bluuebunny/crossref_metadata_2025 huggingface dataset:
External validation of a suggested extension of the ESC 0/1h-algorithm for early rule out of myocardial infarction
Authors: Lopez Ayala P , Nestelberger T , Strebel I , Ratmann P.D , Boeddinghaus J , Koechlin L , Wussler D , Walter J , Rubini Gimenez M , Miro O , Martin-Sanchez F.J , Keller D , Twerenbold R , Mueller C
Published: November 2020

Background

The European Society of Cardiology (ESC) high sensitivity cardiac troponin T 0/1h-algorithm has substantially improved the management of patients with suspected acute myocardial infarction (AMI) by triaging about 75% of patients to rapid rule-out and/or rapid rule-in. However, about 25% of patients remain in the “observe-zone”, and the optimal management of these patients is unknown. Recently, a pilot single center study with a low prevalence of AMI suggested that an absolute change of less than 7ng/L between the 0h and 3h hs-cTnT concentration would allow to help in the evaluation of patients in the observe-zone and allow triage towards rule-out with very high negative predictive value [NPV].

Purpose

To externally validate this suggested modification of the ESC 0/1h-algorithm for early rule out of AMI.

Methods

In an ongoing multicentre international study, we prospectively enrolled unselected patients presenting to the emergency department with symptoms suggestive of MI. Final diagnoses were centrally adjudicated by two independent cardiologists using all available medical records obtained during clinical care including 90 day follow-up information and cardiac imaging. High sensitivity-cTnT (Elecsys) concentrations were measured at presentation and after 1 and 3 hours. The primary outcome was safety, quantified by the sensitivity and NPV for early rule out of NSTEMI.

Results

Among 1633 enrolled patients with available 0, 1 and 3h hs-cTnT concentrations, NSTEMI was the adjudicated final diagnosis in 337 (20.6%) patients. The ESC 0/1h-algorithm ruled out 918 (56.2%) patients, with a sensitivity of 98.8% (95% confidence interval [CI], 97.0–99.5) and a NPV of 99.6% (95% CI, 98.9–99.8). A total of 428 patients (26.2%) remained in the observe zone. After applying the suggested 0–3 hour absolute change cut-off criteria of 7ng/L, 393 (92.0%) additional patients from the observe zone were triaged towards ruled out. However, the safety of this triage step was poor with 62 patients with NSTEMI missed, resulting in a sensitivity of 33.3% and a NPV of 84.2% for rule-out.

Conclusions

The suggested 0/3h absolute change cut-off of 7ng/L for patients remaining in the observe zone of the ESC 0/1h-algorithm does NOT allow safe rule-out of AMI and should therefore NOT be implemented into routine clinical care.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation, the Swiss Heart Foundation, the Stiftung für kardiovaskuläre Forschung Basel, the University of Basel and the University Hospital Basel
Recombinant Interleukin-1 receptor antagonist for the treatment of ST-segment elevation acute myocardial infarction prevents future heart failure events: a pooled analysis of the VCUART program
Authors: Van Tassell B , Wohlford G.F , Ho A.C , Vecchie A , Garmendia C , Trankle C.R , Buckley L.F , Kadariya D , Canada J.M , Carbone S , Markley R , Turlington J.S , Appleton D , Lipinski M.J , Abbate A
Published: November 2020

Background

ST segment elevation myocardial infarction (STEMI) is associated with an intense acute inflammatory response and an increased risk of death and heart failure (HF). We analyzed the effect of recombinant interleukin-1 receptor antagonist (anakinra) 100 mg subcutaneous injection given once or twice daily for 14 days on the occurrence of HF in a pooled analysis of 3 clinical trials.

Methods

Enrollment criteria and study procedures were the same across the three studies. High-sensitivity C-reactive protein (CRP) was measured at baseline, 72 hours, and 14 days to construct an area under the curve (AUC0–14). Clinical events up to 1 year were adjudicated by an independent committee blinded to treatment allocation. Data for anakinra once daily and anakinra twice daily were pooled into a single anakinra group. CRP data are presented as median and interquartile range to allow for deviation from Gaussian distribution and non-parametric tests were used to evaluate differences between groups. Kaplan-Meier survival analyses were conducted and the intervention groups were compared using a log-rank test.

Results

Between 2008 and 2017, 139 patients with STEMI were enrolled. 84 patients were randomized to anakinra and 55 patients were randomized to placebo. Anakinra significantly reduced the CRP AUC0–14 (76 [42–147] vs 222 [117–339] mg*day/L; P<0.001), the composite of death or HF hospitalization (Chi2=7.167; P=0.007), and the composite of death or new onset HF (Chi2=9.43; P=0.002) compared with placebo. Treatment with anakinra had no effect on ischemic events (composite of death, myocardial infarction, and unstable angina; (Chi2=0.574; P=0.45) or the composite of death, myocardial infarction and cerebrovascular accident (Chi2=0.065; P=0.80). Patients receiving anakinra had increased injection site reactions (20.2% vs 3.6%; P=0.005) but no change in infections (14.3% vs 9.1%, P=0.435) versus placebo.

Conclusions

Treatment with anakinra for 14 days following STEMI blunts the inflammatory response and appears to reduce the occurrence of HF events at 1 year. These results support the hypothesis that early and targeted modification of the inflammatory response in STEMI may be a viable strategy to improve patient outcomes.

Adjudicated events at 1 year

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Heart Lung and Blood Institute (USA), American Heart Association (USA)
Prasugrel compared to ticagrelor in primary PCI
Authors: Doerler J , Edlinger M , Alber H , Berger R , Frick M , Hammerer M , Hasun M , Huber K , Lamm G , Lassnig E , Von Lewinski D , Roithinger F.X , Siostrzonek P , Steinwender C , Weidinger F
Published: November 2020

Background

Prasugrel and ticagrelor have similar recommendations in the setting of primary PCI by current guidelines. Data comparing both in daily clinical practice of primary PCI for ST-elevation myocardial infarction is limited.

Purpose

To compare the effect of prasugrel and ticagrelor on in-hospital outcomes after primary PCI.

Methods and results

We prospectively enrolled 5365 patients treated with prasugrel (n=2785, 51.9%) or ticagrelor (n=2580; 48.1%) in the setting of primary PCI from January 2011 to December 2018 in a nationwide registry. In-hospital outcomes were compared and multiple logistic regression analysis was performed. Prasugrel treated patients were younger, less often in cardiogenic shock, with lower rates of previous stroke and had shorter ischemic time. Both groups showed similar rates of previous MI, diabetes and current resuscitation. In the univariate analysis mortality was lower in patients with prasugrel (2.5% vs. 4.4% p<0.01). Similarly, MACE (3.3% vs. 5.3%, p<0.01) and NACE (4.0% vs. 5.7% p<0.01) were lower in prasugrel treated patients, whereas major bleeding events did not differ (0.4% vs. 0.6% p=0.24).

After adjustment in multivariable analysis mortality (0.99 95% CI 0.57 to 1.72), MACE (OR 0.99 95% CI 0.65 to 1.52) as well as NACE (0.86 95% CI 0.61 to 1.22) did not differ in patients treated with prasugrel compared to ticagrelor.

Conclusion

Patients treated with prasugrel showed improved outcomes compared to ticagrelor in a large cohort of primary PCI. However, after adjustment for confounders the Advantage of prasugrel in primary PCI did not persist.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Austrian Society of Cardiology
Sex disparities in completeness of revascularisation and outcomes in patients with ST-elevation myocardial infarction and multivessel coronary artery disease
Authors: Mahdi N , Har B , Graham M.M , Basha A , Bizios A
Published: November 2020

Background

In patients with ST-elevation myocardial infarction (STEMI) and multivessel coronary artery disease (CAD), complete revascularisation is associated with reduced mortality compared to culprit only revascularisation. However, there are limited data regarding the relationship between sex and revascularisation strategy in STEMI with multivessel CAD and outcomes.

Purpose

Our aim is to evaluate sex related differences in treatment strategies and outcomes in patients with STEMI and multi-vessel CAD.

Methods

We included all consecutive patients from a provincial registry presenting with STEMI and multivessel CAD treated with percutaneous coronary intervention (PCI) from 2008–2015. The study population consisted of 856 females and 3152 males who were treated with culprit vessel only PCI or complete revascularisation using staged-PCI. The outcomes were death, admission for acute coronary syndrome (ACS), and admission for heart failure (HF). Multivariate Cox proportional hazard models were used to examine the association between treatment strategy and outcomes. Backward stepwise logistic regression was used to identify predictors of patients undergoing staged-PCI versus culprit vessel only PCI.

Results

At 3 years, the incidence of death was higher in females than males (15.9% vs. 8.2%, p<0.001), as were HF admissions (10.3% vs. 5.0%, p<0.001). Females underwent less staged-PCI than males (10.4% vs. 14.8%; adjusted odds ratio 0.75; 95% CI 0.57–0.97). Younger age and increasing Duke jeopardy score were also associated with performing staged-PCI.

After adjusting for baseline characteristics, females had a higher risk of death (HR 1.35; 95% CI 1.07–1.71), ACS admission (HR 1.27; 95% CI 1.00–1.60), and HF admission (HR 1.38; 95% CI 1.03–1.85). Following additional adjustment for revascularisation strategy, only death and HF admission remained significant. Females undergoing staged-PCI had similar survival to males (figure), with no significant interaction between revascularisation strategy and sex (p for interaction = 0.19)

Conclusion

Females with STEMI and multivessel CAD were less likely to be treated with complete revascularisation by staged-PCI and had worse outcomes when compared to males. Survival in both males and females treated with staged-PCI was similar. Our study suggests that addressing the lack of complete revascularisation in females presenting with STEMI may improve outcomes.

Figure 1

Funding Acknowledgement

Type of funding source: None
External validation of PRECISE-DAPT score and PARIS bleeding risk score in a real-world cohort of patients with acute coronary syndrome
Authors: Chan Pin Yin D.R.P.P , Claassens D.M.F , Van Baal F.P , Vos G.J , Peper J , Kelder J.C , Ten Berg J.M
Published: November 2020

Background

In patients with acute coronary syndrome (ACS) shortened duration of dual antiplatelet therapy (DAPT) should be considered in those at high risk of bleeding. Risk scores may be used to assess the bleeding risk, but their predictive value remains unclear.

Purpose

To externally validate and compare the PRECISE-DAPT and the PARIS bleeding risk scores in patients with ACS.

Methods

From January 2015 to June 2018, all patients admitted with ACS were consecutively included in a single center, observational, prospective registry with follow-up of at least one year. In all patients, the PRECISE-DAPT and the PARIS risk-score were retrospectively assessed. Primary endpoint was moderate or severe bleeding defined as Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding within one year after ACS. Kaplan-Meier curves showed the probabilty of bleeding during follow-up as assessed by both scores. Score discrimination using c-statistic were calculated and calibration curves were visually assessed.

Results

2,729 patients were included for analysis. 93.6% were discharged with ≥2 antithrombotic drugs. At one year follow-up, the event rate of moderate or severe bleeding was 5.5%. High bleeding risk as stratified by both risk scores was associated with higher bleeding rates. Discriminative values for BARC 3 or 5 bleeding at one year were 0.67 [95% CI 0.61–0.72] for the PRECISE-DAPT score and 0.62 [95% CI 0.57–0.68] for the PARIS bleeding score (p=0.31).

Conclusion

The PRECISE-DAPT and the PARIS bleeding scores both showed adequate discriminative performances in predicting moderate or severe bleeding in this study.

Kaplan-meier and ROC-curves

Funding Acknowledgement

Type of funding source: None
Sex-related differences in mortality and heart failure after nstacs. the cardio chus-hsuj registry
Authors: Abou Jokh Casas C , Alvarez Alvarez B , Cordero A , Agra Bermejo R , Alvarez Rodriguez L , Rodriguez Ferreiro T , Martinez Gomez A , Rigueiro P , Garcia Acuna J.M , Gonzalez Juanatey J.R
Published: November 2020

Introduction and objectives

A sex-specific analysis of cardiovascular outcomes afternon-ST segment elevation acute coronary syndrome (NSTACS) using a large contemporary cohort of patients from two Spanish tertiary hospitals.

Methods

This retrospective observational study included 5686 consecutive NSTACS patients between the years 2003 and 2017. We performed a propensity score matching to obtain a well-balanced subset of patients, resulting in 3120 patients. Cox regression models performed survival analyses once proportional risk test were verified.

Results

Among the study participants, 1572 patients (27.6%) were women. The median follow-up was 60.0 months (standard deviation 32 months). Women had higher risk of cardiovascular mortality compared with men (OR (Odds ratio) 1.27, CI (confidence interval) 95% 1.08–1.49) and heart failure (HF) hospitalization (OR 1.39, CI 95% 1.18–1.63), but a similar risk of all-cause mortality (OR 1.10, CI 95% 1.08–1.49). After a propensity score matching, women were associated with a significant reduction in the risk of total mortality (OR 0.77, CI 95% 0.65–0.90) with a similar risk of cardiovascular mortality (OR 0.86, CI 0.71–1.03) and HF hospitalization (OR 0.92, CI 95% 0.68–1.23). After adjustment for baseline characteristics, the risks of all-cause mortality and cardiovascular mortality were less in women; although the risk of HF was similar among sexes.

Conclusions

Women are at similar risk to develop early and late HF admissions after NSTACS, and have better survival compared with male, with lower risk of all-cause mortality and cardiovascular mortality.

Cumulative risk according to gender

Funding Acknowledgement

Type of funding source: None
Early monomorphic ventricular tachycardia is associated with increased long-term mortality in STEMI
Authors: Demidova M , Ulfarsson A.O , Carlson J , Erlinge D , Platonov P.G
Published: November 2020

Background

Malignant ventricular arrhythmias occurring early during ST-elevation myocardial infarction (STEMI) are known to markedly contribute to increased in-hospital mortality, but not to influence the long-term prognosis. However recent data advocate differential approach to the type of arrhythmia and indicate long-term hazard of monomorphic ventricular tachycardia (VT).

Purpose

We aimed to evaluate the prognostic value of monomorphic VT compared to non-monomorphic VT or ventricular fibrillation (VF) during the first 48 hours of STEMI in non-selected cohort of STEMI patients admitted for primary PCI.

Methods

Consecutive STEMI patients admitted to a tertiary care hospital for primary PCI during 2007–2010 were included. The Swedish national SWEDEHEART registry was used for assessment of clinical characteristics and the presence of VT/VF during index admission. The occurrence and type of VT/VF during the first 48 hours from symptom onset were verified in medical records. Information on all-cause mortality endpoint 8 years after STEMI was obtained from the Swedish Cause of Death Register.

Results

In total, 2277 patients were included (age 66±12 years, 70% male). Early monomorphic VT during index STEMI was documented in 35 (1.5%) and non-monomorphic VT or VF – in 115 (5.1%) patients. Patients with monomorphic VT had similar clinical characteristics compared to those with non-monomorphic VT/VF with a trend of higher prevalence of history of myocardial infarction by index admission among those with monomorphic VT (31% vs 21%, p=0.256). In total, 22 (63%) patients with monomorphic VT and 43 (37%) with non-monomorphic VT/VF died by 8 years of follow up (p=0.011). Monomorphic VT was associated with a higher risk of all-cause mortality compared to non-monomorphic VT/VF in a univariate analysis (HR 2.03, 95% CI 1.21–3.39, p=0.007) and after adjustment for age and history of myocardial infarction (HR 1.74, 95% CI 1.02–2.97, p=0.041) (Figure).

Conclusion

Monomorphic VT during the first 48 hours of STEMI is associated with a higher risk of all-cause mortality compared to non-monomorphic VT/VF and deserves further studies in order to refine risk stratification strategies.

Survival after STEMI by VT/VF <48 hours

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): The Swedish Heart-Lung Foundation
Impact of pre-hospital resuscitation on short-and long-term mortality in patients with cardiogenic shock and multivessel disease. Results of the CULPRIT trial
Authors: Zeymer U , Alushi B , Lauten A , Akin I , Desch S , De Waha-Thiele S , Leistner D , Ouarrak T , Schneider S , Thiele H
Published: November 2020

Background

There are only a few prospective data on the outcome of patients with cardio-pulmonary resuscitation (CPR) admitted with acute myocardial infarction (AMI) complicated by cardiogenic shock and an invasive strategy including primary percutaneous coronary intervention (PCI). Therefore, we evaluated the impact of pre-hospital CPR on outcomes in a large group of patients with AMI complicated by cardiogenic shock.

Methods

We used the data of the prospective CULPRIT-Shock trial and registry and including patients with acute myocardial infarction complicated by cardiogenic shock. The primary endpoint was 30-day mortality or renal replacement therapy.

Results

Between 2013 and 2017, a total of 1055 patients were included in the randomized trial (n=686) and in the registry (n=369), 550 (54%) had CPR, 40 had no information regarding CPR. Baseline characteristics, procedural features and outcomes in the two groups with and without CPR are given in the table.

Conclusion

Patients with pre-hospital CPR represent more than half of the population with AMI complicated by cardiogenic shock. They are younger, have less risk factors and more often LAD as infarct vessel. Despite the younger age and a high success rate of PCI patients with CPR have a high 30-day mortality.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Deutsches Zentrum fuer Herz-Kreislauf-Forschung - DZHK
IABP and VA-ECMO is associated with better outcome than VA-ECMO alone in the treatment of cardiogenic shock in STEMI
Authors: Van Den Brink F , Zivelonghi C , Vossenberg T , Sjauw K.D , Bleeker G , Winia V , Ten Berg J.M
Published: November 2020

Introduction

VA-ECMO is an upcoming technique in the treatment of cardiogenic shock in patients with STEMI however it increases afterload. IABP in addition to VA-ECMO has been suggested to reduce afterload and increase survival.

Methods

A multi-center in-hospital registry was kept on all patients undergoing VA-ECMO or VA-ECMO and additional IABP treatment for cardiogenic shock in STEMI. Patients were analyzed for baseline characteristics, coronary anatomy using the SYNTAX score, predicted survival using the SAVE-score, survival, neurological status and complications.

Results

Between 2011 and 2018 18 patients with STEMI underwent VA-ECMO +/− IABP treatment for cardiogenic shock. The majority was male (78% (14/18)) with a median age of 59 (47–75) years. All patients were in Killip class IV. VA-ECMO alone was performed in 61% (11/18) and VA-ECMO and IABP was performed in 39% (7/18). A cardiac arrest was observed 91% (10/11) of the patients in the VA-ECMO alone group vs 71% (5/7) in the VA-ECMO+IABP group (p=0.52).

The VA-ECMO+IABP group had more complex coronary anatomy, i.e. a higher amount of left main (LM) disease, LM + 3 vessel disease, and three vessel disease when compared to the ECMO alone group (ECMO+IABP 87% vs ECMO alone 18% vs p=0.03). The Syntax score was higher in the ECMO+IABP group (ECMO alone 22±14 vs ECMO+IABP 32±13). The SAVE score did not differ between the groups (ECMO alone −5.9±2.4 vs ECMO+IABP −6.1±2.6 p=0.88) and has a predicted survival of 25–35%.

Survival in the VA-ECMO+IABP group was 100% (7/7), survival in the VA-ECMO group was 55% (6/11) (p=0.035). Good neurological outcome was achieved in more patients in the ECMO+IABP group (ECMO alone 45% vs ECMO+IABP 100% p=0.037). There was no difference in leg ischemia between the VA-ECMO alone group vs the ECMO+IABP group (27% (2/11) vs 0% (0/7) p=0.55) or in bleeding complications (18% (2/11) vs 43% (3/7) p=0.28)

Conclusion

VA-ECMO can improve survival in patients with cardiogenic shock due to STEMI even when in cardiac arrest. VA-ECMO in combination with IABP is associated with better outcome than VA-ECMO alone.

Funding Acknowledgement

Type of funding source: None
Modified zwolle score with delta-creatinine: enhancing the safety of early discharge after STEMI
Authors: Bras D , Pais J , Carrington M , Rocha A.R , Picarra B , Neves D , Semedo P , Aguiar J
Published: November 2020

Introduction

The Zwolle score (ZS) is recommended to identify low-risk patients eligible for early discharge after acute ST-segment elevation myocardial infarction (STEMI), but as only one-third of STEMIs have a low ZS, the discharge is often postponed. Creatinine variation (Δ-Cr) also provide prognostic information after STEMI.

Purpose

The authors intend to study the “modified Zwolle Score” (MZS) model, which encompasses Δ-Cr as a variable that may enhance the discriminative power of the standard ZS. The outcome is 30-day mortality, time range that starts right after the ACS.

Methods

This is a retrospective study with data from a national multicentre registry. We have included 3.296 patients with STEMI. Zwolle score was calculated for each patient. It is defined as shown in figure 1.

Δ-Cr was defined as maximum serum creatinine minus admission serum creatinine. A Δ-Cr≥0.3 was assigned 2 points in the Modified Zwolle Score, after interpretation of odds ratio via multivariate analysis.

For prediction quality assessment, we have performed ROC curve analysis with both scoring systems versus 30-day mortality. Regarding survival analysis, we have performed Kaplan-Meier curves with Log-rank analysis. We have also registered complications during hospital stay.

Results

The sample mean age is 63±14, and it is composed by 76.8% of males. The majority of patients presented Killip Class I (87.3%). The STEMI was anterior in 49.7% of patients and inferior in 49.8% of patients. The mean admission time was 5 days. Intrahospital mortality was 3% and 30-day mortality was 4%.

The mean ZS was 3.1±2.8 points, the mean MZS was 3±2.1 points and the mean Δ-Cr was 0.2±0.6mg/dL.

The ROC curve analysis between ZS and early mortality revealed a c-statistic of 0.810 (CI 0.796–0.823), whereas the ROC curve between MZS and early mortality revealed a c-statistic of 0.853 (95% CI: 0.841–0.865). The ROC curves comparison showed superiority of the MZS c-statistic, with a difference between AUC of 0.043 (p<0.001, 95% CI: 0.024–0.063).

Regarding low-risk patients, 30-day mortality was 3.3% using ZS (0–2 points) and 2.4% using modified ZS (0–2 points). Fifty patients (1.5%) died between 3rd and 10th day after ACS: original ZS low-risk criteria registered 0.09% and modified ZS low-risk criteria 0.06% fatalities. Kappa coefficient for intergroup concordance was good (0.73).

Conclusion

We conclude that by adding Δ-Cr to the standard ZS, a renal function parameter that was lacking in the ZS, its predicting capacity regarding early mortality in patients admitted with STEMI was increased. Comparing both scores, low-risk patients defined by MZS registered less complications, 3–10 day mortality and 30-day mortality than low-risk patients defined by the original ZS. This fact may lead to better distinction of patients who will benefit from early discharge.

Zwolle Score, ROC curves and survival

Funding Acknowledgement

Type of funding source: None
Prognostic impact of recommended treatment in patients with myocardial infarction with nonobstructive coronary arteries
Authors: Galan Gil D , Lopez Pais J , Izquierdo Coronel B , Olsen Rodriguez R , Abad Romero R , Espinosa Pascual M.J , Alonso Martin J.J
Published: November 2020

Introduction

Myocardial infarction with non-obstructive coronary arteries (MINOCA), and specially its treatment, is still a challenge in the clinical practice. The Position Paper of the European Society of Cardiology (PP-ESC) of 2016 recommend to treat this patients (pts) like those with obstructive arteries: double antiplatelet therapy (DAPT), betablockers, angiotensin converting enzyme inhibitors (ACEi) or angiotensin II receptor blocker (ARB) and statins. The aim of this study is to analyze the use of the recommended treatment in the clinical practice, and the impact in the prevention of cardiovascular events.

Methods

Analytical and observational study developed in a Universitary Hospital which covers over 220.000 individuals. From January-2016 to December-2019, we registered all the ptsthat were admitted for MINOCA. We analyzed the treatment at discharge and its relationship with mayor adverse cardiovascular events (MACE) at the year of follow up.

Results

During the period studied, 115 pts were diagnosed of MINOCA, with only one case of in-hospital death. At discharge, DAPT AAS were prescribed in 61%, and a second antiplatelet therapy (clopidogrel, ticagrelor or prasugrel) in 36% of pts. Only 63% of MINOCA pts were on betablockers at discharge, while 61% were on ACEi or ARB and 39% with both of them. Regarding other cardiovascular treatment nitrates were prescribed in 10% of MINOCA pts, calcium channel blocker (CCB) in 15% and nondihydropyridine-CCB in 5%. Statins were used in 61% of pts.

We completed the follow up of 97 of the 114 MINOCA pts discharged (85%). After one year of follow up, MACE occurred in 10 pts (10%). This events were less frequent among MINOCA pts treated with betablockers (3,3% vs 22,2%, p 0,005) and with ACEi/ARB (5,1% vs 18,4%, p 0,045). There were a significant difference in MACE between MINOCA pts who takes both betablockers and ACEi/ARB and those without these treatments (2.9% vs 40%, p 0,001). On the other hand, the use of nitrates and CCB were associated with a significant increase of MACE (5,7% vs 50%, p<0,001; 7,3% vs 26,7%, p<0,045). The use of statins or DAPT was not related with MACE in MINOCA pts.

Conclusion

This study showed a reduction in MACE with the use of betablockers and ACEi/ARB in MINOCA pts, and even an added effect with the joint use of them. Otherwise, the use of DAPT or statins did not reduce MACE. Surprisingly, nitrates and CCB appeared to increase the events, maybe showing that these drugs have to be used carefully in MINOCA pts or that the etiology of MINOCA in this concrete pts is the cause of the worse prognostic. In conclusion, more studies are needed to improve the knowledge of MINOCA and its correct treatment.

Funding Acknowledgement

Type of funding source: None
Spontaneous coronary artery dissection and takotsubo syndrome: comparison of baseline clinical and angiographic characteristics and in-hospital outcomes
Authors: Salamanca Viloria J , Garcia-Guimaraes M , Diez-Villanueva P , Macaya F , Sanz R , Roura G , Barahona-Alvarado J.C , Tizon H , Flores-Rios X , Lezcano-Pertejo C , Portero-Portaz J.J , Alvarado Casas T , Aguilar Torres R , Bastante Valiente T , Alfonso Manterola F
Published: November 2020

Background

Spontaneous coronary artery dissection (SCAD) and Takotsubo syndrome (TTS) constitute two relatively common non-atherosclerotic causes of acute cardiac syndrome particularly frequent in women.

Methods

Herein we compared the baseline clinical and angiographic characteristics and in-hospital outcomes of 2 large prospective registries on SCAD and TTS.

Results

A total of 318 SCAD and 106 TTS patients were included (88% women). Patients in the TTS group were older (Table) and presented a higher prevalence of cardiovascular risk factors. Precipitating triggers were more frequent in TTS patients (42% vs. 56%, P=0.009) but emotional stress was more common in the SCAD group (25% vs. 15%, P=0.037). SCAD patients had higher troponin and creatine-kinase levels. The left anterior descending coronary artery was the most frequently involved vessel (44%). Left ventricular dysfunction (ejection fraction 57±10 vs. 40±10%, P<0.001) was more frequently in TTS patients. Major adverse cardiovascular events (including death, myocardial infarction, ischemia-driven revascularization, development of heart failure and stroke during hospitalization) (4.7% vs. 12.3%, P<0.001) occurred more frequently in TTS patients, that also developed more frequently heart failure (<1% vs. 10%, P<0.001) and atrial fibrillation (1% vs. 11%, P<0.001). No differences were found in the rate of stroke in the 2 groups.

Conclusions

TTS patients are older and present a higher prevalence of cardiovascular risk factors than SCAD patients. They also present a worse in-hospital prognosis with higher mortality.

Funding Acknowledgement

Type of funding source: None
Isoflurane sedation in patients undergoing VA-ECMO treatment for cardiogenic shock – an observational propensity-matched study
Authors: Scherer C , Kupka D , Stocker T , Joskowiak D , Scheuplein H , Schoenegger C , Stremmel C , Luesebrink E , Stark K , Orban M , Peterss S , Hausleiter J , Hagl C , Massberg S , Orban M
Published: November 2020

Introduction

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

Methods

Thirty-two cardiogenic shock patients with VA-ECMO treatment under sedation with volatile isoflurane on a cardiac intensive care unit have been enrolled in this retrospective single-center study and were matched by propensity score in a 1:1 ratio with intravenously (IV) sedated patients.

Results

Administration of isoflurane was associated with lower IV sedative drug use during VA-ECMO treatment (86% vs. 32%, p=0.01). Mean systolic arterial pressure was similar (94.3±12.6 mmHg versus 92.9±10.5 mmHg, p=0.65), but mean heart rate was significantly higher in the conventional sedation group, when compared to the isoflurane group (85.2±20.5 / min vs. 74.7±15.0 /min; p=0.02). Catecholamine doses, VA-ECMO blood and gas flow, ventilation time (304±143 h vs. 398±272 h, p=0.16), bleeding complications BARC3a or higher (59.3% vs. 65.3%, p=0.76) and 30-day mortality (59.2% vs. 63.4%, p=0.80) were similar in both groups.

Conclusions

Volatile sedation with isoflurane is feasible in patients with cardiogenic shock and VA-ECMO treatment and was not associated with higher catecholamine dosage or ECMO flow rate compared to IV sedation.

Mortality and bleeding

Funding Acknowledgement

Type of funding source: None
Monocyte subsets predict mortality after cardiac arrest
Authors: Krychtiuk K.A , Lenz M , Richter B , Huber K , Wojta J , Hengstenberg C , Heinz G , Speidl W.S
Published: November 2020

Background

After successful cardiopulmonary resuscitation with return of spontaneous circulation (ROSC), many patients show signs of an overactive immune activation. Monocytes are a heterogenous cell population that can be distinguished into three subsets.

Purpose

The aim of this prospective, observational study was to analyze whether monocyte subset distribution is associated with mortality at 6 months in patients after cardiac arrest.

Methods

We included 53 patients admitted to our medical ICU after cardiac arrest. Blood was taken on admission and monocyte subset distribution was analyzed by flow cytometry and distinguished into classical monocytes (CM; CD14++CD16-), intermediate monocytes (IM; CD14++CD16+CCR2+) and non-classical monocytes (NCM; CD14+CD16++CCR2-).

Results

Median age was 64.5 (IQR 49.8–74.3) years and 75.5% of patients were male. Mortality at 6 months was 50.9% and survival with good neurological outcome was 37.7%. Of interest, monocyte subset distribution upon admission to the ICU did not differ according to survival. However, patients that died within 6 months showed a strong increase in the pro-inflammatory subset of intermediate monocytes (8.3% (3.8–14.6)% vs. 4.1% (1.5–8.2)%; p=0.025), and a decrease of classical monocytes (87.5% (79.9–89.0)% vs. 90.8% (85.9–92.7)%; p=0.036) 72 hours after admission. In addition, intermediate monocytes were predictive of outcome independent of initial rhythm and time to ROSC and correlated with the CPC-score at 6 months (R=0.32; p=0.043).

Discussion

Monocyte subset distribution is associated with outcome in patients surviving a cardiac arrest. This suggests that activation of the innate immune system may play a significant role in patient outcome after cardiac arrest.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): FWF - Fonds zur Förderung der wissenschaftlichen Forschung
Association of chain of survival factors with out of hospital cardiac arrest survival in a region with low average population-density: a retrospective population-based cohort study
Authors: Connolly M , Goldstein J , Giddens K , Nallbani M , Kennedy P , Currie M , Carter A , Travers A , Sapp J
Published: November 2020

Background

Out of hospital cardiac arrest (OHCA) has an average global survival rate to discharge of 8%. Chain of survival factors are heavily time-dependant and optimization can increase survival. Regions with low population density encounter challeges in providing optimal OHCA care. Nova Scotia's average population density is 17.4 persons per square kilometer in compasiron to Toronto with 4334.4 person per square kilometer. OHCAs have been described well in large urban centers globally, however the characterization of OHCA chain of survival in low density populations is sparse.

Purpose

To describe chain of survival factors and identify characteristics of survivors and non-survivors among those treated by paramedics in a low average density provincial population.

Methods

This was a retrospective cohort study of OHCAs responded to by paramedics. All OHCA responses with a cardiac etiology in Nova Scotia, Canada were included. Exclusion criteria were non-cardiac cause arrests, those with “do not resuscitate” (DNR) directives and expected deaths. The paramedic electronic patient care record was reviewed for demographic, bystander, out of hospital treatment and operational characteristics. Primary outcome was survival to hospital discharge. Descriptive statistics were calculated to describe differences between survivorship using Prism 8.0 (San Diego, CA) with alpha=0.05 applying unpaired, Mann-Whitney tests.

Results

Of 1517 OHCA, 463 were excluded leaving 1054 OHCA. Of these, 478 (45.3%) were treated by paramedics and included in this analysis. Most were men (67.2%; n=274) with a mean age 66.8 (±16.4). A total of 7.1% (n=75) survived to discharge with 76% of survivors (n=58) discharged home. Survivors were more likely to present with ventricular fibrillation than non-survivors (42.7% vs. 19.6%). Survivors compared to non-survivors had significantly shorter paramedic response time (8.1 vs. 10.7 min, P<0.001), paramedic time on scene (35.7 vs. 45.4 min, P=0.002), estimated time to paramedic defibrillation (13.2 vs 19.4 min, P<0.001), and estimated time to return of spontaneous circulation (ROSC) (22.9 vs 31.9min, P<0.001).

Conclusion

Links in the chain of survival are associated with survival from OHCA. OHCA survival is lower in the less densely populated province of Nova Scotia compared to studies in urban Canadian centers and worldwide. Our study is limited by the retrospective nature of data collection and lack of access to neurological outcomes. Even among survivors, EMS response is delayed compared to more densely populated centers. In Nova Scotia, longer paramedic response times are associated with decreased survival.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Maritime Heart Center
Genome-wide association meta-analysis in 652,134 participants identifies 9 novel susceptibility loci for aortic stenosis
Authors: Chen H.Y , Small A.M , Dina C , Cairns B.J , Whitmer R.A , Lathrop M , Smith J.G , Holm H , Wells Q.S , Rader D.J , Soderberg S , Schott J.J , Engert J.C , Thanassoulis G
Published: November 2020

Background

Aortic stenosis (AS) is the most common form of incident valvular heart disease. While valve replacement is effective, the absence of an approved medical therapy provides no alternatives to patients with contraindications or mild disease. An improved understanding of the genetics of AS could identify targets for pharmacological intervention.

Methods

An inverse variance-weighted, fixed effects meta-analysis of the association of 11,591,806 variants with AS was undertaken using data from 10 European cohorts totalling 652,134 participants (13,758 cases of AS). We queried publicly available datasets to characterize the functional consequences of genome-wide significant variants, conducted a phenome-wide association study to assess their association with other outcomes, and constructed polygenic risk scores to examine their association with AS. We also performed gene- and gene-set enrichment analyses, estimated genetic correlation with cardiovascular traits, and assessed whether five lipid or immunological biomarkers were causally associated with AS using Mendelian randomization.

Results

Eighteen independent variants at 16 loci attained genome-wide significance in the meta-analysis, including variants at all seven previously reported loci. Many of the significant variants were intronic or intergenic, and the phenome-wide association study revealed extensive pleiotropy with apolipoprotein B, C-reactive protein, and other cardiovascular and immunological traits. A weighted polygenic risk score composed of the 18 variants was strongly associated with AS (adjusted OR per SD, 1.38; 95% CI, 1.33 to 1.44; p=4.6×10–57), and improved the discriminatory ability for AS when added to a model that contained clinical risk factors (difference in the area under the curve p=2.0×10–11). Gene-based approaches indicated higher IL6R expression in the blood among AS cases compared to controls (p=3.1×10–6), and the association of LDLR with AS (p=2.3×10–10). Gene set analyses revealed that genes bound by the transcription factor TCF7 or micro-RNAs miR-21, miR-219, miR-491, and miR-19 were differentially expressed in the liver depending on AS status (p≤5.7×10–4), suggesting disease development may be mediated by tissue-specific transcriptional and post-transcriptional regulation. Mendelian randomization supported a causal association of five lipid and immunological biomarkers with AS, including low-density lipoprotein cholesterol (OR per mmol/L, 1.61; 95% CI, 1.48 to 1.75; p=1.3×10–30).

Conclusions

Evidence from large-scale genetic analyses indicate that lipid metabolism, inflammation, and calcification are key contributors to AS.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Canadian Institutes of Health Research, National Institutes of Health
Lipoprotein(a) is a strong risk factor for Aortic Valve Calcium
Authors: Kaiser Y , Singh S.S , Zheng K.H , Verbeek R , Kavousi M , Pinto-Sietsma S , Sijbrands E.J.G , Boekholdt S.M , De Rijke Y.B , Stroes E.S.G , Bos D
Published: November 2020

Background

Aortic valve calcium (AVC) is an important hallmark of aortic valve stenosis, which is the most common valvular heart disease in the Western world. Studies suggesting an important role for lipoprotein(a) [Lp(a)] in the etiology of AVC are accumulating, yet population-based evidence is scarce. Therefore, we investigated the association of Lp(a) with the presence of AVC in two large cohorts.

Methods

A total of 2412 participants from the population-based Rotterdam Study (52% women, mean age=69.6±6.3), and 859 asymptomatic persons from the Amsterdam Medical Center outpatient clinic for familial premature (non-valvular) atherosclerosis (57%women, mean age=45.9±11.6) underwent blood sampling to determine serum Lp(a) and non-enhanced cardiac CT-scan to assess AVC. We combined both cohorts and investigated the association of Lp(a) with the presence and amount of AVC using logistic and linear regression models, adjusting for age, sex, smoking, body mass index, non-high density lipoprotein cholesterol and use of antihypertensive medication.

Results

Out of a total of 3271 subjects with an average age of 63.4±7.98, AVC was present in 844 (25.8%) individuals. Higher levels of Lp(a) were associated with the presence of AVC, independent of age, sex and cardiovascular risk factors [Odds ratio (OR) per 1-SD increase in Lp(a): 1.39 (95% CI:1.27; 1.51). In persons with AVC, a higher level of Lp(a) was also related to larger volume of AVC [β per 1-SD increase in Lp(a): 0.76 (95% CI:1.27; 1.51)]. All findings were similar across both cohorts.

Conclusion

Lp(a) is a prominent and independent marker of the presence and amount of AVC in the general population. Future studies investigating the effect of Lp(a) lowering on the progression of AVC are warranted.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): NESTOR program for geriatric research, the Netherlands Heart Foundation, the Netherlands Organization for Scientific Research, the Health Research and Development Council (28-2975 and 97-1-364), and the Municipality of Rotterdam
Prevalence and prognosis of severe tricuspid regurgitation in patients with atrial fibrillation with normal left ventricular systolic function
Authors: Prapan N , Ratanasit N
Published: November 2020

Background

Significant functional tricuspid regurgitation (FTR) can be found in some patients with atrial fibrillation (AF). The results of the previous studies are still controversial whether significant FTR in patients with AF can cause worse outcomes such as heart failure or death.

Purpose

To study the prevalence, predictors and prognosis of significant FTR in patients with AF with normal left ventricular (LV) systolic function.

Methods

We conducted a retrospective cohort study in patients with AF and normal LV ejection fraction (LVEF) from May 2013 through January 2018. Significant FTR was defined as moderate to severe FTR. Pulmonary hypertension (PH) was defined as right ventricular systolic pressure >50 mmHg or mean pulmonary artery pressure >25 mmHg. We evaluated the prevalence of significant FTR and evaluated the adverse outcomes between significant and insignificant FTR groups. The adverse outcomes were defined as heart failure visit or hospitalization and all cause death within 2 years of follow up. We also evaluated the factors associated with significant FTR in AF patients.

Results

There were 498 patients with AF and 300 (mean age 68.8±10.8 years, 50% female) were included in the study. Paroxysmal, persistent and permanent AF were found in 34.7%, 44.7% and 20.6% respectively. Mean LVEF was 65.3±6.3%. PH and significant FTR were reported in 30.7% and 21.7%, respectively. All cause death and heart failure (visit and hospitalization) were found in 26 (8.7%) and 39 (13%) patients, respectively. There was no statistically significant difference in death between patients with significant and insignificant FTR (12.3% vs. 7.7%; 95% confidence interval (CI) 0.70–4.08, p=0.24). Patients with significant FTR had heart failure more often than those with insignificant FTR (61.5% vs. 38.5%; 95% CI 4.15 - 17.75, OR 8.58, p<0.001). The multivariate analysis showed that the predictors of significant FTR were female gender, permanent AF and presence of PH (OR 2.5, 3.6 and 6.1, respectively). The predictors of the adverse outcomes in patients with AF were high CHA2DS2-VASc score (95% CI 1.09 - 1.92, p=0.01) and significant FTR (95% CI 9.61 - 698.17, p<0.01).

Conclusions

Significant FTR was common in patients with AF and associated with heart failure outcomes. Female gender, permanent AF and presence of PH were independent predictors of significant FTR, while high CHA2DS2-VASc score and significant FTR were independent predictors of the adverse outcomes in patients with AF and normal LVEF.

Funding Acknowledgement

Type of funding source: None
How is juvenile rheumatic heart disease different: baseline results from a prospective north Indian registry
Authors: Mahajan K , Prakash Chand Negi D.R
Published: November 2020

Introduction

Juvenile rheumatic heart disease (RHD) refers to RHD in patients <20 years of age. There are no contemporary data highlighting the differences between juvenile and older RHD patients.

Purpose

We aim to report the age related differences in the pattern, and consequencies of valvular dysfunction in patients of RHD.

Methods

The 2475 consecutive patients of RHD diagnosed using clinical and echocardiographic criteria were registered prospectively from 2011 till December 2019. Patients were divided into 3 groups according to their age: Group 1 (Juvenile RHD), Group 2 (21–50 years), and Group 2 (>51 years).The data concerning the socio-demographic and clinical profile were recorded systematically, and the nature and severity of valvular dysfunction was assessed by echocardiography. The data were analyzed using the Epi-InfoTM Software.

Results

Out of 2475 RHD patients, Juvenile RHD comprised of 211 (8.5%) patients. Group 2 and 3 comprised of 1691 (68.3%) and 573 (23.2%) patients respectively. Overall, 1767 (71.4%) patients were females, however this female predilection was less pronounced in juvenile RHD (55.5% females vs 44.5% males) as compared to older groups. Past history of acute rheumatic fever was more commonly recorded in Juvenile RHD group (37.9% vs 18.8% in group 2 and 10% in group 3, p=0.0001). At the time of registration, the presence of advanced heart failure symptoms (dyspnea class III and IV) (11.4% group 1 vs 13.9% group 2 vs 20.6% group 3, p<0.0001), right heart failure symptoms (0.9% group 1 vs 2.5% group 2 vs 7.3% group 3, p<0.01), thromboembolic events (0% group 1 vs 4.1% group 2 vs 3.3% group 3, p<0.01), atrial fibrillation (2.8% group 1 vs 24.5% group 2 vs 45.9% group 3, p<0.0001), and pulmonary hypertension (27.1% group 1 vs 40.3% group 2 vs 51.9% group 3, p<0.01), were all more commonly recorded in non-juvenile older RHD groups. Multivalvular involvement was also less common in juvenile RHD (34.6% vs 42.4% and 44.5%, p=0.04). Mitral regurgitation was the most common lesion in Juvenile RHD followed by aortic regurgitation (68.7% and 40.2% respectively). Stenotic lesions (both mitral and aortic) were present more commonly in older age groups.

Conclusion

RHD is predominantly a disease of females, however the predilection is less common in juvenile patients. Juvenile RHD predominantly affects the mitral valve and mainly leads to regurgitant lesions. As the age advances, the complications of RHD, mainly heart failure symptoms, thromboembolic events, pulmonary hypertension, and atrial fibrillation, become more common.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Self sponsored registry