peak troponin values (OR 1.07, 95% CI 1.02–1.13, p=0.01) and the presence of non-obstructive coronary artery disease at coronary angiography (OR 5.49, 95% CI 1.20–25.09, p=0.028).

Conclusion

The presence and extension of LGE at early CMR evaluation is an important feature in the setting of MINOCA. In addition, simple baseline characteristics (such as ST elevation, peak troponin value and LVEF) may aid the identification of a greater ischemic necrosis burden at CMR and therefore these high-risk MINOCA subjects could be benefit from a stricter management effort.

Funding Acknowledgement

Type of funding sources: None.
Myocardial bridging is significantly associated with myocardial infarction with non-obstructive coronary arteries
Authors: Matta A , Nader V , Canitrot R , Delmas C , Bouisset F , Lhermusier T , Blanco S , Parada F C , Elbaz M , Carrie D , Galinier M , Roncalli J
Published: October 2022

Background

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a common disorder characterized by the presence of clinical criteria for acute myocardial infarction in the absence of obstructive coronary artery disease on angiography. We aim to investigate the relationship between myocardial bridging (MB) and MINOCA.

Methods

An observational retrospective study was conducted on 15,036 patients who had been referred for coronary angiography and who fulfilled the Fourth Universal Definition of Myocardial Infarction. The study population was divided into STEMI and non-STEMI patients, from which we defined two main groups: the MINOCA group and the coronary artery disease (CAD) group. Statistical analyses were carried out by using SPSS, version 20.

Results

The prevalence of angiographic MB among the groups was significantly greater in the MINOCA group (2.9% vs. 0.8%). MINOCA accounted for 14.5% of spontaneous myocardial infarction, and the clinical presentation was frequently NSTEMI rather than STEMI (84.3% vs. 15.7%). After adjusting for confounders, multivariate analyses showed a positive association between MB and MINOCA [OR=3.28, 95% CI (2.34; 4.61) p<0.001]. Cardiovascular risk factors were less common in the MINOCA population, which was younger and more often female.

Conclusion

MB is a risk factor for MINOCA. Because MB prevalence differed significantly between the controls (CAD group) and cases (MINOCA group), which were positively associated to MB, it seems likely that MB would be a potential cause of MINOCA. Investigations for MB in MINOCA cases and especially in NSTEMI patients seem necessary.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Rangueil Hospital
Prognostic role of early cardiac magnetic resonance in myocardial infarction with non-obstructive coronary arteries
Authors: Armillotta M , Bergamaschi L , Amicone S , Sansonetti A , Stefanizzi A , Impellizzeri A , Tattilo F P , Angeli F , Fabrizio M , Paolisso P , Rinaldi A , Foa' A , Casella G , Galie' N , Pizzi C
Published: October 2022

Background

Myocardial infarction with non-obstructive coronary arteries (MINOCA) represents a significant proportion of acute myocardial infarction (AMI) population. MINOCA is a working diagnosis and an accurate investigation of the underlying causes should always be performed. In this setting, cardiac magnetic resonance (CMR) imaging plays a pivotal diagnostic role. However, a prognostic stratification based on the CMR findings in ischemic MINOCA is still unavailable.

Purpose

To evaluate the potential prognostic impact of specific CMR findings - especially ischemic late gadolinium enhancement (LGE) patterns - in order to look for measurable parameters that may guide the management of this still troubled clinical entity.

Methods

We assessed 461 MINOCA from January 2016 to June 2021. We excluded acute myocarditis, Tako-tsubo syndromes, cardiomyopathies, or non-pathological CMR. According to CMR findings, MINOCA were classified in two phenotypes: LGE-positive (an ischemic subendocardial or transmural LGE pattern) or LGE-negative (cases without LGE but exhibiting regional myocardial injury defined by myocardial edema in a coronary territory with a typically ischemic “wave-front” and/or regional wall motion abnormality consistent with coronary distribution).

All-cause mortality, re-infarction, stroke, heart failure (HF) and the composite endpoint (MACE) were evaluated. Extended LGE was considered as the presence of >2 segments with transmural LGE. The mean follow-up was 36.1±15.2 months and CMR was performed at a mean of 6±2.9 days from the acute presentation.

Results

The final cohort included 175 MINOCA with a likely-ischemic etiology: 121 (69.1%) constituted the LGE-positive group. The mean age of the study population was 62.3±12.9 years and more than 61% were females. During follow-up, HF (15.7% vs 1.9%, p=0.008) and MACE (20.7% vs 7.4%, p=0.029) occurred more frequently in MINOCA “LGE-positive” compared to the “LGE-negative” ones. Extended LGE was significantly more prevalent in patients with versus without subsequent HF. On multivariable Cox regression, extended LGE was an independent predictor of HF occurrence (HR 18.49, 95% CI 4.65–73.61, p<0.001) and MACE (HR 14.64, 95% CI 3.91–54.86, p<0.001).

Conclusions

Our data suggest that in MINOCA patients the detection of LGE is correlated with the incidence of major cardiovascular events and heart failure during long-term follow-up. In fact, LGE extension was identified as the strongest predictor of cardiac adverse events. The early execution of CMR is useful in the prognostic stratification of MINOCA and this could guide the subsequent clinical and therapeutic management.

Funding Acknowledgement

Type of funding sources: None.
Myocardial infarction with non-obstructive coronary arteries (MINOCA): predictors of long-term outcome
Authors: Abad Romero R , Fraile Sanz A , Izquierdo Coronel B , Olsen Rodriguez R , Perela Alvarez C , Galan Gil D , Espinosa Pascual M J , Nieto Ibanez D , Alvarez Bello M , Martin Munoz M , Mata Caballero R , Awamleh Garcia P , Moreno Vinues C , Lopez Pais J , Alonso Martin J J
Published: October 2022

Introduction

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous clinical entity. There is still limited knowledge about long-term prognosis of MINOCA patients. The aim of this study was to assess the incidence, time-to-event and predictors of mayor adverse cardiovascular events (MACE) in the long-term follow-up.

Methods

We carried out an analytical and observational study including all consecutive patients admitted to our hospital with acute myocardial infarction. Patients were classified as obstructive coronary artery disease (MICAD) or MINOCA using the definition of 2020 ESC acute coronary syndrome guidelines. Cardiovascular death, myocardial infarction, stroke and cardiovascular readmission were considered MACE. To determine MINOCA independent predictors, a multivariate analysis with cox regression was carried out in those variables with clinical or statistical relevance.

Results

During the studied period, 805 patients were included and 81 (10.1%) of them were diagnosed with MINOCA. Baselines characteristics of MINOCA patients: 53% were men, the mean age was 65±15 years, 67% suffered hypertension, 48% dyslipidemia, 21% mellitus diabetes and 43% were smokers. Follow-up (middle [interquartile range] 38 [19–57] months) was completed in 80 (99%) MINOCA patients and 18 (23%) of them had MACE (8 deaths, 6 myocardial infarctions, 2 strokes and 14 readmissions). The mean time to MACE was 53±2.9 months (Figure 1). Comparing MICAD vs. MINOCA, the 6 years rates of MACE (29% vs. 23%), mortality (12.7% vs. 10.0%), myocardial infarctions (6.5% vs. 7.5%), strokes (2.8% vs. 2.5%) and readmissions (17.5% vs. 24.2%) were similar with no statistically significant differences between MICAD and MINOCA patients.

In the multivariate analysis (Table 1) chronic heart failure (HR=18.89; 95% CI 4.94–72.20) and peripheral vascular disease (HR=4.86; 95% CI 1.29–18.36) were independent predictors of MACE in MINOCA patients. The predictive model has a R2 of Nagelkerke of 0.07.

Conclusion

This study shows that chronic heart failure and peripheral vascular disease are associated with adverse outcomes in MINOCA patients and appears to be independent predictors of MACE in the long-term follow-up. Those predictors seem to be similar to factors previously shown to predict MACE in MICAD patients.

Funding Acknowledgement

Type of funding sources: None.
Impact of left bundle branch block in patients with takotsubo cardiomyopathy
Authors: Lopez J , Karpel D , Mark J , Wahood W , Jazaerly M , Ramos F , Chait R
Published: October 2022

Background

Takotsubo cardiomyopathy (TCM) is a syndrome characterized by reversible left-ventricular regional systolic dysfunction in the absence of obstructive coronary artery disease (CAD). The presence of left bundle branch block (LBBB) has been described as an independent predictor of mortality in patients with CAD. One study using the National Inpatient Sample (NIS) for 2016 found that the presence of LBBB was associated with worse outcomes in patients with TCM.

Purpose

To better clarify the association between LBBB and various in-hospital outcomes in patients with TCM.

Methods

The NIS database was queried from 2016–2019 to identify all admissions with a primary diagnosis of TCM that had a cardiac catheterization to improve the specificity of the diagnosis. International classification of diseases, tenth revision clinical modification (ICD-10-CM) codes were used to divide patients based on the presence or absence of LBBB. A 1:3 propensity score matching based on age, race, gender, and risk factor stratification was used to reduce selection bias. Multivariate linear and logistic regression analysis was performed to compare various outcomes among both groups.

Results

A total of 27,125 patients admitted with a primary diagnosis of TCM that also underwent diagnostic coronary angiography were identified. In the study sample, 955 (3.5%) were determined to have a LBBB. After calculating propensity scores, 955 patients with LBBB were paired to 2,865 patients without LBBB. LBBB was associated with higher rates of ventricular arrhythmias (AOR=3.098, 95% CI 1.483–6.471, p=0.003); however, it was not statistically associated with cardiogenic shock, sudden cardiac arrest (SCA), acute kidney injury, acute heart failure, and hospital length of stay. In addition, there was no statistical difference in intra-hospital mortality.

Conclusions

LBBB is associated with left ventricular dyssynchrony. It has been proposed that intraventricular dyssynchrony might be a predisposing factor for ventricular arrhythmias (VA) and SCA. Several trials have demonstrated that cardiac resynchronization therapy alone (i.e., without defibrillation) reduces the rate of VA and SCA. The mechanism for this improvement is unclear but may be related to hemodynamic improvement from ventricular synchrony in heart failure (HF). In fact, LBBB has been reported as an independent risk factor for all-cause mortality and SCA at one year in patients with HF. Our analysis did not find any significant association between LBBB and SCA but did find an association with VA. Moreover, there were not enough events of intra-hospital mortality to assess a possible association between LBBB and mortality. Therefore, a prospective study with a longer follow-up would be needed to clarify the role of LBBB in mortality and establish causality between LBBB and VA in patients with TCM.

Funding Acknowledgement

Type of funding sources: None.
Takostubo syndrome during the COVID-19 pandemic: a single center experience
Authors: Rallidis L , Iordanidis D , Kosmas N , Kiouri E , Papathanasiou K , Vlachos S , Filippatos G
Published: October 2022

Background

Takotsubo syndrome (TTS) is a major psychosomatic cardiovascular disease. It has been suggested that in the current pandemic of coronavirus disease 2019 (COVID-19), the psychological, mental and physical consequences of the restrictive measures taken to combat the pandemic, is likely to make individuals more vulnerable to TTS.

Purpose

In our study, we investigated whether TTS incidence has increased during the COVID-19 era in a major tertiary hospital in Athens.

Methods

The study population included 316 consecutive patients admitted to the Coronary Care Unit (CCU) of our hospital throughout the 16 months (March 2020-June 2021) pandemic COVID-19 with the initial diagnosis of acute coronary syndrome (ACS). For comparison 342 patients with ACS admitted to CCU during the 16 months period preceding the COVID-19 pandemic (November 2018-February 2020) were analyzed. All ACS patients underwent coronary angiography within 48 hours of admission. A prerequisite for admission to CCU of all ACS patients during the pandemic period was a negative reverse transcription-polymerase chain reaction test for COVID-19.

Results

The vast majority (95%) of TTS patients were women and the mean age was 71.1±15.4 years. There was a significant increase in the incidence of TTS during the 16 months COVID-19 period (6.3%, i.e., 20 TSS among 316 ACS patients) compared with the corresponding incidence of TTS 16 months prior the pandemic (2.6%, i.e., 9 TTS among 342 ACS patients) [Figure 1]. The incidence rate ratio comparing the TTS cases of COVID-19 pandemic period to the pre-pandemic period was 2.22 (95% CI: 0.97–5.54, p=0.021).

Conclusions

COVID-19 pandemic was associated with a significant increase in the incidence of TTSprobably due to the additional psychological burden imposed by the pandemic.

Funding Acknowledgement

Type of funding sources: None.
Cardiac troponin elevation and mortality in takotsubo syndrome: new insights from the International Takotsubo (InterTAK) registry
Authors: Stahli B E , Schindler M , Cammann V L , Szawan K A , Schweiger V , Niederseer D , Schonberger A , Schonberger M , Koleva I , Mercier J C , Petkova V , Wurdinger M , Ruschitzka F , Ghadri J R , Templin C
Published: October 2022

Background/Introduction

Cardiac biomarker elevations are frequently observed in Takotsubo syndrome (TTS). The clinical relevance of cardiac troponin (cTn) elevations in TTS patients remains uncertain and threshold values indicating clinically relevant myocardial injury are unknown.

Purpose

This study sought to investigate the role of cTn elevations in mortality prediction of patients with TTS.

Methods

A total of 2,938 patients enrolled in the prospective International Takotsubo (InterTAK) Registry from January 2011 to February 2020 and with available data on baseline and peak cTn levels were included in the analysis. The threshold at which myocardial injury drives mortality was identified using restricted cubic spline analysis.

Results

Out of 2,938 patients, 222 (7.6%) patients died during 1-year follow-up. A more than 28.8-fold increase of cTn above the upper reference limit was identified as threshold for clinically relevant myocardial injury. Mortality at 1 year was significantly higher in patients with clinically relevant myocardial injury than in those without (Log Rank p<0.001, Figure 1). The presence of clinically relevant myocardial injury was significantly associated with an increased risk of mortality at 5 years (adjusted HR 1.58, 95% CI 1.18–2.12, p=0.002). Clinically relevant myocardial injury was related to 5-year mortality in patients with apical TTS (adjusted HR 1.57, 95% CI 1.21–2.03, p=0.001), with presence of physical stressors (adjusted HR 1.60, 95% CI 1.22–2.11, p=0.001), and with absence of emotional stressors (adjusted HR 1.49, 95% CI, 1.17–1.89, p=0.001).

Conclusions

This study for the first time determined a troponin threshold for the identification of TTS patients at excess risk of mortality. These findings advance risk stratification in TTS and assist in identifying patients in need for close monitoring and follow-up.

Funding Acknowledgement

Type of funding sources: Foundation.
Impact of limbs pneumatic compression during cardiopulmonary resuscitation (CPR) on cardiac arrest patients: a randomized controlled trial
Authors: Han B , Li B , Guifeng Z
Published: October 2022

Background

Limbs pneumatic compression during cardiopulmonary resuscitation (CPR) for cardiac arrest patient were rarely reported.

Purpose

To evaluate the effect of this therapy on the patients of cardiac arrest.

Methods

A randomized, controlled and trial, a total of 62 elderly (75.8±8.3 yrs) cardiac arrest patients were included and randomized to “CPR group” (n=31) and “CPR + Pneumatic Compression group” (n=31). Each individual in CPR group received standard CPR. In addition to the standard CPR, all patients in “Pneumatic Compression group” accepted intermittent pneumatic compression (IPC) by Air Compression Therapy System, which digital six-tiered rippling full-body pressure (0.45–0.6 kg/cm2) and 1 minute interval every 5 minutes.

Results

Compared with standard CPR group, significant improvements of cardiac output (CO) and survival of patient were found in Pneumatic Compression group (Figure 1). Patients with pneumatic compression had lower incidence (19.4% vs. 45.2%, p=0.03) of acute kidney injury (AKI) than that in standard CPR group. Besides, the lower occurrence of hypoxic ischemic encephalopathy (HIE) was observed in Pneumatic Compression group (Figure 2). There was no ischemic myonecrosis of limbs caused by compression.

Conclusions

Intermittent limbs pneumatic compression during cardiopulmonary resuscitation (CPR) maybe could improve the blood flow of the crucial organs (e.g. brain) and increase survival of cardiac arrest patients, which is superior to the strategy for CPR alone.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): SHOU FA2020-4-1045 Fundation
Incremental value of myocardial work in predicting beneficial response to aortic valve replacement in patients with aortic stenosis
Authors: Golanski G , Grzeskowiak K , Przybylski R , Protasiewicz M , Kubler P , Aleksandrowicz K , Mazur M , Reczuch K , Ponikowski P , Przewlocka-Kosmala M , Kosmala W
Published: October 2022

The predictors of favorable clinical response to aortic valve replacement (AVR) in aortic stenosis (AS) are still insufficiently defined. The increased LV afterload in AS affects the interpretation of the majority of LV systolic indices, which are load-dependent. The estimation of myocardial work (MW) is a newly developed approach, which, allowing correction of global longitudinal strain (GLS) for LV afterload, gives a more adequate insight into the intrinsic LV contractility.

Aim

To investigate whether the assessment of MW can improve the prediction of clinical and neurohormonal improvement post AVR in patients with AS.

Methods

We evaluated 126 patients (75±9 years) with severe AS who underwent transcatheter AVR (n=100) or surgical AVR (n=26). Transthoracic echocardiography, blood sampling and 6 min walk test (6MWT) were performed pre and 3 months post AVR. The following indices of MW were assessed: global work index (GWI), global constructive work (GCW), global wasted work (GWW), global work efficiency (GWE).

Results

Post-AVR changes in the clinical and echocardiographic profile are presented in Table. Post-treatment increase in 6MWT distance was noted in 95 patients, and decrease in NT-proBNP in 94 patients. In multivariable analysis including clinical parameters and echocardiographic indices of cardiac function, morphology and aortic valve hemodynamic, baseline GWW was the only independent echocardiographic predictor of post-AVR improvement in 6MWT distance (beta=−0.24, SE 0.09, p=0.01), whereas baseline GWE was, in addition to tricuspid regurgitation pressure gradient (TRPG) and E/e' ratio, independently associated with the post-AVR decrease in NT-proBNP (beta=0.27, SE 0.09, p=0.004).

Conclusions

In patients with severe AS undergoing AVR, higher values of GWW do not favor post-treatment functional improvement as assessed by 6MWT. The beneficial neurohormonal response to AVR is more pronounced in patients with less efficient LV contraction at baseline.

Funding Acknowledgement

Type of funding sources: None.
Patient delay in acute myocardial infarction: a long journey still ahead
Authors: Marques C , Cabrita A , Maia Araujo P , Proenca T , Pinto R , Carvalho M , Costa C , Amador A F , Calvao J , Pinho A , Oliveira C , Santos L , Cruz C , Macedo F
Published: October 2022

Background

It is overly known that time delays in acute myocardial infarction (AMI) strongly influence its outcomes. Patient delay (PD) is repeatedly pointed out as the longer one in this context, as well as it is the less modifiable one by organizational measures. Therefore, it is crucial to understand the reasons for longer PD in our population, to define proper strategies to improve PD and, ultimately, AMI-outcomes.

Methods

In this six-month prospective study of patients (pts) admitted in a tertiary hospital due to type-1 AMI, 194 pts were consecutively enrolled between May and October 2021. Data was based on a pts well-structured interview within 48h after admission and review of medical records.

Results

Our work spotted several aspects significantly influencing PD in AMI context (Figure 1). Concerning pts cardiovascular background, a trend towards a shorter PD was found in pts with at least one cardiovascular risk factor (CVRF) (p=0,08) and with a previous history of AMI (p=0,08). Regarding clinical presentation, a significantly shorter PD was found in pts presenting with associated symptoms (p=0,02), higher chest pain intensity (chest pain intensity ≥7 vs <7 in a 0–10 scale; p=0,03) and symptoms onset on weekdays rather than weekends (p=0,003). Regarding pts knowledge, significant differences were found when pts recognized their symptoms as AMI, presenting a shorter PD in this context (p=0,006). Curiously, pts ability to correctly identify AMI symptoms, when asked, or to acknowledge their CVRF (when present), did not influence PD. Considering sociodemographic factors, higher incomes (p=0,03) and non-rural residence (p=0,03) significantly translated into shorter PD. No differences were found in PD according to pts age, gender or educational level. After this initial univariate analysis, multiple linear regression was performed to identify possible predictors of PD. Four variables were identified: pts ability to recognize their symptoms as AMI (β −0.199; 95% CI: −277 to −34,87; p=0.012), living in a non-rural residence (β 0.154; 95% CI: 0.12–161.44; p=0.05), presenting associated symptoms (β −0.194; 95% CI: −257.43 to −28.84; p=0.014) and occurrence of symptoms on weekdays (β 0.170; 95% CI: 12.73–259.49; p=0.031) predicted shorter patient delays.

Conclusion

Our study clearly points to the need for increasing public awareness and educational measures, mainly in pts living in rural areas, in order to: 1) Improve pts knowledge about AMI symptoms, clarifying that atypical symptoms can happen; 2) Reinforce the importance of shortening AMI time delays, clearly explaining the concept “time is muscle”.

Funding Acknowledgement

Type of funding sources: None.
Socioeconomic status and waiting time in the emergency department for patients with chest pain
Authors: Herlitz S , Svensson P , Ohm J , Ekelund U , Habel H
Published: October 2022

Introduction

Acute coronary syndrome (ACS) is one of the leading causes of death in the world and timeliness of treatment and diagnosis is of utmost importance to reduce mortality and morbidity. Emergency department (ED) crowding results in longer waiting times and length of stay in the ED and is a globally growing phenomenon with clear negative consequences for patients. Low socioeconomic status (SES) has previously been associated with poor prognosis after ACS, but it remains unclear if treatment and diagnostics in the acute state is a contributing factor. ED length of stay has been linked to crowding and poor patient outcomes whereas mechanisms for generally worse prognosis in low SES remains poorly understood.

Purpose

To investigate whether SES, measured as disposable income, is associated with ED waiting times among patients with the most common chief complaint in ACS, chest pain.

Methods

A registry-based cohort study on all 140,388 patients arriving at 14 Swedish emergency departments between 2015 and 2019 with chest pain as their chief complaint registered in the Swedish Emergency Registry (SVAR). Individual-level sociodemographic and clinical data were linked from multiple national registries. The associations between disposable income quintiles and ED length of stay and time to doctor were assessed using multivariable regression models adjusting for age, sex, education, comorbidities (diabetes, hypertension, hyperlipidemia, obesity and cardiovascular disease) and ED-visit characteristics (arrival mode, triage level, arrival time (day, evening or night as well as weekday or weekend) and hospital type).

Results

Median length of stay was 11 minutes (4.4%) longer among patients in the lowest income quintile, 4:04 [hours:minutes] (95% confidence interval [CI] 4:02–4:05), compared to patients in the highest income quintile (3:53, 95% CI 3:52–3:55). Similarly, time to doctor was 6 min (8.7%) longer among patients in the lowest income quintile (1:15 min, 95% CI 1:14–1:16) than patients in the highest income quintile (1:09, 95% CI 1:08–1:10). The associations were independent of adjustment for studied confounders and mediators.

Conclusions

Among ED chest pain patients, low income was associated with longer length of stay and time to doctor which may impact negatively on patients with serious cardiovascular diagnosis such as ACS. Longer waiting times may delay diagnosis and timely treatment for the individual patient such as anti-ischemic and antithrombotic therapy.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Supported by grants provided by Region Stockholm (ALF-project)
Prevalence of illicit drugs use and association with in-hospital major adverse events in patients hospitalised for acute cardiac events: the ADDICT-ICCU Trial
Authors: Pezel T , Dillinger J G , Trimaille A , Delmas C , Piliero N , Bouleti C , Pommier T , El Ouahidi A , Andrieu S , Lattuca B , Rossanaly Vasram R , Fard D , Noirclerc N , Vicaut E , Henry P
Published: October 2022

Background

The prevalence and short-term cardiovascular consequences of illicit drug use in patients admitted to the intensive cardiac care unit (ICCU) for acute cardiovascular events are not well established.

Purpose

The Addiction in Intensive Cardiac Care Units (ADDICT-ICCU) study was designed to assess prospectively the prevalence of illicit drugs use, and their association with the occurrence of in-hospital major adverse events (MAEs) in consecutive patients admitted to ICCUs for acute cardiovascular events.

Methods

From 7 to 22 April 2021, screening for illicit drug was performed by systematic urinary testing in a prospective study including all consecutive patients admitted to ICCU in 39 centres throughout France. The primary outcome was the prevalence of the illicit drugs detected. The secondary clinical outcome was in-hospital Major Adverse cardiac Events (MAEs) defined by death, resuscitated cardiac arrest or cardiogenic shock.

Results

Among 1,499 consecutive patients screened (age 63.3±14.9 years, 69.6% male), 161 (10.7%) had a positive test for illicit drugs (cannabis: 9.1%, opioids: 2.1%, cocaine: 1.7%, amphetamines: 0.7%, 3,4-methylenedioxymethamphetamine: 0.6%). Patients who used illicit drugs were young (33.0% at age <40 vs. 5.9% at age ≥60 years), and more frequently male (11.9% vs. 8.1%, p<0.001). Self-reported current use was 56.5% in patients with a positive test. After a median duration of hospitalisation of five days, there were 61 in-hospital MAEs (4.1%).

The detection of illicit drugs was associated with a higher rate of MAEs after adjustment for known predictors of severity (OR=8.84; 95% CI: 4.68–16.7, p<0.001) or after using a propensity score adjustment (OR=5.81; 95% CI: 4.14–8.14, p<0.001). After adjustment for age and sex, detection of cannabis or cocaine was significantly associated with MAEs (OR=3.53; 95% CI: 1.25–9.95, p<0.001; OR=5.12; 95% CI: 1.48–17.2, p=0.004 respectively). Multiple drug detection (28% of positive patients) was associated with a higher incidence of MAEs than single drug detection.

Conclusions

The prevalence of illicit drugs use in patients hospitalised in the ICCUs for acute cardiovascular events was 10.7% and was under-reported. Illicit drugs detection was independently associated with a higher occurrence of in-hospital MAEs.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Fondation Coeur et Recherche
Targeted metabolomics in Out-of-Hospital Cardiac arrest (OHCA)
Authors: Paulin Beske R , Henriksen H H , Obling L O , Kjaergaard J K , Jeppesen J B J , Nielsen N , Johansson P J , Hassager C H
Published: October 2022

Background

Out-of-hospital cardiac arrest is a leading cause of death. Even if successfully resuscitated, mortality and morbidity remain high due to ischemic and reperfusion injury (I/R). The oxygen deprivation leads to a metabolic derangement amplified upon reperfusion resulting in an uncontrolled generation of reactive oxygen species, triggering cell death mechanisms and organ damage. Understanding the I/R damage in humans following OHCA remains sparse, with no existing treatment to attenuate the reperfusion injury.

Aim

Describe metabolic derangement in patients following OHCA.

Methods

Blood samples from consecutive resuscitated unconscious OHCA patients drawn at hospital admission were analyzed using ultra-performance liquid mass-spectrometry. Sixty-one metabolites of the ∼3000 compounds detected were prespecified for quantification and analyzed in the current study. We used hierarchical cluster data analysis to identify metabolic clusters/phenotypes.

Results

In total, 163 patients were included, of which 143 (88%) were men, and the median age was 62 years (53–68). All measured metabolites from the tricarboxylic (TCA) cycle were significantly higher in non-survivors vs. survivors (180-days survival). Hierarchical clustering identified four (A-D) phenotypes of patients with distinct metabolic profiles. The mortality was significantly different in two phenotypes; A and B (A: 62% and B: 59% vs. C: 21% and D: 24%, p<0.001). There were no significant differences in age between the four phenotypes (p=0.35). Phenotype A and B had longer time to ROSC (A: 33 min (21–43), B: 27 min (24–35), C: 18 min (13–28), and D: 18 min (12–25), p<0.001). Phenotype A and D, who both had higher levels of free fatty acids, also a higher prevalence of ST-elevation or acute left bundle branch block in first ECG as compared to phenotype B and C (A: 76%, B: 55%, C: 36% and D: 75%, p<0.001.

Conclusion

Circulating levels of metabolites from the TCA cycle best described the variance between survivors and non-survivors. Four different metabolic phenotypes were identified. These phenotypes had significantly different mortality.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Novo Nordisk Foundation
First sampled plasma troponin T is associated with one-year mortality in sepsis and septic shock, independent of age, gender, comorbidities, and clinically relevant biomarkers
Authors: Loerstad S , Shekarestan S , Tehrani S , Jernberg T , Astrand P , Gille-Johnson P , Persson J
Published: October 2022

Background

Patients with sepsis and septic shock often have elevated troponin T levels indicating acute myocardial injury. Studies investigating the relationship between troponin T levels as a predictor for mortality in sepsis have been contradictory.

Purpose

To investigate if the first in-hospital sampled plasma troponin T value is associated with one-year mortality in sepsis and septic shock independent of comorbidities, Sequential Organ Failure Assessment (SOFA)-score, Clinical Frailty Scale, Charlson Comorbidity Index (including age) and clinical biomarkers (e.g., serum lactate, creatinine, C-reactive protein).

Methods

Patients with sepsis and sepsis shock were included if they were admitted to the intermediate and intensive care units at our institution between 1st of March 2012 and 30th of September 2021, and if at least one troponin T value was recorded within the first two calendar days from symptom onset. Variables were collected from medical records. Normal troponin-T was defined as <15 ng/L. Elevated troponin T values were divided into quartiles (Q): Q1 15–35.9 ng/L, Q2 36–61.9 ng/L, Q3 62–125.9 ng/L and Q4 ≥126 ng/L. Kaplan-Meier stratified survival curves were plotted for normal levels and Qs of elevated troponin T. Multivariate Cox regression was used for multivariate analysis.

Results

586 patients were included and 529 (90%) had a first sampled troponin T ≥15 ng/L. 523 (89%) met the Sepsis-3 criteria for septic shock, the remainder met the criteria for sepsis. The mean age was 71 years and 220 (38%) were women. One-year mortality was 45% (n=264). Increasing levels of first sampled plasma troponin T were associated with higher hazard ratios (HR) for one-year mortality compared to normal levels (<15 ng/L): Q1 HR 5.29 (95% confidence interval [CI] 1.9–14.7); Q2 HR 7.47 (95% CI 2.71–20.6); Q3 HR 12.81 (95% CI 4.7–35.0); Q 4 HR 13.82 (95% CI 5.06–37.7) (Figure 1). Troponin T was independently associated with one-year mortality after adjustment for gender, plasma lactate, plasma CRP, prior atrial fibrillation, in-hospital onset atrial fibrillation, SOFA-score, CFS, and CCI (including age) (Table 1).

Conclusions

Elevated first sampled plasma troponin T in patients with sepsis and septic shock was associated with higher one-year mortality, independent of age, gender, comorbidities, and clinically relevant biomarkers. There was a risk gradient across the Qs of elevated troponin T with increasingly higher risk of death at one year per higher Q. Further studies are needed to ascertain whether elevated troponin T levels and clinical assessment scores can be used together in the clinical setting to identify patients for more aggressive treatment and cardiac work-up.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Region Stockholm
Relationship between liver fibrosis and in-hospital outcomes in patients with acute coronary syndrome undergoing PCI
Authors: Biccire F G , Barilla F , Sammartini E , Dacierno E M , Tanzilli G , Pastori D
Published: October 2022

Background

Patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) still experience a high rate of in-hospital complications. Liver fibrosis (LF) is a risk factor for mortality in the general population. However its prognostic role in ACS patients has been poorly investigated.

Purpose

We investigated whether the presence of LF detected by the validated fibrosis-4 (FIB-4) score may indicate ACS patients at higher risk of poor outcome.

Methods

In the prospective ongoing REAl-world observationaL rEgistry of Acute Coronary Syndrome (REALE-ACS), LF was defined by a FIB-4 score >3.25. The primary endpoint was in-hospital adverse events (AEs) including a composite of in-hospital cardiogenic shock, PEA/asystole, acute pulmonary edema and death.

Results

A total of 469 consecutive ACS consecutive patients were enrolled. Overall, 21.1% of patients had a FIB-4 score >3.25. Patients with LF were older, less frequently on P2Y12 inhibitors (p=0.021) and admitted with higher serum levels of white blood cells (p<0.001), neutrophils to lymphocytes ratio (p<0.001), C-reactive protein (p=0.013), high-sensitive troponin T (p<0.001), creatin-kinase MB (p<0.001), D-Dimer levels (p<0.001). STEMI presentation and higher Killip class/GRACE score were more common in the LF group (p<0.001). 71 patients experienced 110 AEs. At the multivariate analysis including clinical and laboratory risk factors, FIB-4 >3.25 (OR 3.1, 95% CI 1.4 to 6.9), admission left ventricular ejection fraction% below median (OR 9.2, 95% CI 3.9 to 21.7) and Killip class ≥II (OR 6.3, 95% CI 2.2 to 18.4) were the strongest independent predictors of in-hospital AEs.

Conclusions

LF detected by FIB-4 score >3.25 was associated with more severe ACS presentation and worse in-hospital AEs irrespective of clinical and laboratory variables.

Funding Acknowledgement

Type of funding sources: None.
The influence of hemolysis upon admission on the performance of neuron-specific enolase in predicting death after resuscitated out-of-hospital cardiac arrest – a substudy of the IMICA trial
Authors: Abdi Isse Y , Wiberg S , Grand J , Obling L , Frikke-Schmidt R , Kjaergaard J , Hassager C , Meyer M A S
Published: October 2022

Background

The predominant cause of mortality among out-of-hospital cardiac arrest (OHCA) patients admitted to the intensive care unit in a comatose state is hypoxic-ischemic brain injury and consequent withdrawal of life sustaining therapies. Current guideline for post-resuscitation care suggests a multimodal approach for neuroprognostication including measuring a blood-born biomarker of neuronal injury termed neuron-specific enolase (NSE). However, NSE is also present in erythrocytes and therefore hemolysis – which frequently occurs immediately after resuscitation – must be assessed by measuring free-hemoglobin (free-hgb), and samples discarded if the threshold index is surpassed to minimize false positive results. In addition, the plasma half-life of NSE is much longer than free-hgb, and hemolysis occurring prior to the sampling point of NSE measurement, may cause elevated NSE levels due to destruction of erythrocytes rather than neurons, although free-hgb is no longer detectable in plasma.

Purpose

To investigate the relationship between hemolysis at hospital admission and NSE measured at 48 hours, and to determine the influence of hemolysis on the clinical performance of NSE in predicting all-cause mortality in comatose OHCA patients.

Methods

Free-hgb was measured at admission (0h) to quantify hemolysis. NSE was measured at 48 hours after admission. In each NSE sample hemolysis index was measured and mathematically corrected according to standard laboratory procedure. The relationship between free-hgb at 0h and NSE at 48h was investigated by Pearson's correlation analysis. The area under the receiver operating characteristic curves (AUROC) for prediction of all-cause mortality at 30 days were determined for both NSE and free-hgb, and the difference in AUROC between the two was calculated. Further, the positive and negative predictive values (PPV and NPV respectively) of NSE with a cut-off value at >60 μg/l (as recommended by guidelines) in predicting all-cause mortality were calculated.

Results

Admission free-hgb and NSE at 48 hours were available for 64 consecutive patients surviving beyond 48 hours. The 30-day mortality in this population was 33%. There was no correlation between free-hgb at 0h and NSE at 48h (r=0.13, p=0.30; Figure 1). The AUROC for NSE was 0.92 (Figure 2), and 0.59 for free-hgb at 0h. The PPV for NSE>60 μg/l was 1.0 (1.0–1.0) and NPV 0.84 (0.74–0.94).

Conclusions

The performance of NSE at 48 hours for predicting all-cause mortality among out-of-hospital cardiac arrest patients was not influenced by the degree of hemolysis at the time of admission, and NSE at 48 hours had both high positive and negative predictive values irrespectively of early hemolysis.

Funding Acknowledgement

Type of funding sources: None.
Echocardiographic assessment alone is inadequate for determining elevated left sided filling pressures in patients with cardiogenic shock
Authors: Brahmbhatt D H , Scolari F L , Doumouras B S , Billia F , Szekely Y
Published: October 2022

Background

Left atrial (LA) filling pressure assessment is of paramount importance in tailoring treatments for patients with cardiogenic shock (CS). ESC guidelines advocate for the use of mitral inflow Doppler and mitral annulus tissue Doppler measurements to predict elevated left atrial pressure in clinical practice. Echocardiographic measurement of LA pressures could reduce the need for invasive monitoring in CS patients, but its utility remains unproven in this population.

Purpose

We assessed the validity of mitral inflow velocity and mitral annulus velocity indices to determine LA pressures, correlating them with invasive measurement of pulmonary capillary wedge pressure (PCWP) in CS patients admitted to the cardiac intensive care unit (CICU).

Methods

We prospectively evaluated consecutive patients who underwent pulmonary artery catheter insertion in the CICU, measuring their haemodynamic parameters, including PCWP. This was immediately followed by a transthoracic echocardiography (TTE) performed by a critical care cardiologist, blinded to the invasive measurements. The early (E) and late (A) mitral inflow velocities were measured using mitral inflow Doppler and septal and lateral mitral annulus velocities (e') were measured using tissue Doppler, all in the apical 4-chamber view. TTE images were later reported by a second cardiologist, blinded to the invasive measurements and the patient. Correlations between E; E/A ratio; E/e' ratio and PCWP were evaluated using Pearson's correlation.

Results

Sixty patients were recruited into the study, aged 58±14 years, 27% female, with 96 assessments undertaken. The majority (55%) of patients were SCAI stage C, with 14% having had a cardiac arrest prior to CICU admission and 27% required mechanical ventilation at the time of assessment. Mean PCWP was 16.0±6.5 mmHg. Full mitral valve Doppler and tissue Doppler profiles were measured in 67 (70%) assessments, limited due to E/A fusion, atrial fibrillation and limited acoustic windows. There was only weak correlation between PCWP and E/A ratio (R=0.33, p=0.01), with no correlation between PCWP and the other measured values (Table 1), including E/e'. The AUC for identifying patients with elevated PCWP (≥15 mmHg) using E/A ratio was 0.67 (p=0.02), although there was no suitable value to use as a cut off with adequate sensitivity and specificity (Figure 1).

Conclusion

Echocardiographic non-invasive assessment of left sided cardiac filling pressures is technically challenging in patients with CS. Even when possible, there is weak correlation between echocardiographic and invasive measurements, suggesting limited value in this technique. Alternative non-invasive modalities, such as lung ultrasound, should be investigated in this population to assist clinical assessment.

Funding Acknowledgement

Type of funding sources: None.