bluuebunny/crossref_metadata_2025 huggingface dataset:
Association of risk factors on mortality in ST-elevation myocardial infarction patients with diabetes mellitus: a systematic review and meta-analysis of cohort studies
Authors: Ipek R , Szczerba E , Polzin A , Roden M , Kelm M , Schlesinger S , Cramer M
Published: October 2024

Introduction

Despite advancements in medical therapy and revascularization strategies for ST-elevation myocardial infarction (STEMI), diabetes mellitus (DM) remains independently associated with enhanced morbidity and mortality in STEMI. The causes for this are still unknown. Therefore, we aimed to summarise and quantify existing evidence in a systematic review and meta-analysis on the association between risk factors and mortality in STEMI patients with DM from prospective and retrospective cohort studies.

Methods

The systematic literature search was performed on the database of PubMed, Scopus and the Cochrane library up to July 2022. Relevant data were extracted and the risk of bias (RoB) of each study was assessed by using the Quality In Prognosis Studies (QUIPS) tool. All steps were conducted by two researchers independently. Summarised relative risks (SRR) and 95% confidence interval (CI) were estimated using a random effects model. I² was calculated as a measure of inconsistency.

Results

Out of 7601 studies, 18 were included after full-text screening, meeting our inclusion criteria. The RoB was moderate for 6 and high for 12 studies. Results of 7 studies reported on in-hospital mortality, 7 on all-cause-mortality up to 72 months, 3 on both outcomes, and 1 on cardiac death followed-up for 3.5 years. We found an increased risk of mortality for female compared to male sex (SRR [95% CI]: 1.56 [1.20; 2.01], n = 3 studies), age per 5 year increase (SRR [95% CI]: 1.26 [1.23; 1.30], n = 10 studies), admission blood glucose ≥ 7,8 mmol/l (SRR [95% CI]: 2.54 [1.60; 4.04], n = 3 studies), insulin treatment (SRR [95% CI]: 1.72 [1.33; 2.21], n = 2 studies), and dedicated Killip classification III-IV (SRR [95% CI]: 2.97 [2.58; 3.41], n = 3 studies) in STEMI patients with DM. Similar findings were observed for pre-existing comorbidities: prior myocardial infarction (SRR [95% CI]: 1.25 [1.06; 1.47], n = 3 studies), and heart failure (SRR [95% CI]: 2.68 [1.83; 3.93], n = 2 studies). Current smoking (SRR [95% CI]: 0.68 [0.52; 0.88], n = 3 studies) and hypercholesterinemia (SRR [95% CI]: 0.67 [0.57; 0.79], n = 2 studies) showed a reduced risk for mortality, while no association was found for multivessel disease (SRR [95% CI]: 1.03 [0.55; 1.92], n = 3 studies).

Conclusion

We identified specific risk factors of diabetes for mortality after STEMI. Our results confirm higher risk of mortality among STEMI patients with DM, particularly in women, older individuals, those with high admission blood glucose or insulin-dependent diabetes, and cardiac comorbidities. The role of smoking and hypercholesterinemia as a predictor for mortality might be explained by reverse causality and warrants further investigation.
Predicting ECGs masquerading AS STEMI with machine learning
Authors: Tran T H , Fathieh S , Faour A , Long M , Tams G , Al Jazaery A , Gibbs O J , Assad J , Faddy S C , Lo S T H , Juergens C P , French J K
Published: October 2024

Background

Advancements in the management of ST elevation myocardial infarction (STEMI) in the last 15 years include early STEMI identification in the prehospital setting leading to expedited cardiac catheterisation laboratory (CCL) activation or fibrinolytic therapy. We have previously reported of patients who met the Glasgow algorithm (GA) ECG criteria for STEMI; 50% did not actually have an acute STEMI according to the 4th universal definition of MI (4UDMI)1. Identifying such patients could avoid unnecessary emergency CCL activations or inappropriate fibrinolytic administration.

Methods

From June 2010 to October 2021, we identified 2992 patients with ECG transmissions to Liverpool Hospital, Sydney Australia which met GA criteria for STEMI. These were adjudicated according to the 4UDMI for true-positive STEMI. We used univariate and multivariate logistic regression to identify likely patient characteristics that were predictive of true-positive STEMI. We then improved model performance using receiver-operator curve (ROC) with simple random forest machine learning algorithms. Results Among 2994 patients with prehospital ECG transmissions that met GA-criteria, 1553 (51%) were adjudicated as true-positive STEMI, which is comparable to previous findings1. All standard modifiable and non-modifiable risk factors were independently predictive of true-positive STEMI; however, in multivariate logistic regression gender, hypertension and diabetes lost significance. Dyslipidemia and current smoking were positively predictive of true-positive STEMI status (OR = 1.64 and 1.32 respectively), whereas age and previous MI were negatively associated (OR = 0.98 (per year increment) and 0.4). Using these identified predictors in a random forest to predict true-positive STEMI yielded an AUC of 0.65 (Figure 1).

Conclusion

Specific clarification of dyslipidaemia and current smoking status at first medical contact may be the most salient in predicting a true-positive STEMI during prehospital assessment which may assist in avoiding unnecessary emergency CCL activation or inappropriate fibrinolytic administration.ROC of ST elevation STEMI recognition
Satisfactory self-rated health is associated with better clinical outcomes in patients with ST-segment elevation myocardial infarction
Authors: Cao S , Liu J Y , Hu S T , Zhang Y K , Gu T S , Jiang C , Zhang J K , Wu X , Liu X , Liu T , Chen K Y
Published: October 2024

Background

It is well known that health status is a risk factor for cardiovascular diseases, but its specific impact on the prognosis of patients with acute myocardial infarction remains unclear.

Purpose

This study was aimed to investigate the impact of varying health self-evaluation on the long-term outcomes of patients diagnosed with ST-elevation myocardial infarction (STEMI).

Methods

Data for this study were obtained from a retrospective cohort of patients admitted to and discharged from 72 secondary and tertiary hospital from 2010 to 2023. Patients were divided into satisfied group and dissatisfied group based on their responses to a self-assessment health questionnaire. Baseline data of the two groups were compared, and the relationship between health status and major cardiovascular and cerebrovascular adverse events (MACCE) was analyzed using multivariate cox regression. MACCE, defined as the composite endpoint of cardiac death, recurrent myocardial infarction, stroke and revascularization, was the primary endpoint, with each component considered a secondary endpoint.

Results

Among STEMI patients, 25214 patients reported satisfaction with their health, while 375 patients expressed dissatisfaction. The satisfied group exhibited a younger age, fewer females, a higher rate of primary percutaneous coronary intervention (PPCI) and PCI during hospitalization, a better Killips classification and a lower prevalence of concomitant disease such as diabetes, hypertension, chronic kidney disease, and cerebrovascular disease. After a median follow-up of 1626 days, the satisfied group demonstrated significantly lower proportions of total death, cardiac death, recurrent myocardial infarction and stroke compared to dissatisfied group. Multivariate COX regression showed that satisfactory health self-rating was associated with a decreased risk of MACCE (HR 0.813, 95%CI 0.704-0.939, P=0.005), stroke (HR 0.670, 95%CI 0.511-0.878, P=0.003), and recurrent myocardial infarction (HR 0.732, 95%CI 0.548-0.979, P=0.035).

Conclusions

Satisfactory self-rated health is associated with better clinical outcomes in STEMI patients.
Trends in major cardiac events after ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention from 2003 to 2017: the western Denmark heart registry
Authors: Thrane P , Olesen K K W , Thim T , Gyldenkerne C , Hansen M K , Stoedkilde-Joergensen N , Kristensen S D , Maeng M
Published: October 2024

Background

In Denmark, primary percutaneous coronary intervention (PCI) has been the national reperfusion strategy since 2003. We recently reported a gradual decline in 1-year mortality in patients treated with pPCI-treated STEMI from 2003 to 2017. To elucidate potential causes of this observation, we examined temporal trends in the 1-year risk of major adverse cardiovascular events (MACE).

Purpose

To examine trends in 1-year risks of MACE following STEMI treated with pPCI from 2003 to 2017.

Methods

Using the Western Denmark Heart Registry, we identified STEMI patients undergoing first-time pPCI from 2003 to 2017 and divided the patients into four time periods. The main outcome was 1-year risk of MACE, defined as recurrent myocardial infarction, ischaemic stroke, or cardiovascular death. Cause-specific adjusted hazard ratios (HR) were used to assess temporal trends using the first period (2003-2006) as reference. Further, temporal trends were compared to an age-, sex-, and calendar-year matched general population.

Results

From 2003 to 2017, 18,540 pPCI-treated STEMI patients were identified (median [Q1-Q3] age, 64 [55-74] years); 13,639 men [74%]). Trends in 1-year risk of MACE showed a gradual reduction over time from 13.0% in 2003-2006, 11.8% in 2007-2010, 9.7% in 2011-2014, to 8.7% in 2015-2017 (Figure). The adjusted relative risk reduction was 33% when comparing 2015-2017 with 2003-2006 (adjusted HR 0.67, 95% CI 0.58-0.76). Comparable relative risk reductions were observed for all three individual components of MACE of 33-35%. Compared to the matched general population, the 1-year risk difference in MACE decreased from 11% in 2003-2006 to 7% in 2015-2017.

Conclusions

In a high-income European country with a fully implemented pPCI strategy, 1-year risk of MACE declined by approximately one-third after first-time STEMI between 2003 to 2017. This MACE reduction was substantially larger than observed in the matched general population, i.e., confirming an important reduction in the excess risk associated with STEMI.
Comparison of clinical symptoms and prognosis of non-post-menopausal women to age matched men admitted with ST-elevation myocardial infarctions
Authors: Schmucker J , Fach A , Osteresch R , Ruehle S , Hambrecht R , Wienbergen H
Published: October 2024

Background

Although ST-elevation-myocardial infarctions (STEMI) in women before menopause are relatively uncommon, previous studies have shown that women in general are more likely to present with atypical symptoms and to show higher adverse event rates, which might at least be attributable to the on average higher age of women during the index event. Aim of the present study was therefore to compare in an age-matched cohort of STEMI-patients younger 55 years the likelihood of atypical symptoms between genders and to investigate the impact of female gender on short and long-term-outcome.

Methods

Patients <55 years of age with STEMI admitted between 2006 and 2022 to a German heart center were included in the analysis and women were compared to men with regard to clinical symptoms and outcome. To exclude local bias women of all ages with STEMI from the registry were compared to men in a control group.

Results

Of 12094 STEMI-patients in the total cohort 3343 (28%) were women and 8751 (72%) were men. Women had a mean age of 69.7±13 yrs. compared to 62.2±12 in men. Women with STEMI had a 40% higher chance to present without typical chest pain (no CP, 12.0% vs. 8.5%, p<0.01) and were more likely to present with dyspnea (26.1% vs. 22.7% p<0.01). While rates of late STEMI-presenters were numerically higher in women, this difference failed to reach significance (12.8% vs. 11.9%, p=0.16). When focusing however on the study group (<55 yrs. of age) there was no more age difference (women 47.2±6 yrs. vs. 47.5±6 yrs. in men, p<0.3) and rates of no CP were not different between genders: 5.7%(women) vs. 5.4% (men), p=0.79, nor were rates of dyspnea : 20.0% (women) vs. 18.5% (men), p=0.45. There was even a trend towards lower rates of late STEMI-presenters in women: 8.3% vs. 10.9% in men, p=0.077, although diabetes-rates were higher in women (16.9% vs. 11.8%, p<0.01). Despite similar initial symptom presentations, women showed a marked 60% increase in 30-day- (6.9% vs. 4.3%, p=0.017) and 1-year-mortality (8.7% vs. 5.3%, p<0.01). The disadvantage for women remained, when adjusting mortality rates for confounders (age, diabetes, anterior STEMI, multivessel disease, PCI result) in a Cox regression model (table, upper part). This could be confirmed in a subgroup multivariate analysis excluding patients with no CP or not undergoing emergency PCI (table, lower part).

Conclusions

In STEMI-patients younger 55 years women showed a more than 60% higher short- and long-term-mortality compared to their male peers. This disadvantage, at least with our data, cannot be sufficiently explained by higher rates of delayed STEMI-presentations or absence of typical chest pain. Further studies are needed to identify possible causes for this higher vulnerability of young women to acute myocardial infarctions.Table:Mortality in Women vs. men<55 yrs
Prognostic value of multiparametric cardiac magnetic resonance after revascularized STEMI
Authors: Igual Munoz B , Ferre Valverdu M F V , Miro Palau V M P , Berenguer Jofesa A B J , Plaza Lopez D P L , Melero Ferrer J M F , Vicente Montagud V M B , Domenech Tort D D T , Facila Rubio L F R , Ridocci Soriano F R S , Paya Serrano R P S
Published: October 2024

Despite early revascularization of STEMI through angioplasty, the prognosis following STEMI remains poor for a non-negligible percentage of patients (1). In this setting, multiple imaging parameters have demonstrated their prognostic value. The aim of the present study is to evaluate which of these parameters are the most potent predictors of events following revascularized STEMI.

Methods

A prospective observational study was conducted, including a cohort of revascularized STEMI patients and who underwent cardiac MRI during the first week. The protocol included cardiac functional analysis and with b-SSFP sequences for evaluation of volumes, mass, ejection fraction and also circumferential and radial strain with feature tracking. STIR sequences were used to assess edema and salvaged myocardium, IR-FGE sequences were employed for evaluation of necrosis size and microvascular obstruction. Intra-infarct hemorrhage assessment was performed using T2* mapping sequences as previosly described (2,3,4) . A semi-automatic analysis was conducted, considering as microvascular obstruction segments with hypointensity in the infarct core and as segments with hemorrhage those with a T2* less than 20 ms. The association of imaging parameters with cardiovascular events in the first year following STEMI was studied using ROC curves. Variables with significant association were analyzed using a multivariate logistic regression model.

Results

Ninety-four patients with a mean age of 63 (SD 13) years were included. Nine of them had cardiovascular events in the first year and two of them died. The relative extent of necrosis and microvascular obstruction, minimal radial strain, left ventricular ejection fraction (LVEF) and indexed left ventricular end- systolic volume (ILVESV) showed significant association with cardiovascular events after STEMI. Variables with significant association were entered into a multivariate predictive model, revealing that the extent of microvascular obstruction (OR: 1.9, p=0.02) and the left ventricular end-systolic volume (OR: 1.04, p<0.01) are the only independent predictors of cardiovascular events following STEMI.

Conclusion

Although multiple imaging parameters have shown prognostic value after STEMI, the ILVESV and the extent of microvascular obstruction are the only independent predictors of events following STEMI.Multiparametric cardiac MR in STEMIAREA UNDER ROC CURVE OF CMR PARAMETERS
Early coronary revascularization among stable patients with non-ST-segment elevation acute coronary syndromes: the role of diabetes and age
Authors: Cenko E , Fabin N , Bergami M , Yoon J , Vadala G , Kedev S , Kostov J , Vavlukis M , Vraynko E , Milicic D , Vasiljevic Z , Zdravkovic M , Galassi A R , Manfrini O , Bugiardini R
Published: October 2024

Background

Diabetes mellitus affects 10-30% patients hospitalized with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and two-fold higher mortality risk compared to non-diabetics. Despite higher post-PCI complications in diabetic patients, guidelines advise early invasive NSTE-ACS treatment for all, based expert opinion, and limited evidence.

Purpose

To investigate the impact of an early coronary revascularization (<24 hours) compared with initial conservative strategy on clinical outcomes in diabetic patients with NSTE-ACS who are in stable condition at hospital admission.

Methods

The ISACS-TC database was queried for a sample of diabetic and nondiabetic patients with diagnosis of NSTE-ACS. Patients with cardiac arrest, hemodynamic instability, and serious ventricular arrhythmias were excluded. The characteristics between groups were adjusted using logistic regression and inverse probability of treatment weighting models. Primary outcome measure was all cause 30-day mortality. Risk ratios (RRs) and odds ratios (ORs) with their 95% CIs were employed.

Results

Of the 7,589 NSTE-ACS patients identified, 2,343 were diabetics. The data show a notable reduction in mortality for the elderly undergoing early revascularization compared to those receiving an initial conservative strategy both in the diabetic (3.3% versus 6.7%; RR: 0.48; 95% CI: 0.28-0.80) and nondiabetic patients (2.7% versus 4.7%: RR: 0.57; 95% CI: 0.36-0.90). In multivariate analyses, diabetes was a strong independent predictor of mortality in the elderly (OR: 1.43; 95% CI: 1.03-1.99), but not in the younger patients OR: 1.04; 95% CI: 0.53-2.06).

Conclusions

Early coronary revascularization does not lead to any survival advantage within 30 days from admission in young NSTE-ACS patients who present to hospital in stable conditions with and without diabetes. An early invasive management strategy may be best reserved for the elderly. Factors beyond revascularization are of considerable importance for outcome in elderly diabetic subjects with NSTE-ACS.
Baseline heart rate as a key prognostic indicator in AMI patients with cardiogenic shock undergoing successful primary PCI
Authors: Abe T , Kamishima K , Shimazaki K , Shibahashi E , Yamada T , Kobayashi H , Oka T , Tanaka H , Yamaguchi J , Jujo K
Published: October 2024

Background

Cardiogenic shock presents as a critical condition in patients experiencing acute myocardial infarction (AMI). Even that primary percutaneous coronary intervention (PCI) has become widespread, the mortality rate of AMI complicated with cardiogenic shock remains high. However, comprehensive prognostic stratification remains elusive.

Objective

Our study sought to elucidate the relationship between baseline parameters and prognostic outcomes in AMI patients with cardiogenic shock.

Methods

From the GETBACK-AMI multicenter retrospective registry encompassing 935 AMI patients who underwent primary PCI and attained TIMI 3 flow upon final angiography. There were 73 patients diagnosed with cardiogenic shock were ultimately analyzed. The primary endpoint of our study was all-cause mortality.

Results

Over a median follow-up duration of 425 days, 17 patients (23%) succumbed, of which 14 were in-hospital fatalities. Employing the Cox regression model, we identified that heart rate (HR) at the time of admission bore a potent and independent correlation with the primary endpoint (hazard ratio: 1.04 [95% CI: 1.01-1.06], p=0.002), even post-adjustment for various covariates. ROC analysis pinpointed an admission HR of 82 bpm as the threshold for the primary endpoint. Kaplan-Meier curves further highlighted a pronounced elevation in the primary endpoint occurrence rate for patients with HR > 82 bpm compared to those with HR < 82 bpm (53% vs. 13%, p=0.0002).

Conclusions

Within our multicenter study cohort, a heightened admission HR was demonstrably linked to increased mortality in AMI patients with cardiogenic shock who reached a final TIMI 3 flow. This readily accessible and impactful prognostic marker may guide clinicians in identifying high-risk patients, subsequently allowing for enhanced support and interventions to optimize patient outcomes.
One-year prognosis difference of MINOCA versus MI-CAD in developing countries: insights from the Moroccan experience
Authors: Bouchlarhem A , Bazid Z , Ismaili N , El Ouafi N
Published: October 2024

Introduction

The debate remains open as to the difference in prevalence of mortality and occurrence of acute events in patients with Myocardial infarction with non-obstructive coronary arteries (MINOCA) and others with Myocardial infarction with coronary arteries disease (MI-CAD) (1).

Purpose

We carried out an analysis of the clinical characteristics and one-year prognosis of MINOCA versus MI-CAD.

Methods

We conducted a prospective study for patients admitted for Acute coronary syndrome (ACS) during 2-years, to analyze the clinical and prognostic characteristics of patients with MINOCA versus MI-CAD. We defined 1-year all-cause mortality as the primary outcome, and the secondary outcome as a composite of 1-year readmission for myocardial infarction or acute heart failure (AHF). The primary and secondary outcomes was studied using a Cox proportional hazards regression model to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), adjusting for variables described in the literature.

Results

Our study included 1077 patients, 95.3% with MI-CAD and 4.7% with MINOCA. At admission, 71.1% patient were diagnosed STEMI and 28.9% with NSTEMI. The difference between the two groups was found on age (p<0.001), hypertension, diabetes with consecutive p-values of 0.007 and 0.001, as well as Ejection fraction (p<0.001). For the outcomes studied, we found, firstly before adjustment, that patients in the MINOCA group had a better prognosis than the MI-CAD group, for all-cause 1-year mortality (HR=0. 442; 95%CI 0.227-0.760; p=0.041) with a significant difference in the Kaplein Meier survival analysis with a log-rank test (p-value =0.02) (Figure 1), and a lower risk of readmission for ACS (HR=0.297; 95%CI 0.316-0.821; p=0.034), as well as for readmission for AHF (HR=0.555; 95%CI 0.329-0.836; p=0.045) also with a significant difference between the two groups in the Kaplein Meier analysis with consecutive log-rank test p-values of 0.033 and 0.035 (Figure 2). After adjustment for age, arterial hypertension, diabetes, active smoking, EF<40%, proximal LAD or LM as culprit artery, TIMI 0-I flow, CRP >300mg and cardiogenic shock during hospitalization, the results remained significantly in favor of a better prognosis for MINOCA: (HR=0. 672; 95%CI 0.376-0.872; p=0.003) for 1-year all-cause mortality, (HR=0.301; 95%CI 0.482-0.879; p=0.012) for readmission for ACS and finally (HR=0.604; 95%CI 0.309-0.812; p=0.039) for readmission for AHF.

Conclusion

Despite the ambiguity in the genesis of MINOCA, the short- and long-term prognosis of these patients remains generally favorable.Figure 1.Figure 2.
Cardiac magnetic resonance in MINOCA patients: a non-tertiary hospital experience
Authors: Mata Caballero R , Izquierdo Coronel B , Fraile Sanz A , Aguilar Rivilla E , Olsen R , Nieto Ibanez D , Perela C , Martin Munoz M , Alvarez Bello M , Gil Mancebo N , Rodriguez Montes P , De La Serna Real De Asua M , Espinosa Pascual M J , Carnicero Carreno J A , Alonso Martin J J
Published: October 2024

Background

Cardiac magnetic resonance (CMR) is a key tool in the diagnostic process of myocardial infarction with non-obstructive coronary arteries (MINOCA), impacting patient management and prognosis. Its use in non-tertiary hospitals is often constrained mainly by accessibility. Thus, the aim of this study was thoroughly evaluate CMR application in this context to optimize the process.

Methods

136 MINOCA patients who were admitted to our hospital between 2016 and January 2024 were analyzed. Each MINOCA patient was reviewed by experts to align with the diagnosis criteria outlined in the 2020 ESC Guidelines and the American Heart Association position paper, which recommended CMR for MINOCA patient’s evaluation. To assess the factors associated with normal-CMR, a logistic regression analysis was performed. In a first step, some factors were detected, showing a trend in the association. In a second step, a backward elimination procedure was used, excluding factors with p>0.1.

Results

CMR was performed in 65 MINOCA patients (48% of the cohort), with a mean age of 59±15 years old, 35 of them were males (54% of total patients). During the follow-up, there were 4 deaths (6%) and 4 readmissions (6%). Out of the total 65 patients, the CMR diagnosis was myocardial infarction (MI) in 14 (21.5%) and myocarditis in 16 (24.6%), and was normal in 35 (53.9%). Therefore, CMR provided diagnostic information in 46% of the cases.

It was noted that a normal CMR was associated with female gender, (OR 2.7, 95% CI 0.96-7.34, p=0.057), hypertension (OR 2.25, 95% CI 0.81-6.22, p=0.11), absence of segmental abnormalities in echocardiography (OR 0.14, 95% CI 0.035-0566, p=0.06) and lower high-sensitivity Troponin T (OR 0.79, 95% CI: 0.66-0.95, p=0.001). In the second step, only segmental abnormalities (OR 0.2, 95%CI 0.04-1.09, p=0.063) and troponin (OR 0.31, 95%CI 0.10-0.99, p=0.048) remained included. Additionally, the Youden Index was determined to obtain the threshold for troponin, resulting a value of 606 nG/mL, area under ROC curve (AUC) = 0.784 (figure).

Conclusions

- CMR was performed in 48% of the MINOCA patients, reflecting the limitation for its use in routine clinical practice. Furthermore, it was useful in 46% of those patients.

- The main factors associated with normal CMR were absence of segmental echocardiography abnormalities and reduced troponin levels.

- A troponin cutoff point of 606 ng/mL identified patients with a normal CMR (AUC=0.784).Figure 1.CMR in MINOCA patientsFigure 2.Area under ROC curve = 0.784
Trends in Takotsubo syndrome
Authors: Schweiger V , Cammann V L , Wuerdinger M , Gilhofer T , Niederseer D , Luescher T F , Ruschitzka F , Bossone E , Ghadri J R , Templin C , Di Vece D
Published: October 2024

Background

Previously considered a rare and relatively benign cardiac condition, Takotsubo syndrome (TTS) has undergone a significant shift in perception over the last two decades. This shift was mainly driven by results indicating that TTS is associated with signicant mortality and morbidity. Consequently, also the criteria for diagnosing TTS have been updated to reflect its recognition as a complex, multifactorial disease.

Purpose

The aim of the present study was to investigate trends in clinical presentation, demographics, and outcomes of patients with TTS.

Methods

The study analyzed 3,675 patients diagnosed with TTS from 2004 to 2021. Participants were divided into groups based on diagnosis, using three-year intervals, to perform trend analyses on demographics, risk factors, clinical presentations, and outcomes. The Cochran-Mantel-Haenszel test was used for categorical data trends, while the Mann-Kendall test assessed numerical variables. Mortality rates were compared using the log-rank test.

Findings: The study period saw a steady increase in male patients (from 10% to 15%, p = 0.003). While apical TTS continued to be the most common type, the occurrence of midventricular TTS increased (from 18% to 37%, p = 0.002). Emotional triggers remained constant, whereas the prevalence of physical triggers significantly rose (from 35% to 50%, p = 0.034). The incidence of cardiogenic shock increased (from 11% to 20%, p=0.030), leading to a rise in in-hospital mortality rates (from 2% to 9%, p<0.001). A landmark analysis showed a significant increase in 60-day mortality rates (p < 0.001), but no difference in one-year mortality over the years (p = 0.140, Figure 1).

Summary: This study of temporal trends in TTS highlights a shift in patients demographic with agrowing prevalence among males, increasing recognition of midventricular TTS type, and increased rates of cardiogenic shock and mortality in recent years. This shift aligns with the rising prevalence of physical triggers, as an expression of increased recognition of TTS in association with acute comorbidities.
A new prehospital cardiac risk assessment index derived from vital signs by first contact emergency medical service, including prehospital oxygen saturation, for accurate prehospital triage of acute m
Authors: Kirii Y , Kurita T , Ito H , Takasaki A , Moriwaki K , Kumagai N , Omura T , Sawai T , Seko T , Tanigawa T , Kitamura T , Dohi K
Published: October 2024

Background: Rapid and accurate triage is essential to improve the prognosis of patients with severe acute myocardial infarction (AMI). However, prehospital triage using vital signs, including prehospital oxygen saturation (SpO2), by first medical contact has not been evaluated.

Purpose: The purpose of this study was to develop a new risk stratification index for AMI using vital signs including SpO2 for rapid and accurate prehospital triage.

Methods: From January 2013 to June 2022, 3006 AMI patients who were directly transported by ambulance were enrolled from the Mie ACS registry. Based on observed risk relationships in 3,006 AMI patients, we developed and evaluated a prehospital cardiac risk assessment index (P-CRAI) using age, heart rate, and systolic blood pressure (SBP) and SpO2 to predict 30-day mortality: (heart rate×[age/10]2)/SBP＋1.1(100-SpO2). We also analyzed whether P-CRAI predicted the need for mechanical circulatory support (MCS) or ventilator use.

Results: In the receiver operating characteristic (ROC) curve analysis, P-CRAI 38.1 has a sensitivity of 84.4%, specificity of 72.7%, and accuracy of 84.3% for predicting 30-day mortality, and P-CRAI was a strong predictor of 30-day mortality compared with the other indices and variables (Figure 1A). When divided into two groups with P-CRAI 38, Kaplan-Meier survival curves showed significant differences in 30-day survival between the high and low groups (83.7% vs. 98.7%, P<0.001, Figure 1B). P-CRAI≥38 was the strongest independent predictor of 30-day mortality with a hazard ratio of 7.64 compared to the other factors by multivariate Cox regression analysis. The spline curve of 30-day mortality by P-CRAI shows a correlation with prognosis (Figure 2A). In this study, we then used the bootstrap method to generate a calibration curve and validate P-CRAI. The results showed an excellent fit and that P-CRAI accurately estimated patient prognosis (Figure 2B). In addition, P-CRAI was a robust predictor of the very early events of death at 24 hours and MCS or ventilator use by ROC curve analysis. (c-statistic 0.835 and 0.726, respectively, P<0.01).

Conclusion: The P-CRAI was found to be a useful tool for prehospital triage of AMI patients, accurately predicting 30-day mortality and the need for MCS.Figure 1.Figure 2.
Preserved left ventricular ejection fraction with abnormal myocardial work in sepsis
Authors: Salinas P , Dieiev V , Barnett J , Kramer D , Lamptey M , Erickson L , Jain R
Published: October 2024

Background

Sepsis is a life-threatening condition associated with a dysregulated response to infection, leading to an increased risk of multi-organ dysfunction and death. Left ventricular (LV) dysfunction has been reported in up to 60% of patients with sepsis. Still, it’s true incidence is difficult to determine as defined by standard methods like left ventricular ejection fraction (LVEF) due to its dependency on loading conditions. Myocardial work (MW) is a validated novel parameter informing true LV contractility. MW is calculated using echocardiography strain data, noninvasive BP measurements, and GE Healthcare proprietary software. There are four MW indices; here, we evaluated the global work index (GWI), the indexed total work performed by the LV through mechanical systole, including isovolumic relaxation and contraction.

Purpose

To describe our patient population diagnosed with sepsis with GWI calculated as part of their echocardiography. We also sought to compare the GWI values with GWI normal reference values reported in current literature to determine whether our observed mean GWI in a cohort of patients with sepsis deviates significantly from these established benchmarks in an average healthy population.

Methods

This report was a retrospective analysis of 179 consecutive patients ≥18 years with sepsis as defined by the Third International Consensus Definitions for Sepsis and Septic Shock who presented at our center from January 2020 to October 2023. LVEF (%) and GWI (mm Hg%) were reported as mean (±SD). A one-sample t-test was used to determine if the mean MWI for males and females diagnosed with sepsis at our center significantly differed from the reported GWI literature of reference patients without sepsis.

Results

Males (n=90, 50.3%) from our center had a significantly lower GWI mean (1353.06 ± 490.75) than the literature-reported male reference value of 2062 (P < 0.001) and a 95% confidence interval (1250 to 1455.84). See the Table.

In 89 (49.7%) females with sepsis, mean GWI was also significantly lower, 1511 ± 595.79 (P < 0.001), than the normal reported female reference GWI value 2155 with a 95% CI (1385.57 to 1636.58). The pooled GWI mean was 1440.0±561.8 (ref: 2118±277). Septic males and females had preserved mean LVEF values of 51.6±13.11 and 56.8±14.4, respectively. The pooled mean LVEF was 54.0±13.8.

Conclusion

These findings revealed preserved LVEF alongside decreased global work index in patients with sepsis. To our knowledge, this is the first description of MW indices in septic patients. The results highlight the importance of further investigations into the role of MW indices in sepsis and the potential for these indices to enhance our understanding and clinical approach to myocardial dysfunction in sepsis.
Recreational drugs use as prognostic factor of major adverse cardiovascular and cerebrovascular events in patients hospitalised for acute cardiovascular events
Authors: Mirailles R , Trimaille A , Toupin S , Delmas C , Bouleti C , Schurtz G , Lattuca B , Rossanaly Vasram R , Noirclerc N , Fauvel C , Bochaton T , Gerbaud E , Dillinger J G , Henry P , Pezel T
Published: October 2024

Background

Among patients admitted to the intensive cardiac care unit (ICCU), systematic screening for recreational drugs evidenced a significant prevalence of recent use and was associated with a higher rate in-hospital outcomes. However, long-term cardiovascular consequences of recreational drug use remain uncertain.

Purpose

We aimed to evaluate the prognostic impact of recreational drugs use at 1-year follow-up to predict major adverse cardiovascular and cerebrovascular events (MACCE) in consecutive patients admitted to ICCUs for acute cardiovascular events from the Addiction in Intensive Cardiac Care Units (ADDICT-ICCU) study.

Methods

In this prospective multicentric study, all consecutive patients admitted to ICCUs over two weeks in April 2021 at 39 centres across France were included. Screening for recreational drugs use was performed by systematic urinary testing. One-year follow-up consisted of a clinical visit or direct contact with the patient and the referring cardiologist. The primary composite outcome was the occurrence of one of the combined MACCE defined as cardiovascular death, nonfatal myocardial infarction (MI) or stroke. Subgroup analysis was performed in patients hospitalised at baseline for acute coronary syndrome.

Results

Of the 1499 consecutive patients screened, 1392 (93%) patients (63±15 years, 70% males) had a complete 1-year follow-up. Among them, 157 (11%) had an initial positive test for recreational drug use (cannabis, opioids, cocaine, amphetamines, 3,4-methylenedioxymethamphetamine [MDMA]). After 1-year of follow, 94 (7%) patients experimented MACCE. Patients with positive testing exhibited a higher rate of MACCE than non-users (13% vs 6%, respectively, p=0.002). After adjustment for traditional prognosticators, recreational drug use was independently associated with the occurrence of MACCE (HR=2.99; 95% CI: 1.73-5.16, p<0.001).

In the subgroup analysis of 713 patients hospitalised at baseline for acute coronary syndrome, 96 (14%) had a positive recreational drug test and 50 (7%) experienced MACCE. Using a multivariable Cox analysis in this population, recreational drug use was still independently associated with MACCE after adjustment for traditional prognosticators (HR=2.98; 95% CI: 1.43-6.21, p=0.004).

Conclusions

In a large cohort of consecutive patients admitted to ICCUs for acute cardiovascular events, the prevalence of recreational drug use was 11%. Recreational drug use was strongly associated with the occurrence of 1-year MACCE even after adjustment for traditional prognosticators.Central illustrationPrognostic impact of drug use
The majority of 30-days survivors return to work one-year after in-hospital cardiac arrest
Authors: Yonis H , Granger C B , Torp-Pedersen C , Meaidi A , Kragholm K
Published: October 2024

Background

Surviving in-hospital cardiac arrest poses a significant risk of anoxic brain damage, which can impede survivors’ ability to return to work.

Purpose

This study aimed to examine return to work among in-hospital cardiac arrest survivors.

Methods

In this cohort study we included all 30-day survivors of working age (18-64 years), who experienced an in-hospital cardiac arrest between January 1st, 2013, and December 31st, 2018. Data was obtained from the national Danish in-hospital cardiac arrest registry (DANARREST) and employment status was retrieved from a registry from the Danish National Labor Market Authorities. We used a previously validated definition of "working" as any individual who was not on any social benefits, except state education fund grants, maternity leave pays, or leave-of-absence. Only patients working four weeks prior to the event were included in the study. Kaplan-Meier survival analysis was applied to estimate the probability of returning to work.

Results

Among 7,254 in-hospital cardiac arrest patients in Denmark from 2013-2018, 1,781 were of working-age, with 734 surviving at least 30 days. A total of 348 patients, who were working four weeks before their event, formed the final study population (Figure 1). Median age was 54 (Interquartile range (IQR) 46-59) and 70.4% were male. The cumulative incidence for return to work was 67.0% (95% CI: 62.0%-71.9%) with 4.6% (95% CI: 2.4%-6.8%) dying by one-year post-arrest as a competing risk (Figure 2). Age and sex distribution were comparable between survivors returning to work, those who did return to work, and those who died. A higher proportion of survivors returning to work had a Carlson’s Comorbidity Index score of 1 (70.8%) compared to survivors without work (58.1%) and those who died (33.3%). Additionally, an initial shockable rhythm was more frequent among survivors returning to work (49.8%) compared to survivors who did not return to work (45.2%), and those who died (9.1%).

Conclusion

We found that 67% of 30-day survivors of in-hospital cardiac arrest returned to work one year after their event. While survivors retuning to work shared comparable age and sex distributions with survivors who did not return to work and non-survivors, factors such as a lower Carlson’s Comorbidity Index score and a higher proportion with an initial shockable rhythm were distinguishing characteristics for those who returned to work.FlowchartCumulative incidence curves
Subendocardial ischemic-like state in patients with severe aortic stenosis: insights from myocardial histopathology and ultrastructure
Authors: Reis Santos R , Abecasis J , Maltes S , Lopes P , Manso R T , Gil V , Cardim N , Ramos S , Felix A
Published: October 2024

Background

myocardial adaptation to severe aortic stenosis (AS) is a complex process that involves myocardial fibrosis (MF) beyond cardiomyocyte hypertrophy. Perfusion impairment is believed to be involved in myocardial remodeling in chronic pressure overload.

Aim

to describe morphological and ultrastructural myocardial changes at EMB, possibly reflecting subendocardial ischemia, in a group of patients with severe AS referred to surgical aortic valve replacement (AVR), with no previous history of ischemic cardiomyopathy.

Methods

one-hundred-fifty-eight patients (73 [68-77] years, 50% women) referred for surgical AVR because of severe symptomatic AS with pre-operative clinical and imaging study and no previous history of ischemic cardiomyopathy. Intra-operative septal EMB was obtained in 129 patients. Tissue sections were stained with Masson ́s Trichrome for MF quantification and periodic acid-Schiff (PAS) staining was performed to assess the presence of intracellular glycogen. Ultrastructure was analyzed through Transmission electron microscopy (TEM).

Results

MF totalized a median fraction of 11.90% [6.54-19.97%] of EMB, with highly prevalent perivascular involvement (95.3%). None of the samples had histological evidence of myocardial infarction. In 58 patients (45%) we found subendocardial groups of cardiomyocytes with cytoplasmatic enlargement, vacuolization and myofiber derangement, surrounded by extensive interstitial fibrosis. These cardiomyocytes were PAS positive, PAS-diastase resistant and Alcian Blue/PAS indicative of the presence of neutral intracellular glyco-saccharides. At TEM there were signs of cardiomyocyte degeneration with sarcomere disorganization and reduction, organelle rarefaction but no signs of intracellular specific accumulation.

Conclusion

almost half of the patients with severe AS referred for surgical AVR have histological and ultrastructural signs of subendocardial cardiomyocyte ischemic insult. It might be inferred that local perfusion imbalance contributes to myocardial remodeling and fibrosis in chronic pressure overload.
LncRNA MEG3 promotes aortic valve calcification by inducing osteoblast differentiation via Wnt catenin signaling pathway
Authors: Tang L , Yang Y , Wang Z J , He Y , Zhou S H
Published: October 2024

Background

Calcific aortic valve stenosis (CAVS) is the most common valvular heart disease in elderly population. This study aimed to investigate the role of long non-coding RNAs (lncRNAs) in the development of CAVS.

Methods

ldlr-/-mice were feeding with western diet for 6 months to induce CAVS. RNA-seq analysis was performed to identify differentially expressed molecular signaling between aortic valves of CAVS mice and control mice. The degree of aortic stenosis was detected by ultrasound. Calcium salt deposits were detected by Haematoxylin and eosin (H&E) staining, Von Kossa staining and alizarin red S staining. PCR and western blotting were employed to detect osteogenic differentiation markers after various interventions.

Results

A mouse CAVS model was successfully established, as evidenced by increased thickness and calcium deposition in the aortic valve leaflets and increased transvalvular peak jet velocity. RNA-seq analysis showed that lncRNA MEG3 was significantly enriched in aortic valves of CAVS mice as compared to that of control mice. MEG3 expression in aortic valve, assessed by RNA in situ hybridization and PCR, was also significantly upregulated during the osteoblast differentiation of AVICs in vitro. Gain- and loss-of-function experiments indicate that MEG3 could indeed promote osteoblast differentiation of primary AVICs as evidenced by increased calcified nodule formation and expressions of osteoblast differentiation markers (Runx2 and osterix). Consistent with these in vitro data, MEG3 knockdown in vivo through tail injection of antisense oligonucleotide chain MEG3 (ASO-MEG3) at 6 weeks interval for 12 weeks significantly attenuated aortic valve calcification in CAVS mice. Subsequent KEGG analysis demonstrated that the Wnt/β-catenin signaling pathway was significantly enriched during the CAVS progression. Overexpression of MEG3 activated the Wnt/β-catenin signaling pathway and upregulated osteogenic protein expressions, while this upregulation could be significantly ameliorated by Dickkopf 1, a Wnt/β-catenin pathway inhibitor.

Conclusion

Present study demonstrates that LncRNA MEG3 could promote aortic valve calcification by inducing osteoblast differentiation via activating Wnt/β-catenin signaling pathway. Our results provide experimental evidence of targeting MEG3 and Wnt/β-catenin signaling pathway as potential promising therapeutic option for prevention and treatment of aortic valve calcification.
Increased risk of infective endocarditis following transurethral resection of the prostate (TUR-P)
Authors: Stahl A , Loldrup Fosboel E , Roeder A , Bagi Nordsten C , Oestergaard L , Sehested T S G , Dahl A , Ihlemann N , Bundgaard H , Iversen K , Valeur N , Gislason G , Torp-Pedersen C , Bagi P , Koeber L
Published: October 2024

Background

Transient bacteremia is a well-known complication of transurethral resection of the prostate (TUR-P). Still, the associated risk of bacteremia and subsequent infective endocarditis (endocarditis) after TUR-P has been sparsely examined.

Purpose

To examine the risk of bacteremia and infective endocarditis following TUR-P.

Methods

We identified all patients who underwent TUR-P between 2010-2020 with ICD-10 codes from Danish nationwide registries. Patients were compared to an age-matched cohort of males from the general population (1:1 match-ratio). We defined a 6-month exposure window following TUR-P and examined the risk of bacteremia and endocarditis within the first 6 months and compared with the following 6-12 months after TUR-P. Microbiology findings were based on complete data on blood culture results. Incidences of bacteremia and endocarditis were calculated, and groups were compared with cumulative incidences. To account for predisposing endocarditis risk factors, multivariable time-dependent Cox regression analyses were performed on the associated risk of bacteremia and endocarditis.

Results

In total, 25.781 patients underwent TUR-P. Median age was 70.7 years (IQR: 64.9-76.3). Incidence of bacteremia was higher in the TUR-P group than the control group (727.47 [681.49-776.56] per 10,000 person years vs 84.75 [95% CI: 70.19-102.35)] per 10,000 person years). Incidence of endocarditis was also higher in the TUR-P group than the control group (34.64 [95% CI: 25.78-46.55] per 10,000 person years vs 3.14 [95% CI: 1.18-8.35] per 10,000 person years). In 72.7% of endocarditis-cases, Enterococcus Faecalis was the disease-causing pathogen in the TUR-P group. As compared with an age-matched control group, we found an increased associated risk of bacteremia in patients undergoing TUR-P within the first 6 months from the procedure (adj. HR: 7.72 [95% CI: 6.25-9.53]) and the increased risk persisted within the following 6-12 months (adj. HR 2.31 [95% CI: 1.83-2.91]). TUR-P was also associated with endocarditis within 6 months from the procedure (8.16 [95% CI 3.06-21.79]), but not significantly the following 6-12 months after (2.15 [95% CI: 0.91-5.07]) as compared with the age-matched control group.

Conclusion

Transurethral resection of the prostate (TUR-P) is associated with an almost 8 times increased risk of bacteremia and an 8 times increased risk of infective endocarditis. Our findings emphasize the necessity for development of better preventive strategies against infective endocarditis after TUR-P.Risk of endocarditis post-TUR-P