bluuebunny/crossref_metadata_2025 huggingface dataset:
Cancelled STEMI patients: what happen to them?
Authors: Martin Dominguez C , Palacios J C , Agudelo V , Rodriguez A , Aguilo O , Perez V , Diaz G , Gaitan E , Martinez J M , Vicente M , Brugada R , Aboal J
Published: November 2023

Introduction

In the STEMI care network, the number of inappropriate cases sent to cathlab remains high 1. The use of technological innovations to share the diagnostic ECG tracing with the cardiology department has been shown to be effective in improving patient discrimination.

Objective

Our aim was to study the characteristics and prognosis (at discharge and 1-year follow-up) of patients whose transfer to the cathlab was cancelled.

Material and Method

Prospective study analysing all STEMI alert activations in 2022. Information on ECG pattern and clinical history was transmitted using an APP (ODiSEA 2-3) and used for cancellation. Patient characteristics, myocardial infarction, ECG activation pattern, angiography results, final diagnosis and clinical events during admission and 1-year follow-up were recorded. Patients who underwent urgent coronary angiography were excluded from the study.

Results

A total of 406 infarction codes were activated through the ODISEA APP. 122 (30%) of these were cancelled. The characteristics of the patients are shown in Table 1.

Reasons for cancellation based on ECG pattern are shown in Figure 1.B. The most common were ST depression (23%) and intraventricular conduction disturbances (22.9%). The final diagnosis was ACS in 32.8% (STEMI 2.5%, NSTEMI 27% and unstable angina 3.3%). In the remaining 67.2%, the final diagnosis was atypical chest pain with negative biomarkers in 22.9%, arrhythmia in 17.2%, pericarditis in 9%, gastrointestinal pathology in 4.9%, heart failure in 4.9%, aortic dissection in 3.2%, PTE in 1.6% and other pathologies in 3.5%. (Figure 1.A).

Coronary angiography was performed in 41 patients (33.6%). There were 36.6% with one vessel, 9.8% with two vessels and 22% with three vessels. Percutaneous revascularisation was required in 70% of patients.

Discharge from the emergency department occurred in 46% of the patients. Hospital mortality occurred in 14 patients (11.4%). Of these, 3 (2.4%) were due to cardiac causes. Regarding events at 12 months, 6 (4.9%) were deaths (5 natural deaths and 1 due to cancer). 5 patients (4%) had ACS, 3 patients (2.4%) had stroke and 1 patient (0.8%) had digestive bleeding.

Conclusions

STEMI alert cancelled transfer patients are older, have more comorbidities and are less likely to have a final diagnosis of ACS or to have coronary lesions. They have a high rate of non-cardiovascular in-hospital mortality and a low rate of cardiovascular events at one year of follow-up.A.Final diagnosis. B. ECG patternTable 1.Patients characteristics
Long-term prognostic value of white blood cell count variation during hospital stay in patients with STEMI
Authors: Boukhris M , Dierx Molie C , Chenard P , Gourceyrol A , Gasnier A , Pradel V , Virot P , Aboyans V
Published: November 2023

Background

In patients with ST-elevation myocardial infarction (STEMI), white blood cell count (WBCC) is associated with infarct size and cardiovascular outcome. We sought to determine the impact of WBBC variation (∆WBCC) during hospital stay on the long-term outcome after STEMI.

Methods

From 06/2011 to 12/2019, consecutive patients referred for STEMI were enrolled. Those with at least two WBCC during hospitalization were included in this study. ∆WBCC was calculated as: [WBCC (admission) – WBCC (before discharge)]. The population was divided into 3 groups according to ∆WBCC tertiles. The primary outcome was all-cause mortality.

Results

A total of 1782 patients (mean age 64.5 ±14.1 years, 75.7% males), were included and divided in 3 groups: Group 1 (∆WBCC<880/mm3); Group 2 (∆WBCC 880-3265/mm3); and Group 3 (∆WBCC >3265/mm3). Patients in Group 1 were the oldest (67.9±13.8, vs. 65.1±13.9 and 60.5±13.7 years in Groups 2 and 3 respectively, p<0.001). Hypertension, prior coronary artery bypass and cancer were more prevalent in Groups 1 and 2. Troponin peak was the highest in Group 3 (3601±563, vs. 2810±439 and 2451±467 ng/ml in Groups 1 and 2, respectively; p<0.001).

The 5-year survival was the lowest in Group 1 (78.5% vs. 87.4% and 87.5% in Group 2 and 3, respectively; p<0.001) (Figure). Adjusted to age, gender, cardiovascular risk factors, MI territory and left ventricular ejection fraction, ∆WBCC<0.880/mm3 was independently associated with all-cause mortality [HR 1.46; 95%CI 1.12-1.91; p=0.005].

Conclusion

Low variation of WBCC (∆WBCC<880/mm3) is associated with increased mortality, and can represent an interesting prognostic tool in STEMI patients.
The CRP Troponin Test (CTT) stratifies mortality risk in patients with Non-ST Elevation Myocardial Infarction (NSTEMI)
Authors: Brzezinski R Y , Shacham Y , Banai S , Katz Shalhav M , Rogowski O , Shapira I , Zeltser D , Shenhar-Tsarfaty S , Berliner S , Mizrahi M
Published: November 2023

Introduction

The CRP-Troponin test (CTT) comprises serial measurements of both CRP and cardiac troponin and might reflect the systemic inflammatory response in patients with acute coronary syndrome. Here, we sought to test the ability of the CTT to stratify the short and long-term mortality risk in patients with non-ST elevation myocardial infarction (NSTEMI).

Materials and Methods

We examined 1,675 patients who were diagnosed with NSTEMI on discharge and had at least two successive measurements of combined CRP and cardiac troponin (up to 6 h apart), all within the first 48 hours of admission. We used a tree classifier model to determine which measurements and cutoffs could be used to best predict mortality during a median follow-up period of 3 years [IQR 1.8–4.3] (Figure 1A).

Results

Patients with high CRP levels (above 90th percentile, >54 mg/L) had a higher 30-day mortality rate regardless of their troponin test status (Figure 1B). However, among patients with "normal" CRP levels (<54 mg/L), those who had high troponin levels (above the 80th percentile, 4,918 ng/L) had a higher 30-day mortality rate compared with patients with normal CRP and troponin concentrations; 7% vs. 2%, p<0.01 (Figure 1B). A multivariate cox regression analysis showed that the CTT test result was an independent predictor for overall mortality even after adjusting for age, sex, and existing co-morbidities (Figure 1C).

Conclusion

Early serial CTT results may stratify mortality risk in patients with NSTEMI, especially in those presenting with "normal" CRP levels. The CTT is a simple diagnostic tool that could potentially assess the impact of inflammation during myocardial necrosis on the outcomes of patients with NSTEMI. The CTT might be used to identify patients who could benefit from novel anti-inflammatory therapies following myocardial infarction.Figure 1
Ten-year major clinical outcomes between first- and second-generation Drug-Eluting Stents in unstable angina patients underwent Percutaneous Coronary Intervention
Authors: Rha S W , Choi S Y , Choi B G , Byun J K , Cha J , Hyun S , Park S , Kim J B , Choi C U
Published: November 2023

Background

There are very limited long-term clinical outcome data comparing first-generation (1G) versus second-generation (2G) drug-eluting stents (DES) in unstable angina (UA) patients. The authors sought to compare the efficacy and safety 2G-DES with 1G-DES in dyslipidemia patients who underwent percutaneous coronary intervention (PCI) during ten-year clinical follow-up periods.

Methods

Finally, a total of 878 eligible UA patients who underwent PCI with 1G-DES (paclitaxel-, sirolimus-eluting stent, n = 333) or 2G-DES (zotarolimus [endeavor, endeavor resolute]- or everolimus-eluting stent [promus element, xience], n = 545) were enrolled. The study endpoints were individual and composite clinical outcomes up to ten-year.

Results

After PSM, two propensity-matched (PSM) groups (216 pairs) were generated. During the ten-year follow-up period, the 2G-DES group had a lower incidence of target lesion revascularization (TLR; hazard ratio [HR], 0.43; 95% confidence interval [CI], 0.22 – 0.84; p = 0.013), target vessel revascularization (TVR; HR, 0.40; 95% CI, 0.23 – 0.71; p = 0.002), any revascularization (HR, 0.48; 95% CI, 0.31 – 0.75; p < 0.001), total major adverse cardiac events (MACE; HR, 0.54; 95% CI, 0.37 – 0.81; p = 0.003), TLR MACE (HR, 0.54; 95% CI, 0.30 – 0.97; p = 0.038), and MACCE (HR, 0.62; 95% CI, 0.42 – 0.90; p = 0.012, table).

Conclusion

In our single-center, all-comer registry, 2G-DES had better efficacy especially repeat revascularization compared with 1G-DES in UA patients during 10-year follow-up periods.
The BE-ALIVE score: predicting 30-day mortality in patients presenting with acute coronary syndromes and cardiogenic shock
Authors: Tindale A , Panoulas V
Published: November 2023

Aims

The aim of this study was to create and validate a simple scoring system for predicting 30-day mortality in patients presenting with acute coronary syndromes (ACS) and any sign of shock at their moment of admission.

Methods and results

2407 consecutive patients presenting to Harefield Hospital with clinical features of cardiogenic shock, from January 2011 to December 2020, were studied to build the training set. 30-day mortality was 17.2%. A scoring algorithm was built using binary logistic regression of variables available on admission and then converted to an additive risk score. The resultant scoring system is the BE-ALIVE score, which incorporates the following factors:

Base Excess (1 point for < -2 mmols/L), Age (<65 years: 0 points, 65-74: 1 point, 75-84: 2 points, ³85: 3 points), Lactate (<2 mmols/L: 0 points, 2 - 4.9: 1 point, 5 - 9.9: 3 points, ³10: 6 points), Intubated (2 points), Left Ventricular function (mildly impaired or better: -1 point, moderately impaired: 1 point, severely impaired: 3 points) and External / out of hospital cardiac arrest (1 point).

The scoring system was validated using a testing set of 515 patients presenting to Harefield hospital. The validation metrics were excellent with an AUC of 0.9, Brier score of 0.06 versus a naïve classifier of 0.15, Spiegelhalter’s z-statistic probability of 0.267 and a calibration slope of 1.08.

Conclusion

The BE-ALIVE score is a simple and accurate scoring system to predict 30-day mortality in patients presenting with ACS and shock.
Validation of the BALLAR score for predicting 30-day mortality in patients requiring Impella monotherapy
Authors: Tindale A , Panoulas V
Published: November 2023

Background

The BALLAR score was published in 2021 with the aim of allowing clinicians to calculate 30-day mortality quickly and easily for patients requiring left-sided Impella monotherapy. The points are assigned as follows:

Base Excess (mmol/L): < -2: 2 points, ≥ -2: 0 points

ALbumin (mmol/litre): <25: 6 points, 25 - 34.9: 3 points, >34.9: 0 points

LActate (mmol/litre): <2: 0 points, 2 – 4.9: 1 Point, >4.9: 4 Points

Renal function - Creatinine Clearance (ml/min): <30: 6 points, 30 - 59.9: 4 points, 60 - 89.9: 1 point, >89.9: 0 points

The scoring system performed well on its initial training cohort but had not previously been validated.

Purpose

To validate the BALLAR score using a predominantly external validation cohort requiring left-sided Impella therapy only, for any indication.

Methods

The data required to calculate the BALLAR score was retrospectively acquired for 89 patients. 39 patients were from our own UK tertiary centre, 7 from our sister hospital, and 43 from centres across the United States from the Impella Quality (IQ) assurance program.

Results

For the entire validation cohort of 89 patients, the BALLAR score showed both excellent discrimination and calibration statistics. The area under the receiver-operator characteristic (ROC) curve was 0.91 (0.84–0.98) (Figure 1), the Brier score was 0.11 versus a Naïve classifier of 0.23, the calibration slope was 0.92 calibration with Spiegelhalter’s Z-statistic of 0.98 (p=0.323, Figure 2).

For the external validation cohort of patients, the discrimination remained excellent with the area under the ROC curve of 0.88 (0.79-0.98). The Brier score remained better than a naïve classifier at 0.15, but the calibration slope was unsurprisingly worse at 0.73 with a Spiegelhalter’s Z statistic of 2.07 (p=0.04).

The negative predictive value of a BALLAR score ≤5 was 94%, and the positive predictive value was 100% of a BALLAR score > 12, highlighting the rapid escalation of mortality risk in patients in the mid-zone of the shock spectrum.

Conclusions

The BALLAR score maintains high discriminatory ability when applied to a validation cohort of patients requiring left-sided Impella monotherapy for any indication. Further prospective work is underway, including app development, to assess the clinical utility of the BALLAR score as a means of categorising patient risk.Image 1Image 2
Low incidence of mechanical complications in patients with AMI
Authors: Kobo O , Toukan N , Hamuda N , Sanchez-Jimenez E , Abu- Fanne R , Levi Y , Saada M , Roguin A
Published: November 2023

Background

Despite early and currently effective epicardial coronary recanalization in patients with acute myocardial infarction (AMI), the mortality rate after mechanical complication (MC) remains high. Despite its impact on the prognosis of patients with AMI, up-to-date real life data regarding to epidemiology and management of patients with MC following AMI still scarce and most studies exclude patients with MC.

Methods

Using the National Inpatient Sample database from 2015 to 2018 to identify patients with AMI, we aimed to determine the epidemiology, predictors and outcomes of patients with MC following AMI in the US.

Results

We identified 2,427,315 patients with AMI; 2345 (0.1 %) developed MC. Regarding subtypes, 960 (40.9 %) had ventricular septal rupture (VSR), 540 (23.0 %) papillary muscle rupture (PMR), 530 (22.6 %) pseudoaneurysm, and 315 (13.4 %) free wall rupture FWR). Mortality was 12 times higher (OR: 11.663, CI: 10.582–12.855,p< 0.001) in patients with MC compared to patients without MC (49.7% vs. 4.6 %,p< 0.001) and all subtypes of MC showed a significant increase in mortality.

Conclusions

Nowadays, the incidence of MC after an AMI is lower than in the past, nonetheless the in-hospital mortality rate remains very high. It tends to occur more in older patients and in those with fewer comorbidities. The subtype with the highest frequency and highest mortality rates was VSR.
Accuracy of the GRACE Score for mortality prediction in myocardial infarction with nonobstructive coronary arteries (MINOCA)
Authors: Lopes V , Moreira N , Fernandes R , Cunha G , Ferreira J , Costa G , Monteiro E , Fernandes D , Guimaraes J , Milner J , Marinho V , Monteiro S , Goncalves F , Goncalves L
Published: November 2023

Introduction

Myocardial infarction with nonobstructive coronary arteries (MINOCA) patients account for 3.5 to 15% of all myocardial infarctions. The GRACE risk score is a well-validated tool for estimating short- and long-term risk in acute coronary syndrome, but the accuracy of the risk score for prognostic stratification in patients with MINOCA remains uncertain.

Purpose

We aimed to investigate whether the GRACE risk score can predict mortality in a real-world cohort of patients presenting with MINOCA.

Methods

We retrospectively analyzed patients admitted with MINOCA in a single center. Patients who were diagnosed with myocarditis and Takotsubo syndrome were excluded from the analysis. The GRACE risk score on admission was calculated. Patients were divided into a low-intermediate risk group (≤ 140 points, 71.5%) and a high-risk group (>140 points, 28.5%) according to their GRACE risk scores. Receiver operating characteristic (ROC) analysis was used to quantify the accuracy of the GRACE risk score to estimate both in-hospital and one-year mortality in MINOCA patients.

Results

Of a total of 3721 myocardial infarction patients, MINOCA was identified in 11.6% (n=430). 313 patients had complete data for the calculation of the GRACE on admission and were included in the analysis. Mean age was 65±12 years, and 49% (n=154) of patients were male. Mean GRACE score was 125±31 points.

Patients in the high-risk group were older (74±9 vs. 61±11 years, p<0.001), had a higher incidence of in-hospital mortality (0.4% vs. 5.6%, p=0.008), and had a higher rate of one-year mortality (2.7% vs. 19.5%, p<0.001), compared with the low-intermediate risk group. There were no differences regarding sex and cardiovascular risk factors between the groups.

In-hospital mortality was 1.9% and one-year mortality was 7.3%. ROC curve analysis showed that the GRACE risk score has a high value in predicting in-hospital mortality (AUC ROC 0.892; 95% CI 0.798–0.986; p=0.001), and one-year mortality (AUC ROC 0.826; 95% CI 0.739–0.0.914; p<0.001) in MINOCA patients. (Figure 1).

The overall c-statistics were similar compared with estimates obtained from patients with myocardial infarction and significant coronary artery disease: in-hospital mortality (AUC ROC 0.0.849; 95% CI, 0.807–0.891; p<0.001); and one-year mortality (AUC ROC 0.776; 95% CI, 0.747–0.806; p<0.001).

Conclusions

In conclusion, the GRACE risk score provides potentially valuable prognostic information on in-hospital and one-year mortality when applied to MINOCA patients.Figure 1
The role of cardiac magnetic resonance imaging in patients with MINOCA in daily clinical practice
Authors: Mata Caballero R , Olsen Rodriguez R , Abad Romero R , Fraile Sanz A , Perela Alvarez C , Nieto Ibanez D , Izquierdo Coronel B , Avarez Bello M , Martin Munoz M , Gil Mancebo N , Rodriguez Montes P , Espinosa Pascual M J , Alberca Vela M T , Perea Egido J , Alonso Martin J J
Published: November 2023

Background

In patients with ‘myocardial infarction with non-obstructive coronary arteries’ (MINOCA), the underlying cause is not always known. Cardiac magnetic resonance imaging (CMRI) is recommended as a key investigation in MINOCA because it can exclude myocarditis, takotsubo syndrome, and cardiomyopathies, as well as provide imaging confirmation of AMI. However, CMRI is not widely available. The aim of our study was to analyze the role of CMRI in patients with MINOCA in routine clinical practice in a non-tertiary hospital of the Spanish national health system.

Methods

We analyzed 62 consecutive MINOCA patients admitted to our University Hospital from 2019 to January 2023. The database were revised by a group of experts in order to adequate MINOCA to 2020 ESC Guidelines definition and the American Heart Association position paper. The tako-tsubo syndrome was excluded. According to these guidelines CMRI is recommended in the evaluation of MINOCA patients.

Results

Only in 32 patients, corresponding to 52% of the patients with MINOCA, the CMRI was performed because of the limited availability of this test in our health System. Of the CMRI performed, 46% provided the underlying mechanism of the MINOCA: myocarditis (21%) or confirmation of AMI (25%). The other CMRI were normal (54%) (figure). Although patients with normal CMRI had a significantly lower mean TropT hs (236.02 vs 794.02 ng/L, p=0.03), troponin levels were not able to discriminate patients with normal CMRI. Thus up to 33% of patients with pathological CMRI had a TropThs level less than 244 ng/L (which was the median of the series).

There were no significant differences in other biomarkers (PCR, CK) or clinical or analytical parameters. There were also no differences in prognosis at follow-up (death or readmissions) between patients with normal CMRI and patients with diagnostic CMRI.

Conclusions

1) In routine clinical practice, only 52% of patients with MINOCA underwent CMRI, 2) Of the patients who underwent CMRI, it provided the underlying mechanism of the MINOCA in 46% of them, 3) Although the TropThs level was lower in patients with normal CMRI, the troponin level was not useful to select the patients that would benefit most from such a test.CMRI in MINOCA patients
Prognostic role of late gadolinium enhancement and abnormal mapping values in myocardial infarction with non-obstructive coronary arteries
Authors: Armillotta M , Bergamaschi L , Amicone S , Fedele D , Impellizzeri A , Casuso M , Angeli F , Rinaldi A , Foa' A , Paolisso P , Casella G , Pavon A G , Lovato L , Galie' N , Pizzi C
Published: November 2023

Background

Myocardial infarction with non-obstructive coronary arteries (MINOCA) represents an extremely heterogeneous clinical entity, as multiple pathophysiological mechanisms may result in variable outcomes. Cardiac magnetic resonance (CMR) plays a pivotal diagnostic role in MINOCA. However, to date, a prognostic stratification based on the CMR findings in ischemic MINOCA is still lacking.

Purpose

To assess the potential prognostic utility of early collected CMR parameters in a large cohort of selected MINOCA, in order to identify measurable parameters that may improve the risk stratification and management of this still not well-defined clinical entity.

Methods

We assessed 437 MINOCA from January 2017 to October 2021. We excluded patients with non-ischemic myocardial damage due both cardiac (i.e., myocarditis, cardiomyopathies, Takotsubo syndromes) and non-cardiac conditions. Patients were classified into 3 subgroups according to the CMR phenotype: i) presence of late gadolinium enhancement (LGE) and abnormal mapping (M) values (LGE+/M+), ii) regional ischemic injury with abnormal mapping and no LGE (LGE-/M+) and iii) non-pathological CMRs (LGE-/M-). The primary outcome was the presence of major acute cardiovascular events (MACE). The mean follow-up was 33.7±12.0 months and CMR was performed on average at 4.8±1.5 days from the acute presentation.

Results

The final cohort included 198 MINOCA: 116 (51.1%) comprised the LGE+/M+ group. The mean age of the study population was 60.2 years and more than 57% were females. During follow-up, MACE occurred significantly more frequently in MINOCA LGE+/M+ than in the LGE+/M- and normal-CMR (LGE-/M-) subgroups (20.7% vs. 6.7% and 2.7%, p=0.006). The extension of myocardial damage at CMR was significantly greater in patients who developed MACE. In multivariable Cox regression, %LGE was an independent predictor of MACE (HR=1.123, 95% CI 1.064 – 1.185, p<0.001) together with T2 mapping values (HR=1.190, 95% CI 1.145 – 1.237, p=0.001).

Conclusions

In MINOCA with early CMR execution, the %LGE and abnormal T2 mapping values were identified as independent predictors of adverse cardiac events at ∼3.0 years follow-up. In the complex world of MINOCA, the non-invasive myocardial characterization provided by CMR represents a powerful tool to rapidly identify high-risk patients and guide appropriate clinical decision-making as well as therapeutic management.
Systemic inflammatory disease in patients with spontaneous coronary artery dissection
Authors: Kang M , Offen S , Reddavid C , Grewal T , Saw J
Published: November 2023

Background

Spontaneous coronary artery dissection (SCAD) is an increasingly recognised cause of non-atherosclerotic myocardial infarction (MI). Systemic inflammatory diseases are commonly associated with SCAD patients, but the link between inflammatory diseases and SCAD remains unclear.

Purpose

To determine the prevalence of systemic inflammatory disease (SID) and elevated inflammatory markers (EIM) at SCAD presentation. To compare long-term outcomes between SCAD patients with and without SID, and with and without EIM at presentation.

Methods

We reviewed patients enrolled in the Canadian SCAD Study who had laboratory measurements of inflammatory markers at presentation with SCAD. We compared the baseline demographics, presence of SID, presentation characteristics, and long-term outcomes between patients with and without SID, and between patients presenting with and without EIM at time of SCAD. SID was determined using past medical history and patient self-identification. C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) were used as inflammatory biomarkers. Major adverse cardiovascular events (MACE) were defined as the composite of all-cause mortality, stroke or transient ischemic attack, MI, hospitalization for heart failure and unplanned revascularization.

Results

Of 1307 patients with SCAD, 360 had inflammatory markers measured at presentation. Of these 360 patients, 150 (43.1%) had EIM at presentation, and 13 (3.6%) reported a history of SID. Mean age was 52.9±9.8 years for patients with EIM, vs. 50.8±10.9years for patients without EIM (p=0.06). Patients with EIM had significantly higher body mass index compared to those without EIM (35.5% vs 17.6%, p=0.001). Of the patients with reported SID, there was higher prevalence of diabetes and hypertension. There was no significant difference in mean inflammatory marker levels, ESR (13.4±15.6mm/h vs 13.7±13.2mm/h, p=0.965) and CRP (15.6± 23.1mg/L vs 11.9± 26.8mg/L, p=0.644) among SID vs. no SID patients at SCAD presentation. Overall mean follow-up was 3.7±1.9 years. There was no difference in in-hospital MACE and overall MACE between patients with EIM vs. no EIM, and between SID and no SID cohorts. There were also no significant difference in angiographic findings, fibromuscular dysplasia prevalence, proportion treated conservatively vs. with revascularization in these cohorts.

Conclusion

There was no significant difference between presentation, laboratory values, treatment, or outcomes between SCAD patients with or without SID, and between patients who present with and without EIM. This suggests that both active inflammation and history of inflammatory diseases do not contribute to SCAD or outcomes.Table 1.SCAD cohort demographics & data
Termination-of-resuscitation rule in the emergency department for patients with initial pulseless electrical activity after out-of-hospital cardiac arrest
Authors: Funada A , Goto Y , Takamura M
Published: November 2023

Background/Introduction

In several Asian countries including Japan, emergency medical service (EMS) providers are prohibited from performing field termination-of-resuscitation (TOR) in patients with refractory out-of-hospital cardiac arrest (OHCA). In 2022, we developed a TOR rule in the emergency department for patients with initial asystole after refractory OHCA, which includes three criteria: unwitnessed arrest, EMS-initiated cardiopulmonary resuscitation (CPR) duration was more than 20 min, and there was no prehospital return of spontaneous circulation (ROSC). However, until now a TOR rule in the emergency department for patients with initial pulseless electrical activity (PEA) has not been developed.

Purpose

This study aimed to develop and validate a TOR rule in the emergency department for patients with initial PEA after refractory OHCA.

Methods

We analysed the records of 137,230 adult patients (≥18 years-old) with initial PEA from the nationwide all-Japan Utstein registry from 2016 to 2020. Patients were divided into two groups: development (n=109,642, 2016 to 2019) and validation (n=27,588, 2020). The primary outcome measures were specificity, false positive rate (FPR), and positive predictive value (PPV) of the TOR rule for patients with initial PEA in the emergency department for predicting 1-month mortality. Using recursive partitioning analysis, we developed a new TOR rule for patients with initial PEA after OHCA.

Results

The overall 1-month survival rate of the participants was 7.4% (95% confidence interval [CI], 7.2–7.5%). Recursive partitioning analysis for the development group in predicting 1-month mortality revealed that a TOR rule for patients with PEA could be defined if patients with OHCA met all the following four criteria immediately after hospital arrival: (1) unwitnessed arrest by any laypersons, (2) EMS-initiated CPR duration more than 20 min, (3) no prehospital ROSC, and (4) age greater than or equal to 80 years. The specificity, FPR, and PPV of the rule for predicting 1-month mortality were 99.1% (95% CI, 98.9–99.3%), 0.87% (95% CI, 0.69–1.09%), and 99.2% (95% CI, 98.9–99.3%), respectively. The proportion of patients who fulfilled the rule and the area under the receiver operating curve (AUC) was 7.8% (95% CI, 7.7–8.0%), and 0.80 (95% CI, 0.79–0.80), respectively. In the validation group, the specificity, FPR, PPV, proportion of patients who met the rule, and AUC were 99.1% (95% CI, 98.5–99.4%), 0.93% (95% CI, 0.58–1.49%), 99.3% (95% CI, 98.8–99.5%), 8.3% (95% CI, 8.0–8.6%), and 0.789 (95% CI, 0.775–0.797), respectively.

Conclusions

We developed and validated a TOR rule in the emergency department for patients with initial PEA after OHCA. The rule includes four criteria (unwitnessed arrest, EMS-initiated CPR duration was more than 20 min, no prehospital ROSC, and age was greater than or equal to 80 years) with a more than 99% predictor of 1-month mortality.
Agreement of continuous non-invasive arterial blood pressure monitoring (CNAP) and pulmonary artery catheter thermodilution method in estimating the hemodynamic parameters of post CABG patients
Authors: Sulit J , Tan A D
Published: November 2023

Background

The use of hemodynamic parameters in monitoring patients after coronary artery bypass surgery is an essential element of clinical practice. It helps intensivist and physicians to properly manage patients after surgery where hemodynamic parameters are usually dynamic and complicated. Pulmonary artery guided thermodilution (PACT) has been the gold standard in assessing the adequacy of cardiac output, however, its invasive nature is also associated with more complex procedures and the risk of complications, including infections. With the emergence of new non-invasive hemodynamic monitoring devices such as the CNAP (continuous non-invasive arterial pressure), alternative methods for hemodynamic monitoring is now possible. Compared to invasive methods, it is easier to use with an error-free application, safer, less risk of infection and more cost effective.

Purpose

To determine the agreement of Continuous non-invasive arterial pressure (CNAP) and pulmonary artery guided thermodilution in monitoring the hemodynamic parameters of patients who underwent coronary artery bypass graft surgery.

Methods

This is a cross-sectional study conducted at the cardiovascular surgical intensive care unit and included 63 patients with Coronary artery disease who underwent elective coronary artery bypass graft surgery. Cardiac output, Cardiac Index, Stroke volume and Systemic vascular resistance were simultaneously obtained using both the CNAP and PACT. Three consecutive sets of measurements were recorded for each patient with a 3 hour interval; during arrival at the ICU, 3 hours post op, and 6 hours post op.

Results

The mean difference between PACT-CO and CNAP-CO was -0.81 L/min (SD -1.18 to -0.44) with a 95% limits of agreement of -3.74 to 2.11 L/min on the 0 hour, -0.81L/min (SD -1.22 to -0.41) with a 95% limits of agreement of -1.98 to 1.18 L/min on the 3rd hour, and -0.77L/min (SD -1.08 to -0.46) with a 95% limits of agreement of -3.22 to 1.68 L/min on the 6th hour post op. The results showed a significant difference between the PACT and CNAP. However, a positive correlation was noted between PACT-CO and CNAP-CO, the correlation coefficient on the 0, 3rd and 6th hour were 0.5384, 0.5158, and 0.6265 respectively.

Conclusion

CNAP derived hemodynamic parameters had a high mean difference compared to the PACT and there was no agreement between the two methods. However, it was able to have a positive correlation with the PACT, making it possible for the CNAP to track the hemodynamic changes during the post operative course.
Prognostic scores in predicting 90-day mortality in the cardiac intensive care units
Authors: Koutsoumpos P , Sidiras G , Kokkoris S , Georgopoulos S , Sioziou P , Leleka M , Barmparousi M , Kampisiouli E , Pistolas D , Xydonas S , Stalikas D , Vasileiadis I , Zakynthinos S , Routsi C
Published: November 2023

Introduction

During the last years the Coronary Care Units (CCU) have evolved into Cardiac Intensive Care Units (CICU) for patients with acute cardiovascular diseases. The prognostic scores were developed in general Intensive Care Units with the aim of evaluating the severity of the disease and predicting the short-term outcome of the critically ill patients. Although a number of prognostic scores have also been used in the CICU, none of them has been proposed, so far, for prediction of the 90-day mortality which is considered a more reliable outcome metric.

Purpose

To evaluate the predictive ability for 90-day mortality of five prognostic scores in patients admitted to the CICU due to various cardiovascular etiologies.

Methods

This is a single-center, prospective cohort study in a CICU admitting patients with acute cardiovascular diseases. APACHE II, SOFA, FRAILTY and MCARS scoring systems as well as CHARLSON comorbidity index (CCI) were calculated on CICU admission.

Results

A total of 527 patients [mean (SD) age 70 (15) years, 69% males] were included (NSTEMI 23%, STEMI 22%, Heart Failure 10%). Crude 90-day mortality was 16%. The univariate analyses showed that all five scores (FRAILTY, MCARS, SOFA, APACHE II, and CCI) were significantly higher in non-survivors as compared to survivors. The area under the receiver operating characteristic curve (AUC) for FRAILTY, MCARS, SOFA, APACHE II, and CHARLSON’s scores was 0.83, 0.91, 0.92, 0.90, and 0.74, respectively. A multivariate logistic regression including all five prognostic scores revealed FRAILTY, MCARS and SOFA scores as independent predictors of 90-day mortality (OR, CI: 0.57, 0.42-0.77; 0.70, 0.53-0.90; 0.83, 0.70-0.99, respectively).

Conclusion

MCARS, SOFA, and FRAILTY scores at CICU admission were independent risk factors for 90-day mortality. Therefore, they could be recommended as tools for accurate risk stratification in patients admitted to the CICU.
Prognostic importance of lung ultrasound sonography in patients with st-elevation myocardial infarction
Authors: Petrosyan H , Hayrapetyan H , Torozyan S H , Tsaturyan A , Ghrmajyan H
Published: November 2023

Background

Lung ultrasonography (LUS) is a relatively new method for assessing subclinical lung congestion. It has been approved to predict prognosis in heart failure; however, the importance of LUS as a prognostic marker in acute myocardial infarction is not well studied.

Purpose

Our goal was to assess the predictive value of LUS in patients with ST-segment elevation myocardial infarction(STEMI).

Methods

The study involved 140 patients in total. The primary percutaneous coronary intervention was performed on all patients. We used the 8-zone approach to perform LUS in patients with STEMI within 6 hours of admission. LUS detected lung congestion as B-lines, and the sum of the B-line from 8 chest zones was determined. The patients were divided into two groups depending on the amounts of B lines. Patients with a number of B-lines < 15 were included in Group 1 (70 patients) and patients with a B-lines ≥ 15 were included in Group 2 (70 patients). The NT-proBNP analysis was performed both upon admission and six months later. The groups' other characteristics were similar. The primary outcome was a 6-month death rate after admission for STEMI. The secondary endpoint was NT-proBNP level over six months and cardiac cause of rehospitalization.

Results

NT-proBNP levels were, on average, 1471.6±272.8pg/ml in group 1 and 1512.3 ±285.8pg/ml in group 2 at the beginning of the study (p=0.39). It was 653.5±241.6 pg/ml and 857.4±217.8pg/ml, respectively, at the end of six months (p < 0.0001). Cardiovascular mortality during follow-up was 2.86 % in group 1 and 12.86 % in group 2 (p =0.029), and hospitalization for a cardiac cause was 7.14% and 18.57%, respectively (p =0.044).

Conclusions

LUS may be used as part of the initial risk stratification in STEMI patients because it provides important prognostic information. B-lines detected by lung ultrasound can be an independent predictor of poor prognosis in STEMI patients.
Vasoactive medication requirements in the first 24 hours of cardiogenic shock: association with mortality and mechanical circulatory support
Authors: Sarma D , Kashani K , Jentzer J
Published: November 2023

Background

Vasoactive medications and Mechanical Circulatory Support (MCS) are both central to the contemporary management of cardiogenic shock (CS). There are limited data on the interaction between vasoactive medication dosing and MCS in patients with CS.

Purpose

We investigated the association between in-hospital mortality and vasoactive medication dosing among patients with CS who did and did not receive MCS during hospitalization.

Methods

We included patients with CS admitted to our cardiac intensive care unit (CICU) between 2007 and 2015. The peak combined vasoactive medication dose during the first 24 hours of CICU admission was recorded and converted to norepinephrine equivalents (NEE)(references 1 & 2). The primary outcome was in-hospital mortality. Multivariable logistic regression was used to adjust for relevant variables and calculate adjusted odds ratios (OR).

Results

Of 1078 patients with CS (median age 69.0 years [Interquartile Range 59.1-77.3], 36.8% female, 59% with acute myocardial infarction), 721 (66.9%) received vasoactive medications in the first 24 hours and 510 (47.3%) received MCS (87% intra-aortic balloon pump). Among those receiving vasoactive medications during the first 24 hours, the median NEE was 0.16 (Interquartile Range 0.06-0.40) mcg/kg/min. In hospital mortality was 34.4% overall, and was lower among those who received MCS (26.1% versus 41.9%, p<0.001; adjusted OR 0.71 95% CI 0.50-0.99) and higher among those who received vasoactive medications (38.1% versus 26.9%, p<0.001). A gradient of mortality was observed according to the use of vasoactive medications and MCS (Fig. 1). We found a strong incremental association between in-hospital mortality and NEE (adjusted OR 1.11 per 0.1 mcg/kg/min, 95% CI 1.06–1.16, P<0.001; Fig. 2). Mortality was lower across the spectrum of NEE for patients who received MCS (Fig. 2). There was no statistically significant difference in the slope of the relationship between in-hospital mortality and NEE in patients who did and did not receive MCS (p = 0.86).

Conclusion

Increasing vasoactive medication requirement during the first 24 hours of CICU admission is incrementally associated with in-hospital mortality in CS, representing a simplified marker of shock severity. Patients who received MCS were at lower risk of mortality across the spectrum of vasopressor requirements, emphasizing the potential synergy between these two complementary approaches to hemodynamic support.Figure 1Figure 2
Diagnostic performance of noninvasive computed tomography-derived fractional flow reserve in patients with severe aortic stenosis
Authors: Yamanaka F , Shishido K , Moriyama N , Ochiai T , Miyashita H , Yokoyama H , Yamaguchi M , Yamashita T , Matsumoto T , Tobita K , Mizuno S , Tanaka Y , Murakami M , Tsujita K , Saito S
Published: November 2023

Background

Noninvasive fractional flow reserve derived from coronary computed tomography angiography (FFRct) is developed as a decision-making tool in daily clinical practice. However, its diagnostic performance has not been sufficiently explored in patients with severe aortic stenosis (AS).

Purpose

To identify the diagnostic performance of FFRct in patients with severe AS using invasive fractional flow reserve (FFR) as the reference standard.

Methods

This study was a retrospective observational that included consecutive patients with severe AS undergoing TAVI who had concomitant intermediate coronary artery stenosis based on preoperative invasive coronary angiography. Preoperative invasive FFR and CT data preoperatively before TAVI were prospectively collected.

Results

We analyzed the data of patients with severe AS demonstrating intermediate coronary artery stenosis and compared the FFRct values with the invasive FFR values. Among 93 patients (100 vessels), the median FFR and FFRct (Q1, Q3) were 0.85 (0.78, 0.90) and 0.83 (0.72, 0.88), respectively. The FFRct values significantly correlated with the FFR values (r = 0.57; p < 0.0001). The vessel-based analysis of the accuracy of FFRct showed a sensitivity of 90.3%, specificity of 73.9%, positive predictive value of 60.9%, and negative predictive value of 94.4%.

Conclusions

FFRct demonstrated a significant correlation with invasive FFR and a high negative predictive value in patients with severe AS. These findings suggest that FFRct would be a clinically beneficial noninvasive tool for excluding functional coronary artery stenosis in patients with severe AS.
Trends in mechanical circulatory support use and outcomes of patients with cardiogenic shock in Japan, 2010-2020: a nationwide inpatient database study
Authors: Nishimoto Y , Ohbe H , Nakata J , Watanabe T , Yamada T , Fukunami M , Yasunaga H
Published: November 2023

Background/Introduction

Little is known about the impact of the downgrade of guideline recommendations for intra-aortic balloon pump (IABP) use and the approval of the Impella in Japan, where IABPs have been enthusiastically used.

Purpose

This study aimed to describe the annual trends in the mechanical circulatory support (MCS) use and outcomes in patients with cardiogenic shock (CS) requiring MCS.

Methods

This was a retrospective cohort study using the Japanese Diagnosis Procedure Combination database, which contained administrative claims data and discharge abstracts from more than 1,500 acute care hospitals and covered approximately 90% of all tertiary emergency hospitals in Japan. Using the data from July 2010 to March 2021, we identified inpatients with CS requiring MCS. The primary outcome was in-hospital mortality. The secondary outcomes were the length of MCS, length of hospital stay, total hospitalization cost, major bleeding, ischemic stroke, continuous renal replacement therapy, and total blood transfusion volume during the hospitalization. The patients were stratified into three groups: (i) IABP alone, (ii) Impella alone, and (iii) extracorporeal membrane oxygenation (ECMO) regardless of IABP or Impella use. The patient characteristics and outcomes were reported by the fiscal year.

Results

Of the 160,559 eligible patients, 117,599 (73.2%) were identified as the IABP alone group, 1,465 (0.9%) as the Impella alone group, and the remaining 41,495 (25.8%) as the ECMO group. Of the overall 1,107 hospitals, IABP alone was used in 1,096 (99.0%), Impella alone in 120 (10.8%), and ECMO in 831 (75.1%). In-hospital mortality was 17.4%, 38.0%, and 68.3% in the IABP alone, Impella alone, and ECMO groups, respectively. The length of hospital stay was 32.6, 36.6, and 29.4 days and the total hospitalization cost was 4,522, 9,098, and 5,840 thousand yen in the IABP alone, Impella alone, and ECMO groups, respectively. All of major bleeding, ischemic stroke, and continuous renal replacement therapy were most prevalent in the Impella alone group and least prevalent in the IABP alone group. The prevalence of an IABP alone significantly decreased from 80.5% in 2010 to 65.3% in 2020 (P for trend <0.001). In contrast, the prevalence of an Impella alone significantly increased from 0.0% in 2010 to 5.0% in 2020, and the prevalence of ECMO significantly increased from 19.5% in 2010 to 29.6% in 2020. In-hospital mortality significantly increased from 29.3% in 2010 to 32.6% in 2020 in the overall patients with CS requiring MCS, but significantly decreased in those requiring ECMO from 73.7% in 2010 to 64.1% in 2020 (P for trend <0.001 for both).

Conclusions

There were significant annual changes in the patterns of MCS use and clinical outcomes in patients with CS requiring MCS.
The impact of hospital volume on the prognosis of patients with cardiogenic shock requiring mechanical circulatory support
Authors: Araki T , Kondo T , Imaizumi T , Sumita Y , Nakai M , Tanaka A , Okumura T , Yang M , Butt J , Petrie M , Murohara T
Published: November 2023

Background

Short-term mechanical circulatory support (MCS) is indicated in refractory cardiogenic shock (CS). Each hospital's volume of MCS relates to the many factors including population served, clinician experience and availability of MCS. To establish regional integrated Hub-and-spoke care CS systems for improving the prognosis of patients with CS, detailed data on relationship between the volume of MCS and prognosis are required but are lacking. We evaluated the relationship between outcomes, including in-hospital mortality and case volume, and explored whether there is an upper limit to this relationship.

Methods

We used the Japanese nationwide database to identify patients receiving short-term MCS for CS between April 2012 and March 2020. Of 65,837 patients receiving short-term MCS, three sub-cohorts were created based on the MCS type used; the intra-aortic balloon pump (IABP) alone (n=48,643), the extracorporeal membrane oxygenation (ECMO) (n=16,871), and the Impella cohorts (n=696).

Results

The median volume of annual cases in each hospital was 13.5 (7.4–22.1) in the IABP alone cohort, 6.4 (3.4-11.0) in the ECMO cohort, and 7.5 (4.0–10.7) in the Impella cohort. In the IABP alone and ECMO cohorts, the group with the higher case volume had less acute myocardial infarctions and received right heart catheterization more frequently. The highest quintile for the volume of cases in the IABP alone and ECMO cohorts had the lowest in-hospital mortality (IABP alone cohort, 25.1% in quintile 1 vs. 15.2% in quintile 5; ECMO cohort, 73.7% in quintile 1 in 67.4% in quintile 5), while it had the highest cost. Adjusted odds ratios for in-hospital mortality increased as case volume increased (IABP alone cohort, 0.63 [0.58–0.68] in quintile 5; ECMO cohort, 0.73 [0.65–0.82] in quintile 5, with the lowest quintile as reference) but did not increase significantly in the Impella cohort (0.90 [0.58–1.39] in tertile 3, with the lowest tertile as reference) (Figure 1). In continuous models, in-hospital mortality decreased to 28 cases/year in the IABP alone cohort and 12 cases/year in the ECMO cohort, and the mortality became almost flat above that (Figure 2). Hospitals with 28 or more cases/year in the IABP cohort were 3.6 % including 15.5 % of patients, and hospitals with 12 or more cases/year in the ECMO cohort were 4.7% including 20.9% of patients.

Conclusions

Higher volumes of IABP and ECMO are associated with a lower mortality. There is an upper limit to the decline, above which in-hospital mortality remains constant or increases slightly. Centralizing patients with refractory cardiogenic shock in a particular hospital might improve patient outcomes in each region.