bluuebunny/crossref_metadata_2025 huggingface dataset:
Effects of hyperoxia and cardiovascular risk factors on myocardial ischemia reperfusion injury: a randomized, sham and placebo controlled parallel study
Authors: Acheampong A , Melot C , Benjelloun M , Cheval M , Reye F , Delporte C , Van Antwerpen P , Franck T , Mc Entee K , Van De Borne P
Published: April 2021

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Fonds Erasme

Recent studies on O2 supplementation in acute coronary syndrome patients are equivocal. We tested the hypothesis that oxidative stress (OS) is increased in rodents with cardiovascular risk factors and enhances ischemia reperfusion injury in the presence of hyperoxia.

Forty-three Wistar rats (WR), 30 spontaneous hypertensive rats (SHR) and 33 obese Zucker rats (ZR) were randomized in a sham procedure (1/3rd) or a left anterior descending ligation for 60 minutes (2/3rd). This was followed by 3 hours of reperfusion while animals were randomised either in a hyperoxic (HR) or a normoxic reperfusion group (NR). Baseline troponin (cTnT) was larger in SHR and ZR than WR (both p < 0.001). HR was associated with a lesser troponin rise in SHR and ZR than in NR (both p < 0.001); while the reverse occurred in WR (p < 0.001). In SHR, HR limited total MPO (myeloperoxydase) increase as compared to NR (p = 0.0056) to the contrary of total MPO in WR (p = 0.013). NR was associated with a drastic reduction of total thiols as compared to HR both in SHR and in ZR (both p < 0.001).

Despite a heightened baseline OS, HR rather restrained myocardial necrosis and anti/pro-oxidant imbalance in SHR and ZR, to the reverse of healthy WR. Baseline characteristics of the 3 strainWR¹ (n = 41)SHR² (n = 29)ZR³ (n = 33)Age (months)9.0 (7.0 - 10.0)6.0 (6.0 - 8.3) ¹ vs 27.0 (6.0 - 8.0) 1 vs 3, 2 vs 3Weight (mg)590 (553 - 646)436 (419 - 485) ¹ vs 2670 (622 - 716) 2 vs 3Systolic arterial pressure (mmHg)146 (120 - 174)165 (120 - 197)188 (169 - 215) 1 vs 3Heart rate (beat/minute)284 (268 - 310) ¹ vs 2244 (216 - 270)254 (230 - 288) 1 vs 3Troponin T (ng/l)13 (9 - 20)42 (33 - 60) 1vs233 (23 - 53) 2vs3Triglyceride (mg/dl)/87 (64 - 110)1062 (683 - 2459) 2vs3MDA (nmoles)0.10 (0.04)0.09 (0.06)0.14 (0.10) 2vs3Total MPO (ng/ml)2889.7 (932.1)2684.0 (681.7)4479.7 (728.0) 1vs3,2vs3Free total thiols (µM)222.6 (213.9 - 240.5)40.2 (5.3 - 60.2) 1vs282.3 (17.5 - 235.7) 2vs3Abbreviations WR: Wistar rats. SHR: Spontaneous Hypertensive rats. ZR Zucker rats.Both paired t-test and Wilcoxon signed rank test were used. Variables are shown in means with standard deviation (mean (SD)) or in median (interquartile range. IQR). Pairwise test – p < 0.05; 1vs2: WR vs SHR. 1vs3: WR vs ZR. 2vs3: SHR vs ZR.WR were older than the SHR and ZR. ZR were older than SHR. The ZRs were more obese than SHR and more hypertensive than WR. Baseline Troponin T was larger in SHR than ZR and WR. ZR had higher level of triglyceride than SHR. Total MPO was more elevated in ZR than SHR and WR. Oxidative stress was enhanced in ZR than SHR (higher MDA. more elevated total MPO) and total thiols were the lowest in the SHR.Abstract Figure. Troponin T concentration evolution slope
Acute coronary syndrome in COVID-19 times: could it be business as usual?
Authors: Ferreira J , Fonseca M , Farinha JM , Esteves AF , Pinheiro A , Coelho R , Goncalves S , Costa C , Caria R
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Background

In an attempt to cope with the COVID-19 pandemic, several measures of social distancing and reorganization of health care systems have been adopted. In Portugal, these included suspending elective clinical activity and a temporary national lockdown. Data from multiple centres, including central hospitals in Portugal, has shown a reduction in hospital admissions for acute coronary syndrome (ACS) during the COVID-19 outbreak. Fear of going to the hospital and physical inactivity have been pointed as possible explanations.

Purpose

to assess the impact of this pandemic and the measures taken against it on the pattern of admissions and treatment of patients with ACS in a district hospital. 

Methods

A single-centre retrospective study was conducted in the Cardiology Department of a Portuguese district hospital, capable of performing 24h percutaneous coronary intervention. We analyzed the admissions for ACS during the peak of the first COVID-19 outbreak in Portugal (16th of March to 3rd of May 2020, coinciding with the suspension of elective activity) and compared it with two control periods: one immediately preceding the study period (27th of January to 15th of March - 2020 control) and one exactly one year before (16th of March to 3rd of May 2019 - 2019 control).

Results

During the 7 weeks of the first COVID-19 outbreak, 46 patients were hospitalized for ACS in our department, while 54 had been admitted during the 2020 control period and 40 in the 2019 control period, with a mean of 7 admissions/week (vs 8 and 6, respectively; p > 0.05). There were no significant differences between the study group and both controls regarding basal characteristics. Their presentation did not differ: the majority of patients (57%) was admitted for ST-elevation myocardial infarction and median time from symptom onset to admission to the emergency room was 3 hours, with 4% of patients presenting in Killip class ≥III (p > 0.05 for all). We also found no significant differences in the treatment administered nor in the outcomes (96% submitted to coronary angiography, median length of hospitalization of 4 days and in-hospital mortality rate of 2%, p > 0.05 for all). 

Conclusions

Our study suggests that the reduction in admissions for ACS during the COVID-19 outbreak is not universal. Additionally, severity at presentation, treatment administered and outcomes did not seem to differ. The relatively low prevalence of COVID-19 in our hospital"s region might be the cause, since people might fear and refrain less from going to the hospital. Larger studies with other centres in low-prevalence regions are needed to confirm this hypothesis.
Comparison of clinical outcome in acute inferior wall myocardial infarction based on culprit artery: right coronary artery vs left circumflex artery
Authors: Altarejos F , Barea C , Hernandez-Meneses BG , Hidalgo-Urbano R , Almendro-Delia M , Recio-Mayoral A , Garcia-Rubira JC
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION

Acute inferior wall myocardial infarction (AIWMI) is related to Right Coronary Artery (RCA) occlusion in about 80% of cases and to Left Circumflex Artery (LCX) in the rest of them, in most series. However it has not been established yet if there is a difference in prognosis depending on culprit artery.

PURPOSE

This study compares clinical outcome during hospital stay between RCA-related and LCX-related AIWMI.

METHODS

We analysed all patients with AIWMI admitted to the Cardiac Care Unit between August 2011 and February 2019, both ST-elevation (STEMI) and non ST-elevation myocardial infarction, and whose culprit artery was either the RCA or the LCX. Basal characteristics and clinical outcome during hospital stay were compared between RCA and LCX.

RESULTS

Among 2252 patients with acute coronary syndrome, 650 were AIWMI. Among them, the culprit artery was the RCA in 461, the LCX in 149, and other or not defined in 30. The mean age was 61.7 ± 11.6 years, 79% of them were male and 21% female. They had a history of current smoking in 50.7%, diabetes mellitus in 24.4%, hypertension in 52.1%, dyslipemia in 44.3% and obesity in 28.7%, without differences between RCA and LCX. RCA patients presented as STEMI in 93.3% vs 87.2% of LCX patients (p = 0.025). Among those presenting as STEMI, 84.4% of RCA and 90.8% of LCX underwent primary coronary intervention. Mean ejection fraction was 50.8% in RCA and 51.2% in LCX. Three-vessel or left main disease was present in 10.2% of RCA and 10.8% of LCX. There was atrioventricular block in 17.8% of RCA and 3.4% of LCX (p < 0.001); atrial fibrillation in 10.2% of RCA and 11.4% of LCX, ventricular fibrillation in 10.4% of RCA and 7.4% of LCX. Median of peak CPK was 1203 in RCA, vs 1785 in LCX (p < 0.001). There was cardiogenic shock (CS) at admission in 5.4% of RCA vs 1.3% of LCX, (p = 0.038) and CS whenever the hospital stay in 8.4% vs 4.0% (p = 0.072). In-hospital mortality was 3.3% in RCA and 3.4% in LCX. Several models of multivariate logistic regression analysis did not find a predictive value of the culprit artery in the development of CS or in-hospital mortality.

CONCLUSION

AIWMI related to LCX have greater enzymatic size than those related to RCA. However, RCA infarctions present more often atrioventricular block and cardiogenic shock at admission. Multivariate analysis did not shock significant differences in the development of CS or in-hospital mortality. Abstract Figure. Peak CPK depending on culprit artery
Implementation of the ESC 0/3hour accelerated diagnostic protocol,utilising high sensitive troponin T, for suspected acute coronary syndrome:a study on clinical effectiveness involving 3016 patients
Authors: Mohmed S , Campbell M , Batouskaya K , Obeidat M , Khand A
Published: April 2021

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): Liverpool University Hospitals NHS Foundation Trust

Background

There have been relatively few studies detailing the real-world effectiveness and safety of accelerated diagnostic protocols (ADP), using high sensitivity troponins (HSTN).

Purpose

 To analyse the safety and effectiveness of early emergency room (ER) discharge following implementation of the ESC 0/3-hour ADP for suspected acute coronary syndromes (ACS)

Method

We prospectively studied 2 cohorts of consecutive suspected acute coronary syndromes (ACS) presentations to ER before (n = 1642) and after (n = 1376, 2 centres) implementation of the ESC 0/3-hour ADP incorporating limit of detection rule out. All index presentations with HSTNT (high sensitive troponin T) >99th percentile underwent independent two physician adjudication for MI (myocardial infarction) using all available data to six weeks.  Safety was defined by both NPV (negative predictive value) and sensitivity for type 1 or type 2 MI for those with ER discharge and clinical effectiveness by percentage ER discharge.

Results

In the pre-implementation period there was a higher prevalence of MI. Discharge from ER increased by >100% to 56% of the cohort, when the ADP was implemented. This correlated with a marked reduction in length of stay overall and a more modest reduction for those discharged from ER (table)

The greatly increased ER discharge was safe with no signal for hazard.

Analysis of HSTNT values and ECGS revealed a maximum ER discharge rate of 69%, by applying the 0/3-hour protocol, implying potential for further increasing safe ER discharge.

Conclusions

Implementation of an ADP with HSTNs is safe and effective for early rule-out and discharge of suspected ACS. Further research into the shortfall between theoretical and actual early ER discharge achieved is warranted. DischargePre-implementation0/3hour ADP implementationP valuen16421376% male52.352.1nsAge (median)5855<0.001Index Type 1 or 2 MI prevalence (%)11.96<0.001% discharged from ER2756<0.001Median total length of stay (hours) {global population}16.37.1<0.001Median length of stay (hours)- discharged from ER6.25.4<0.001NPV for index type 1 or 2 MI (discharged from ER)99.399.7nsSensitivity index type 1 or 2 MI (discharged from ER)98.597.6ns
Markers of myocodial fibrosis in acute myocardial infarction
Authors: Razin V
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

One of the leading mechanisms in the healing process of acute myocardial infarction (AMI) is damage and loss of extracellular matrix, which plays a leading role in the pathogenesis of LV myocardial remodeling. Tissue inhibitor of matrix metalloprotease-1 is a protein that is a natural inhibitor of metalloproteases, forms complexes with MMP-1 and other metalloproteases (they destroy components of the extracellular matrix of the heart), irreversibly inhibiting their activity. Bayes-Genis A. et al presented histological data on the expression in ruptured and eroded plaques of plasma protein A (PAPP-A), metalloproteinase and insulin-like growth factor-1 detected during pregnancy. Myocardial formation of aldosterone and angiotensin II (as a result of activation of the renin-angiotensin-aldosterone system, including the tissue component) after acute myocardial infarction stimulates the formation of collagen and fibrous tissue in the myocardium with further changes in the structure and geometric characteristics of the left ventricle.

Purpose of the study. To study the markers of interstitial myocardial fibrosis in the acute stage of myocardial infarction and assess the dynamics of these indicators in patients after 2.5-3 weeks of inpatient treatment.

Methods. The study included 31 patients with myocardial infarction with ST segment elevation. The control groups consisted of 20 apparently healthy individuals. During the study, serum parameters of tissue inhibitor of matrix metalloproteinase-1 (TIMMP-1 and aldosterone were measured on days 1-3 after AMI and after 2.5-3 weeks of inpatient treatment.

Results. The level of TIMMP-1 in patients with acute MI was 418.19 ± 103.77 ng / ml and was statistically significantly higher than in practically healthy individuals - 103.44 ± 7.06 ng / ml (p <0.0001) , The level of TIMMP-1 in patients with AMI after 3 weeks, against the background of ongoing therapy, was 366.70 ± 93.34 ng / ml, and the decrease in TIMMP-1, compared with the initial value in the acute stage, had a statistical significance (p = 0.046).

The level of aldosterone in acute myocardial infarction was 165.12 ± 32.67 pg / ml and was statistically significantly higher (p <0.0001) than in the control group. In patients with myocardial infarction who are hospitalized, for 2.5-3 weeks, there is a statistically significant (p = 0.003) decrease in the concentration of aldosterone in blood plasma by 15.1% from 165.12 ± 32.67 pg / ml to 140.24 ± 22.78 pg / ml.

Conclusions. In the acute stage of myocardial infarction (1-3 days), there is a significant increase in the concentrations of markers of interstitial myocardial fibrosis, such as tissue inhibitor of matrix metalloproteinase-1 and aldosterone, which reflects the initiation of fibroblast activation processes and, accordingly, stimulation of collagen synthesis. Subsequently, there is a decrease in the concentration of tissue inhibitor of matrix metalloproteinase-1 and aldosterone.
Effect of remote ischemic post conditioning on incidence of contrast induce acute kidney injury in STEMI patients undergoing primary percutaneous coronary intervention
Authors: Arara D , Fadil M , Karani Y , Nindrea RD
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Primary percutaneous coronary intervention (PPCI) is a treatment of choice in ST elevation myocardial infarction patients (STEMI). However, this approach could increase the risk of contrast induce acute kidney injury (CI-AKI) due to iodinated contrast exposure to the patient. Remote ischemic post conditioning (RIPostC) is a non-invasive and simple method that not only has cardioprotective but also renoprotective effect that could prevent the incidence of CI-AKI. 

Purpose

The aim of this study was to investigate the effect of RIPostC to CI-AKI incident in STEMI patients undergoing PPCI.

Methods

This study uses pre and post-test only with control group design with experimental research designs. Data was taken at the Instalasi Pelayanan Jantung Terpadu (IPJT) RSUP Dr. M. Djamil Padang from June 2019 until March 2020, there were 66 patients with ST-segment elevation myocardial infarction (STEMI) being performed RIPostC procedure. with intermittent ischaemia and reperfusion applied to the arm through five cycles of 5-min inflation and 5-min deflation of an automated cuff device after crossing wire. Creatinine and eGFR were measured pre and 48 hours post PPCI. CI-AKI diagnosis based on increase of creatinine level >0,5 mg/dL or 25% from baseline value on 48 hours after PPCI. Bivariate analysis was performed to determine the effect RIPostC to incidence of CI-AKI using the Chi-square test.

Result

A total of 66 patients who underwent the PPCI procedure were divided into two groups RIPostC (n = 33) and without RIPostC (n = 33). The baseline characteristic in both of group was similar. The RIPostC group had a lower CI-AKI incident if we compare with the non RIPostC (15,2% vs 42,4%, p < 0,05).

Conclusion

RIPostC effectively reduced incidence of CI-AKI in STEMI patient who underwent the PPCI with statistically significant result. Effect of RIPostC in CI-AKI post PPCIPPCICI-AKI (+)(f/%)CI-AKI (-)(f/%)Total(f/%)OR (95% CI)p valueRIPostC (+)5 (15,2)28 (84,8)33 (100)0,024 (0,07-0,76)0,03*bRIPostC (-)14 (42,4)19 (57,6)33 (100)Total19 (28,8)47 (71,2)66 (100)* significant p if < 0,05b, chi square testAbstract Figure. Effect of RIPostC in CI-AKI post PPCI
Characteristics and 1-year prognosis of non-obstructive acute coronary syndrome
Authors: Viegas JM , Goncalves AV , Cardoso I , Rosa SA , Timoteo AT , Ferreira RC
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Among patients admitted at catheterization laboratory with suspicion of acute coronary syndrome (ACS) a minority have no obstructive epicardial coronary disease (MINOCA).  The characteristics and outcomes of this subgroup remains unclear.

Purpose

The aim of the present study is to characterize MINOCA patients and assess the 1-year prognosis regarding total mortality.

Methods

A standardized registry was prospectively performed for all ACS patients admitted in a single tertiary care centre during a ten-year period. Patients were divided according to have at least one obstructive coronary artery (G1), defined by a stenosis above 50%, or not (G2) and baseline characteristics were compared between the two groups. All-cause mortality at 30 days and at 1 year were also compared using univariate Cox analysis.

Results

From 3765 ACS patients admitted during the study period, 461 (12.2%) were included in G2. G2 patients were older (62.6 ± 13.1 vs 66.2 ± 13.7; p < 0.001) and more frequently women (26.3% vs 44.2%; p < 0.001). Smoking was more frequent in G1 (40.0% vs 21.9%; p < 0.001) but the prevalence of hypertension was higher in G2 (55.2% vs 64.2%; p < 0.001). There were no differences regarding dyslipidaemia and diabetes. End-stage chronic kidney disease was higher in G2 (2.4% vs 4.1%; p = 0.025). Regarding the clinical evolution during hospitalization, G2 presented more frequently with Killip-Kimball class ≥II (13.9% vs 19.3%; p = 0.001), but at release there was no difference in the proportion of patients with left ventricular ejection fraction ≤50% (34.8% vs 32.1%; p = 0.286).  ACS with ST-segment elevation was more common in G1 (58.8% vs 52.1%; p = 0.006), but no differences were found regarding left and right bundle branch block patterns at presentation. In-hospital and 30-day mortality was not significantly different between groups (5.9% vs 7.4%; p = 0.205). However, at 1-year follow-up, G2 had a worse outcome regarding total mortality (HR (95%CI); 1.473 (1.103-1.969); p = 0.008, figure 1).

Conclusion

MINOCA patients seem not to be a low-risk group of ACS patients, since in this study they had a higher 1-year mortality than ACS patients with obstructive coronary disease. This higher mortality only became apparent after 30 days from the ACS. A systematic diagnostic work-up for further implementation of the most appropriate treatment should be crucial for getting better outcomes with this group of patients. Abstract Figure.
A sneak peek on Takotsubo Syndrome
Authors: Marques Pires C , Medeiros P , Oliveira C , Campos I , Flores R , Mane F , Azevedo P , Galvao Braga C , Arantes C , Antunes N , Marques J
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION

Takotsubo syndrome (TS) is characterized by transient wall motion abnormality of the left ventricle, which may happen in response to different triggers.

AIM

To characterize the population with confirmed diagnosis of TS.

METHODS

We analysed retrospectively 129 patients (pts) admitted in our center from 2010 to 2018 with this presumptive diagnosis. 29pts were excluded because TS wasn´t confirmed.

For each pt we evaluate clinical characteristics, exams results, inhospital complications and long-term outcomes (minimum FUP of 1 year).

RESULTS

The average age was 66 years and 89% were females. Regarding the cardiovascular (Cv) risk factors, 78% had hypertension, 53% dyslipidemia and 19% Diabetes mellitus. In relation to noncardiovascular comorbidities it’s important to point out that 32% had psychiatric disorders.

The trigger was emotional in 37%, physical in 18%, and unidentifiable in 45%. Concerning the clinical presentation 72% had Killip(K) 1 and 13% K≥3 at admission.

The initial electrocardiogram had ST-elevation in 37%, T wave inversion in 64% and a mean QTc interval of 470ms. The mean ejection fraction (EF) by echocardiogram was 37%, with apical ballooning in 83% and at least moderate mitral regurgitation (MR) in 11%. Only 16% had intraventricular pressure gradient. Coronarography revealed absence of obstructive coronary disease in 71% of pts. In addition, 51% of pts underwent cardiac magnetic resonance (CMR), which had an increase usage since 2013. The mean time until the CMR was 14 days, which may explain why only 14% had segmental kinetic changes.

It’s noteworthy that the mean peak NTproBNP/troponin I ratio was 1,4 ± 2,9. We compared the ratio in TS with EF < 40% with the one obtained in a cohort of ST-elevation myocardial infarction (MI) with EF < 40% and found statistically difference (1,7 ± 3,8vs0,01 ± 0,03; p < 0,001).

Considering inhospital complications, 6% had intracardiac thrombus, 2% acute severe MR, 2% ventricular dysrhythmia and 2% died. During the FUP, 2% had recurrence, 4% had acute heart failure hospitalizations an 17% died.

CONCLUSION

Despite increased awareness TS is still poorly recognized. Lack of non-invasive tools for reliable diagnosis obliged the use of coronarography. It’s noteworthy that the peak NTproBNP/troponin I ratio may help to differentiate TS from MI and the use of CMR should be encouraged to exclude other causes. Although considered a benign condition, significant in-hospital mobility and 2% mortality was observed.
Cardiopulmonary resuscitation training in spanish schools: when first link is not well recognized
Authors: Jorge Perez P , Baneras-Rius J , Martin-Cabeza MM , Barrionuevo-Sanchez MI , Lukic-Otanovic A , Loma-Osorio-Rincon P , Belmonte-Vico R , Rodenas-Alsina E , Anguita-Sanchez M
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

Cardiopulmonar resuscitation working group of the Spanish Society of Cardiology

Background

First aid teaching is mandatory in Spanish schools, but there is a variability in how training is performed within different regions of the country. We aimed to study the degree of implementation of school cardiopulmonary resuscitation (CPR) training in Spain.

Methods

A nationwide cross-sectional survey was carried out from February to December 2019. A self-administered questionnaire was carried out aimed at school children. The association between school children characteristics (sex, age and previous CPR education training) and  CPR knowledge was evaluated.

Results

A total of 5892 valid school children surveys were collected. Regarding to school children, mean age was 14.67 years and  36,2% of them had received CPR training, with similar distribution by sex and with an increase in higher courses (28.7% <13 years, 33.9% 13-16 years, 54.9% >16 years; p = 0.002). At older all CPR  knowledge improves, except the telephone emergency  number. Comparing school children who had or not received previous CPR training, there was no difference in correctly identifying the emergency telephone number (p = 0.169) or OHCA (p = 0.05), but school children (32.4% vs 29%, p = 0.005) who have not received the training better recognize the telephone number.

Conclusions

the implementation of CPR training  programs is insufficient in spanish schools and they also do not work to remember the emergency number. Urgent action is required to improve the first link of the survival-chain by disseminating the emergency telephone number. Table 1 – Students surveys main results VariablesN%Autonomous communities responsesCastile la ManchaValenciaAndalucíaCastile LeonExtremaduraCataloniaAragonMadridNavarraCanary Islands5321364181382335747612630.93.60.10.71.464.96.10.80.121.4Mean age (years)14.67 (± SD 1.92)Age distribution< 13 years13 - 16 years> 16 years830416484314.271.414.4Female292750.1CA knowledge Emergengy number061 or 112Hospital or police numberOther o unkown CPR identificationUnconsciousUnconscious not breathingUnconscious not breathing, no pulseOthers183637936754522472274818831.26.462.47.742.246.93.2CPR experienceWitnessing CA5048.6CPR teachingHearing about CACPR trainingHearing about AED Closest AED knowledge408621074077204869.636.270.135.3
Isoflurane sedation in patients undergoing VA-ECMO treatment for cardiogenic shock
Authors: Scherer C , Kupka D , Luesebrink E , Massberg S , Orban M
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Objectives (Background): The feasibility and hemodynamic effects of isoflurane sedation in cardiogenic shock in the presence of extracorporeal membrane oxygenation (VA-ECMO) treatment is currently unknown.

Design

Retrospective single-center study

Patients/subjects: Cardiogenic shock patients with VA-ECMO treatment under sedation with volatile isoflurane between November 2018 and October 2019 have been enrolled in this study and were matched by propensity score in a 1:1 ratio with intravenously (IV) sedated patients treated between January 2013 and November 2018 from the cardiogenic shock registry of our university hospital.

Measurements and Main Results: Isoflurane sedation was used in 32 patients with cardiogenic shock and VA-ECMO treatment. The mean age of conventionally sedated patients was 58.4 ± 13.8 years and 56.3 ± 11.5 years for patients with isoflurane sedation (p = 0.51). Administration of isoflurane was associated with lower IV sedative drug use during VA-ECMO treatment (86% vs. 32%, p = 0.01). Mean systolic arterial pressure was similar (94.3 ± 12.6 mmHg versus 92.9 ± 10.5 mmHg, p = 0.65), but mean heart rate was significantly higher in the conventional sedation group, when compared to the isoflurane group (85.2 ± 20.5 /min vs. 74.7 ± 15.0 /min; p = 0.02). Catecholamine doses, VA-ECMO blood and gas flow, ventilation time (304 ± 143 h vs. 398 ± 272 h,p = 0.16), bleeding complications BARC3a or higher (59.3% vs. 65.3%, p = 0.76) and 30 day-mortality (59.2% vs. 63.4%, p = 0.80) were similar in both groups. The overall sedation costs per patient were significantly lower in the conventional group, when compared to the isoflurane group (537 ± 624 € vs. 1280 ± 837 €, p < 0.001).

Conclusions

Volatile sedation with isoflurane is feasible – albeit at higher costs - in patients with cardiogenic shock and VA-ECMO treatment and was not associated with higher catecholamine dosage or ECMO flow rate compared to IV sedation.
Soluble neprilysin and survival in critically ill patients
Authors: Lenz M , Krychtiuk KA , Brekalo M , Hengstenberg C , Huber K , Heinz G , Wojta J , Speidl WS
Published: April 2021

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): -) Association for the Promotion of Research on Arteriosclerosis, Thrombosis and Vascular Biology (ATVB) -) Ludwig Boltzmann Cluster for Cardiovascular Research

BACKGROUND

Critically ill patients admitted to an intensive care unit (ICU) exhibit a high mortality rate irrespective of the initial cause of hospitalization. Neprilysin is a neutral endopeptidase degrading an array of vasoactive peptides, including bradykinin, adrenomedullin and natriuretic peptides and became a drug target within the treatment of heart failure with reduced ejection fraction. The aim of this study was to analyze whether circulating levels of neprilysin at ICU admission are associated with 30-day mortality, due to its physiologic effects.

METHODS

In this single-center prospective observational study, 222 consecutive patients admitted to a tertiary ICU at a university hospital were included. Blood was drawn at admission and soluble neprilysin levels were measured using ELISA.

RESULTS

Median simplified acute physiology score was 44 and 30-day mortality was 35.1% in medical patients (n = 151) and 7.1% in patients after surgery and heart valve interventions (n = 71). Neprilysin levels did not differ according to survival status after 30 days and admission type. When assessing neprilysin and survival according to admission type, no association was found in medical patients, while in patients after surgery or heart valve intervention, 30-day survivors exhibited significantly lower neprilysin levels as compared to those that died within 30 days (660.2, IQR: 156.4 – 2512.5 pg/ml versus 6532.6, IQR: 1840.1 – 10000.0 pg/ml; p = 0.02). Neprilysin predicted mortality independently from age, gender, NT-proBNP, and SAPS II score (OR per 1-SD increase of neprilysin: 2.52, 95%CI 1.01–6.32; p = 0.049). Additionally, neprilysin was markedly elevated in patients with sepsis and septic shock (p < 0.05).

CONCLUSION

At the time of ICU-admission, circulating levels of neprilysin independently predicted 30-day mortality in patients following cardiac surgery or heart valve intervention, but not in critically ill medical patients.
Characteristics and outcomes in acute patients receiving mechanical ventilation in a Coronary Care Unit (CCU)
Authors: Rivadeneira Ruiz M , Arroyo Monino DF , Seoane Garcia T , Ruiz Garcia MP , Garcia Rubira JC
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Objectives

Mechanical ventilation is the short-term technical support most widely used and cardiac arrest its main indication in a Coronary Care Unit (CCU). However, the knowledge about the specific moment and ventilator mode of onset to avoid the acute lung injury is still equivocal. Our objective is to determine the survival rate and the prognostic factors in patients supported by mechanical ventilation.

Methods

We conducted a retrospective cohort study of adult patients admitted to the CCU between January 2018 and November 2020 that received mechanical ventilation during the hospital stay.

Results

We collected 94 patients, 28% females with a median age of 68 ± 11,9. 43% were diabetics and almost one quarter of them had some degree of chronic obstructive pulmonary disease (COPD). Ischemic cardiopathy (33%) and heart failure (31%) were frequent pathologies as well as renal injury (29% patients a filtration rate below 45 mL/min/1,73m2). The reason for initiating mechanical ventilation was cardiac arrest in the half of the patients. Volume-controlled ventilation (73%) was the initial setting mode in most cases. The support with vasoactive drugs were highly necessary in these patients (Infection rate of 48%). In the subgroup analysis, we realized that the number of reintubations and the necessity of non-invasive ventilation were higher in the COPD group (p = 0,01), as well as tracheostomy (p = 0,03). COPD patients also needed higher maintaining PEEP, though this was not statistically significant. The mean length of stay in the intensive care unit of our cohort was 11 days (range: 1-78 days; median: 8 days) and the mean length of mechanical ventilation 6 days (range: 1-64 days; median: 3 days). The in-hospital mortality was 41,4%.

Conclusions

Cardiac arrest is the most common reason of mechanical ventilation support. Our study showed that COPD patients presented more complications during the weaning and the period after extubation. In-hospital mortality remains high in intubated patients.
Impella RP versus pharmacologic vasoactive treatment in profound cardiogenic shock due to right ventricular failure: Unloading and end-organ perfusion in a large animal model
Authors: Josiassen J , Helgestad OKL , Udesen NLJ , Banke A , Frederiksen PH , Schmidt H , Jensen LO , Hassager C , Moeller JE , Ravn HB
Published: April 2021

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation Unrestricted research grant from Abiomed

Background

No strong evidence exists regarding the treatment of cardiogenic shock (CS) caused by acute right ventricular (RV) failure which has mainly consisted of vasoactive drugs. There is expert agreement that treatment with the recently developed Impella RP is feasible, but no previous studies have compared vasoactive treatment strategies with the Impella RP in terms of cardiac unloading and end-organ perfusion.

Hypothesis

Treatment with the Impella RP device will be associated with lower RV myocardial workload (pressure-volume area) compared to vasoactive treatment strategies and can furthermore be achieved without compromising organ perfusion.

Methods

CS was induced by a stepwise injection of polyvinyl alcohol microspheres into the right coronary artery in twenty adult female Danish landrace pigs weighing 75-80 kg.

After induction of CS, the pigs were allocated to one of the two interventions for 180 minutes: 1) vasoactive therapy comprised a continuous infusion of norepinephrine (0.1 µg/kg/min) for the first 30 minutes, supplemented by an infusion of milrinone (0.4 µg/kg/min) for the remaining 150 minutes or 2) immediate insertion of and treatment with the Impella RP. 

The results are presented as median [Q1;Q3].

Results

Treatment with the Impella RP was associated with a lower RV workload compared to the vasoactive group, while no difference was observed with regards to left ventricular workload among intervention groups, Figure 1. Renal venous oxygen saturation increased to a similar degree following both interventions compared to the state of CS. A trend towards a higher cerebral venous oxygen saturation was observed with norepinephrine compared to Impella RP (Impella RP 51 [47;61] % vs Norepinephrine 62 [57;71] % ; p = 0.07), which became significantly higher with the addition of milrinone (Impella RP 45 [32;63] % vs Norepinephrine +Milrinone 73 [66;81] %; p = 0.002).

Conclusion

In this large animal model of profound CS caused by predominantly RV failure the Impella RP unloaded the failing RV. The vasoactive treatment, however, caused a higher cerebral venous oxygen saturation, while both interventions increased renal venous oxygen saturation to a similar degree. Abstract Figure 1
High venous to arterial CO2 gap is related to cardiovascular death in cardiogenic shock
Authors: Lopez-Sobrino T , Gazquez Toscano A , Soler Selva M , Romeu Mirabete N , Parellada Vendrell M , Casado Pena M , Ruiz Falques C , Guzman Bofarull J , Forado Benatar I , Calvo Lopez M , Izquierdo Montilla L , Lopez Domenech G , Vleasco Ortiz I , Ortiz Perez JT , Andrea Riba R
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Venous to arterial CO2 gap (CO2gap) is calculated by subtracting partial pressure of arterial CO2 to central venous partial pressure of CO2 (ScvCO2). This marker has been studied in septic shock and indicates hypoperfusion when exceeds 6mmHg. Its kinetics and applicability in cardiogenic shock (CS) are unclear, being mixed/central venous saturation and lactate more commonly used.

Purpose

The objective of the study is to describe CO2gap kinetics in patients with CS. Secondary objective is to analyze if CO2gap is as marker of prognosis in CS.

Methods

Prospective observational study that included patients admitted for CS in the Acute Cardiovascular Care Unit of a tertiary hospital. Gasometric samples were obtained at admission, 6, 12, 24 and 48 hours from the onset of shock. In-hospital mortality was registered.

Results

We included 40 patients with CS during 1 year. Most patients were male (80%), average age was 68 years. There was a high incidence of cardiac arrest (58%), most frequent cause of CS was STEMI (45%), in-hospital mortality was 45%, most cases from non-cardiovascular causes (61%). Refractory shock was frequent (28%). Average lactate peak was 6.02 mmol / L. CO2gap kinetics consisted in a peak at admission (8.8mmHg), a valley 6h (7.7mmHg), new peak at 12h (8.5mmHg) and progressive decrease at at 24 (6.8mmHg) and 48h (5.7 mmHg). Significantly, higher CO2gap values at admission (10.97mmHg vs 8.16mmHg, p = 0.007) was predictor of cardiovascular mortality. Lactate values at 6, 12 and 48 hours were also predictors of cardiovascular mortality, as well as ScvO2 at admission.

Conclusions

Patients with CS present with high CO2gap values during first hours of admission. The kinetics of this marker consists in two peaks at admission and 12 hours from CS onset, a valley at 6 hours and a progressive decrease at 24 and 48 hours. Its determination at admission is associated with cardiovascular mortality. We suggest the potential benefit of combining this marker, along with lactate and ScvO2 values, to guide management of patients with CS. Abstract Figure. CO2 gap and cardiovascular mortality
Validation of quantitative pupillometry, for neuroprognostication in patients resuscitated from cardiac arrest
Authors: Nyholm B , Obling L , Hassager C , Grand J , Moeller JE , Othman MH , Kondziella D , Kjaergaard J
Published: April 2021

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): NovoNordisk Foundation grant

Background/Introduction

Quantitative pupillometry is being recommended as part of a multimodal approach to the bedside armamentarium, for obtaining prognostic information in post-cardiac arrest management. However, recent guidelines are still based on limited evidence, and lack of knowledge about the variability of pupillary measurements may impair clinical usefulness.

Purpose

To assess precision and accuracy of quantitative pupillometry to validate its clinical use in neuroprognostication.

Methods

We conducted a prospective blinded validation study, based on repeated patient assessments in a cardiac intensive care unit. Each assessment was made by two trained staff nurses and consisted of one manual and one quantitative pupillometry each, performed on the same patient within 2 minutes. Data from each measurement was stored in the pupillometers head guard, blinded to the other observer.

To investigate inter-observer variation (precision), the repeated measures of pupillary size (both quantitative and manual individually) were compared, and for accuracy by comparing quantitative with manual assessment. Further we assessed the variation in neurological pupil index (NPi), a scalar value (between 0 and 5) calculated from an algorithm comprising several measured pupillary variables.

Bland–Altman analysis was performed with mean difference between the two methods of measurement and 95% limits of agreement (LoA), and intraclass correlation coefficient (ICC) assessed for absolute agreement between the methods.

Results

A total of 56 measurements (left and right eye) were included in this study. Fifty-seven percent were male, with a mean age of 65 years (SD 14). Out of hospital cardiac arrest constituted 57 %, and 65 % of the measurements were made, while patients were sedated. The 30-day mortality of this population was 50 %.

Bland-Altman analysis showed mean inter-observer differences equal to -0.14 mm (LoA: 0.71, -1.00) for pupillary size measured by manual pupillometry, and 0.03 mm (LoA: 0.36, -0.31) for pupillary size measured by quantitative pupillometry. Mean pupillary size by automated pupillometry and manual assessment, was 2.28 mm (SD 0.84) and 2.22 mm (SD 0.84) respectively, with significant correlation between manual and quantitative pupillometry (R = 0.84, p < 0.001; ICC 0.83).  Mean inter-observer differences for NPi measured by quantitative pupillometry was -0.02 (LoA: 0.40, -0.43).

Conclusion(s)

Quantitative pupillometry has twice the precision in assessment of pupillary size compared with manual assessment. Both pupillary size and NPI may, however, still have a challenging reproducibility. Abstract Figure.
Are high NT-proBNP levels more related to inflammation than to left ventricular systolic dysfunction in acute myocarditis?
Authors: Sara B , Monteiro JJ , Carvalho P , Ribeiro Carvalho C , Chemba J , Ferreira C , Moreira JI
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Plasma levels and N-terminal pro B-type natriuretic peptide (NT- proBNP), a cardiac neurohormone released in response to increased ventricular stress, represent an important predictor of clinical outcomes and left ventricular (LV) dysfunction; Although, its diagnostic and prognostic role in patients with acute myocarditis is not completely established; Our aim was to evaluate the relationship of BNP levels and LV ejection fraction (LVEF) in patients with myocarditis;

Methods

Data from patients (pts) discharged with the diagnosis of myocarditis, from 2008 and 2018 were retrospectively analysed.

Results

62 pts were included. Mean age was 39.7 17 years and 89% (58 patients) were men. Plasma levels of NT-proBNP measured at admission ranged from 24 to 3110 pg/mL (median 514, IQR 947), and exceeded upper normal levels in 51 pts (82%). This values positively correlated with C- reactive protein (CRP) (p= 0.005, r = 0.36), leucocytes (p = 0.03, r= 0.37) and neutrophil-to-lymphocyte ratio (p= 0.05, r= 0.35), but not with left ventricular ejection fraction (LVEF) (p= 0.829). Higher levels of BNP were associated with higher troponin peak levels but not with increased mortality (p = 0.811), need of inotropic support (p= 0.059) or arrhythmic events (p= 0.130). Inflammatory parameters were significantly increased when BNP> 514 pg/mL vs BNP <514 pg/mL (CRP 7.2 vs 4 mg/dL, p= 0.008). This relationship was maintained at BNP > 900. LVEF was comparable in both groups (p = 0.938); In this population, the magnitude of recovery of the NT- proBNP values (variation between NT-proBNP at admission and discharge) strongly correlated with the magnitude of the inflammatory markers at admission (all p < 0,005)

Conclusion

In patients with acute myocarditis, there is a significant relationship between NT-proBNP levels and inflammation (as measured by leucocytes, NLR or CRP), but not with LVEF; Despite the limitation of a small sample size, we could hypothesize that NTproBNP in this subset of patients appears to be regulated not only by hemodynamic changes but also by the underlying systemic inflammatory process and, therefore, it interpretation should take that into account;
Steroids for the prevention of postpericardiotomy syndrome: a meta-analysis
Authors: Saleiro C , Teixeira R , Lopes J , Decampos D , Sousa JP , Puga L , Gomes ARM , Costa M , Goncalves L
Published: April 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Postpericardiotomy syndrome (PPS) can occur in up to 40% of patients after cardiac surgery. Corticosteroid therapy has long been used for pericarditis and pericardial effusion due to its anti-inflammatory proprieties. The benefit of corticosteroids for the prevention of post pericardiotomy syndrome (PPS) in not consensual.

Purpose

We performed a systematic review and meta-analysis of trials assessing the efficacy of corticosteroids to prevent PPS in patients submitted to cardiac surgery.

Methods

We searched MEDLINE, Google Scholar and the Cochrane Library databases using the key terms "corticosteroids" and "post pericardiotomy syndrome" without language or date restriction. Articles were considered for inclusion in the analysis if they comprised a population of patients submitted to cardiac surgery and a comparison between patients treated with corticosteroids for the prevention of PPS and those who were not. Three studies were identified, comprehending a total of 1268 patients. The primary endpoint was the occurrence of PPS. Pooled odds ratios (OR) and 95% confidence intervals (CI) were estimated based on a random effects meta-analysis and were obtained from the pooled adjusted OR of primary studies.

Results

Studies included in the analysis comprehend a controlled randomized trial in children (1 mg/kg methylprednisolone pre-operative and four additional doses over 24h vs placebo); a controlled randomized trial in adults (1 mg/kg dexamethasone intra-operative vs placebo) and a retrospective study in adults (1 mg/kg intra-operative methylprednisolone vs standard care). Of the total 1268 patients included, 641 received glucocorticoids for the prevention of PPS. Main reason for surgery was correction of a congenital heart defect in 19% of the patients; coronary artery bypass graft in 15% and valvular disease in 66% of the cases. 217 patients had PPS during the follow-up time; 15% in the corticosteroid prophylaxis group and 18% in the placebo/standard care group. Overall, corticosteroid prophylaxis was not useful for the prevention of PPS compared to placebo/standard care (pooled OR: 0.78, 95% CI: 0.51–1.20, I2 = 46%) – Figure 1. 

Conclusion

According to our data, steroid therapy has no role as a preventive therapy of post-pericardiectomy syndrome. Abstract Figure 1 - Pooled analysis
Levosimendan, milrinone and dobutamine in acute experimental pulmonary embolism
Authors: Lyhne MD , Dragsbaek SJ , Hansen JV , Schultz JG , Andersen A , Nielsen-Kudsk JE
Published: April 2021

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Laerdal Foundation for Acute Medicine, Novo Nordisk Foundation

Background/Introduction: Acute pulmonary embolism (PE) is a frequent condition in acute cardiac care and is potentially fatal. Cause of death is right ventricular (RV) failure due to increased RV afterload from both pulmonary vascular obstruction and vasoconstriction. Inodilators are interesting drugs of choice as they may improve RV function and lower its afterload.

Purpose

We aimed to investigate the cardiovascular effects of three clinically relevant inodilators: levosimendan, milrinone and dobutamine in acute PE.

Methods

We conducted a randomized, blinded, animal study using 18 female pigs. Animals received large autologous PE until doubling of baseline mean pulmonary arterial pressure and were randomized to four logarithmically increasing doses of each inodilator. Effects were evaluated with bi-ventricular pressure-volume loop recordings, right heart catheterization and blood gas analyses.

Results

Induction of PE increased RV afterload and pulmonary pressure (p < 0.05) causing RV dysfunction. Levosimendan and milrinone showed beneficial hemodynamic profiles by lowering RV pressures and volume (p < 0.001) and improved RV function and cardiac output (p < 0.05) without increasing RV mechanical work. Dobutamine increased RV pressure and function (p < 0.01) but at a cost of increased mechanical work at the highest doses, showing an adverse hemodynamic profile. See Figure.

Conclusion(s): In a porcine model of acute PE, levosimendan and milrinone reduced RV afterload and improved RV function, whereas dobutamine at higher doses increased RV afterload and RV mechanical work. The study motivates clinical testing of inodilators in patients with acute PE and RV dysfunction. Abstract Figure. Inodilators in acute pulmonary embolism