bluuebunny/crossref_metadata_2025 huggingface dataset:
Comparative efficacy of patiromer and sodium polystyrene sulfonate on potassium levels in chronic haemodialysis patients: a randomized crossover trial
Authors: Jaques David A , Stucker Fabien , Ernandez Thomas , Alves Cyrielle , Martin Pierre-Yves , De Seigneux Sophie , Saudan Patrick
Published: May 2022

Background

Hyperkalaemia is frequent in haemodialysis (HD) patients and associated with increased cardiovascular mortality. Despite routine clinical use, evidence regarding the efficacy of potassium (K+) binders in HD is scant. We wished to compare the efficacy of patiromer (PAT) and sodium polystyrene sulfonate (SPS) on K+ levels in this setting.

Methods

We screened patients in three HD centres with pre-HD K+ value between 5.0 and 6.4 mmol/L, after an initial 2-week washout period for those previously on K+ binders. We included patients in an unblinded two-arm crossover trial comparing SPS 15 g before each meal on non-dialysis days with PAT 16.8 g once daily on non-dialysis days with randomized attribution order and a 2-week intermediate washout period. The primary outcome was the mean weekly K+ value.

Results

We included 51 patients and analysed 48 with mean age of 66.4 ± 19.4 years, 72.9% men and 43.4% diabetics. Mean weekly K+ values were 5.00 ± 0.54 mmol/L, 4.55 ± 0.75 mmol/L and 5.17 ± 0.64 mmol/L under PAT (P = .003), SPS (P < .001) and washout, respectively. In direct comparison, K+ values and prevalence of hyperkalaemia were lower under SPS as compared with PAT (P < .001). While the incidence of gastrointestinal side effects was similar between treatments, SPS showed lower subjective tolerability score (6.0 ± 2.4 and 6.9 ± 1.9) and compliance (10.8 ± 20.4% and 2.4 ± 7.3% missed doses) as compared with PAT (P < .001 for both).

Conclusion

Both PAT and SPS are effective in decreasing K+ levels in chronic HD patients. However, at the tested doses, SPS was significantly more effective in doing so as compared with PAT, despite lower tolerability and compliance. Larger randomized controlled trials should be conducted in order to confirm our findings and determine whether they would impact clinical outcomes.
Novel loss-of-function mutations in TNFAIP3 gene in patients with lupus nephritis
Authors: Zhang Changming , Han Xu , Sun Li , Yang Sirui , Peng Jiahui , Chen Yinghua , Jin Ying , Xu Feng , Liu Zhihong , Zhou Qing
Published: May 2022

Background

Heterozygous loss-of-function mutations in the tumour necrosis factor alpha induced protein 3 (TNFAIP3) gene cause an early-onset auto-inflammatory disease named haploinsufficiency of A20 (HA20). Here we describe three unrelated patients with autoimmune lupus nephritis (LN) phenotypes carrying three novel mutations in the TNFAIP3 gene.

Methods

Whole-exome sequencing (WES) was used to identify the causative mutations in three biopsy-proven LN patients. Sanger sequencing and quantitative polymerase chain reaction (qPCR) were used to validate the mutations identified by WES. RNA sequencing, qPCR and cytometric bead array was used to detect inflammatory signatures in the patients.

Results

The patients predominantly presented with an autoimmune phenotype, including autoimmune haemolytic anaemia, multipositive autoantibodies and LN. Additionally, novel phenotypes of allergy and pericardial effusion were first reported. WES identified three novel heterozygous mutations in the TNFAIP3 gene, including a novel splicing mutation located in the canonical splicing site (c.634+2T>C) resulting in an intron 4 insertion containing a premature stop codon, a de novo novel copy number variation (exon 7–8 deletion) and a novel nonsense mutation c.1300_1301delinsTA causing a premature stop codon. We further identified hyperactivation signatures of nuclear factor- kappa B and type I IFN signalling and overproduction of pro-inflammatory cytokines in the blood. This report expanded the phenotype to a later age, as two girls were diagnosed at age 3 years and one man at age 29 years.

Conclusions

Kidney involvement may be the main feature of the clinical spectrum of HA20, even in adults. Genetic screening should be considered for early-onset LN patients.
Correlation of cholesterol efflux capacity with femoral and carotid plaque volume measured by sonographic 3D plaque volumetry
Authors: Noflatscher M , Hunjadi M , Schreinlechner M , Sommer P , Lener D , Mair F , Theurl M , Kirchmair R , Bauer A , Ritsch A , Marschang P
Published: May 2022

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Österreichische Nationalbank

Introduction Atherosclerosis is a systemic multifocal disease that can cause the narrowing and occlusion of arteries resulting in cardiovascular disease (CVD). Hypercholesterolemia plays a pivotal role in the pathogenesis of atherosclerotic plaques by the accumulation of cholesterol in the arterial wall. Cholesterol efflux mediated by HDL is capable of transporting cholesterol from the periphery back to the liver in a process called reverse cholesterol transport. Cholesterol efflux capacity (CEC) is inversely correlated with cardiovascular risk and proposed as a surrogate marker for reverse cholesterol transport. In this study, we set out to study a possible association between CEC and peripheral plaque volume.

Methods

Since lipid-lowering therapy interferes with CEC, we studied a subset of 176 patients (48.9% females) with a median age of 64 (IQR 57-70) without lipid-lowering medication that had been included in a study of 443 patients with at least one cardiovascular risk factor or established CVD. CETP-mediated cholesterol ester transfer was measured by quantifying the transfer of cholesterol ester from radiolabelled exogenous HDL to apoB-containing lipoproteins. CEC was determined using cAMP treated 3H-cholesterol-labeled J774 cells. Plaque volume in the carotid and the femoral artery was measured using a 3D ultrasound system equipped with semi-automatic software.

Results

We found a strong inverse correlation between CEC and high total plaque volume (p = 0.027) in patients without lipid-lowering therapy. On the other hand, there was no correlation between CETP-mediated cholesterol ester transfer (3h) and (16h), LDL- cholesterol, or lipoprotein(a) with total plaque volume.

Conclusion

CEC correlates inversely with peripheral atherosclerosis in patients not taking lipid-lowering therapy, further strengthening its role as a cardiovascular biomarker.
Venoarterial extracorporeal membrane oxygenation support for acute fulminant myocarditis
Authors: Ferraz LM , Costa C , Ferreira R , Faustino A , Albuquerque R , Paiva J , Neves A
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Acute fulminant myocarditis (AFM) may be life threatening. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can provide an effective cardiocirculatory support.

Purpose

This study aims to evaluate the clinical course and the prognosis of patients (P) with fulminant myocarditis supported by VA-ECMO.

Methods

Observational retrospective single-center study of 15 consecutive P (73% women; 45,6±11,6 years; body mass index 26,7±2,23kg/m2) admitted to an intensive care unit (ICU) for AFM managed by peripheral VA-ECMO between 2008 and 2018. Were included P with diagnosis of myocarditis, recent onset of symptoms and severe hemodynamic compromise within 7 days following hospital admission. P were followed during 29,4±8,4 months after discharge to identify rehospitalization due to cardiovascular causes (re-hosp), recurrence of myocarditis or death.

Results

The P had previous history of hypertension (20%), diabetes (13%), dyslipidemia (20%), autoimmune disease (7%), previous acute myocarditis (7%), 20% were former smokers and 7% active smoker. The main clinical presentation was chest pain (27%), dyspnea /heart failure (47%) and epigastric pain/nausea (13%). The media between symptom onset and hospitalization was 14,9±6,5 days. The total hospital length of stay was 37±6,9 days, with 18,7±16,1 days in the ICU. During hospitalization, arrhythmias were documented in 40%: atrial fibrillation/flutter (13%), complete atrioventricular block (13%), ventricular tachycardia (13%), ventricular fibrillation (7%), asystole (7%) and electrical storm (7%). Medical therapy included corticosteroids in 47% of P, immunosuppressive therapy in 13% and intravenous immunoglobulin in 13%. The mean duration of VA-ECMO support was 8,5±6,2 days. 27% had preserved left ventricular systolic ejection fraction (LVEF), 13% left ventricular dilation, 13% pericardial effusion and 13% late gadolinium enhancement. The mean LVEF was 23±8,2%. Endomyocardial biopsy was diagnostic for 3 out of 4P in which was performed. The etiology of myocarditis was identified in 60% of P: viral (33%), autoimmune (7%) and pheochromacitoma (20%). During hospitalization 5P (33%) died (3 in the ICU). The P who died had higher liver sequential organ failure assessment (SOFA) and kidney SOFA scores before starting ECMO, both being predictors of mortality (liver SOFA:Cramér’sV 0,76;95%CI 0,009-0,014;p=0,01;kidney SOFA:Cramér’sV 0,79;95% CI 0,03-0,04; p=0,031). At discharge, the survival rate was 67% and the recovery of LVEF ocurred in 47% of P. During follow-up, there were no re-hosp, recurrence of myocarditis or deaths and 53% of P had preserved LVEF.

Conclusion

AFM is associated with high mortality rates. Percutaneous VA-ECMO is a highly effective haemodynamic support that can be used as a "bridge to recovery". Once a patient recovers, the subsequent clinical outcome seems favourable.
Atrial fibrillation: the difference in thromboembolic events prognosis
Authors: Germanova O , Galati G , Germanov AV
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Aim

To identify the difference between the thromboembolic events in different types of atrial fibrillation (AF).

Materials and methods

We included 188 patients with permanent AF (of them were 99 men and 89 women). According to the data of 24-hours ECG monitoring, all patients were divided into 3 groups depending on the duration of maximum pauses between ventricular complexes in AF:

1. Patients with a pause < 1 second (64 people).

2. Patients with a pause of ≥1, but <2 seconds (62 people).

3. Patients with a pause ≥ 2 seconds or more (62 people).

In control group we included 80 patients without AF. All groups were identical in age, sex and comorbidities. All patients underwent transthoracic or transesophageal echocardiography (we excluded the intra-chamber thrombosis in all the patients as well as the left ventricle aneurisms), Doppler ultrasound of the brachiocephalic vessels, branches of the aorta, arteries of the lower extremities, renal arteries, lipids level. If it was indicated, we performed stress echocardiography, coronary angiography, renal artery angiography, computed tomography of brain with contrast. The patients of all groups were on the standard therapy recommended by current ESC guidelines. We were observing the patients for 1 year after the beginning of the investigation. The endpoints were at 3, 6 and 12 months after the primary visit. During these endpoints, we analyzed the development of thromboembolic complications.

Results

We analyzed the data obtained on thromboembolic complications in 1 year in patients of 1, 2, 3 groups and compared them with the control group. The most frequent incidence of complications was in group 3 compared with other groups and the control group. We believe that the risk factor for thromboembolic complications is not only the fact of permanent form of AF, but also what type of AF. The most unfavorable is AF with pauses between ventricular contractions of 2 seconds or more.

Conclusion

We consider to use the proposed functional classification of AF in clinical practice. Determination of the type of AF will largely determine the further management tactics of each patient, the prognosis of the thromboembolic complications. We supplemented the CHA2DS2-VASc score with the new independent risk factor – type of AF – in accordance to the maximum duration of pauses between cardiocycles.
Cardiac arrest in non-ST segment elevation myocardial infarction: what to expect
Authors: Carvalho P , Goncalves F , Monteiro J , Bernardo M , Carvalho C , Fontes P , Moreira I
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Ischemic heart disease is the leading cause of cardiac arrest (CA). While in ST segment elevation myocardial infarction its approach is well defined, in non-ST segment elevation myocardial infarction (NSTEMI) it is still a matter of debate. This study aimed to characterize patients with NSTEMI and out-of-hospital CA and to evaluate its prognosis.

Methods

This was a national multicenter retrospective study of patients hospitalized for NSTEMI undergoing coronary angiography (ANG) between October 2010 and September 2019.

Results

Out of a total of 9544 patients, 96 were admitted after CA. The baseline characteristics of both groups were similar, with the exception of more past history of heart failure (10,5% vs 5,6%, p=0,038) and peripheral artery disease (11,5% vs 5,9%, p=0,023) in patients with CA. In the peri-arrest period, 64,6% of the patients reported chest pain. Patients with CA had worse left ventricular ejection fraction (49±13% vs 53±12%, p=0,006), ended up reaching higher Killip classes more often and needing more inotropic and mechanical support. The median time from admission to ANG was similar in both groups (0 (0;3) vs 1 (0;2) days, p=0,796). CA patients had more multivessel coronary disease (66% vs 55,5%, p=0,043) and left main artery involvement (25,3% vs 11,2%, p<0,001). The proportion of revascularization procedures was similar. During hospitalization, patients with CA were less treated with beta-blockers (77,9% vs 85,2%, p=0,046) and ACE inhibitors (77,7% vs 86,1%, p=0,018), a difference that disappeared at discharge. However, statin prescription at discharge was lower in CA patients (88,3% vs 94,4%, p=0,040).

In a multivariate analysis for events occurred during hospitalization, CA was associated with a significant increase in myocardial reinfarction (adjusted OR 5,42 (95% CI 2,10-1,98)), stroke (adjusted OR 5,38 (95% CI 1,24-2,32)) and death (adjusted OR 13,86 (95% CI 5,98-32,17)). After excluding patients with indication for an immediate invasive strategy, we verified that mortality was higher in CA patients who underwent ANG in the first 24 hours. CA was not associated with a significant increase in the 1-year mortality rate (adjusted HR 0,67 (95% CI 0,10-4,90)).

Conclusions

In this study, NSTEMI patients surviving CA had more severe coronary events. CA was independently associated with a significant increase in in-hospital major adverse events. However, during the 1-year follow-up there was no significant increase in mortality.
Prognostic impact of hyperuricemia in chronic heart failure
Authors: Carvalho P , Borges S , Monteiro J , Moz M , Fontes P , Moreira I
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Today there is numerous evidence of the importance of hyperuricemia in the progression of chronic heart failure (HF).

Purpose

To study the impact of uricemia in patients (pts) with HF with reduced ejection fraction (HFrEF) followed in a Heart Failure Clinic (HFC).

Methods

Retrospective study of consecutive patients admitted in heart failure clinic of a cardiology center from February/2018 to December/2020, with an initial left ventricular ejection fraction (LVEF) < 50%; Primary outcomes were a composite of death, HF hospitalizations or emergency department admission.

Results

A total of 269 patients were selected, (mean age 71.0 ± 11.1 years; 69% males; ~40% ischemic etiology) of which 31,9% had uric acid (UA) ≥ 7 mg/dl in the first measure. These patients had more ischemic heart disease (44% vs 31,4%, p=0,048) and were mostly man (81,8 vs 63,80%, p= 0,004), but had less arterial hypertension (61,4 vs 72,8%; p=0.41). Both groups had the same incidence of diabetes mellitus (35,1 VS 34,1, p=0,868), active or previous tabagism (11,7 VS 7, p=0,456, 24,7 vs 24,9 p=0,456), dyslipidemia ( 53,2 vs 58, p=0,456), functional NYHA class ≥ 2 (93,8 VS 94,1, p=0,207) and use of allopurinol (68,8 vs 75,7%, p=0,252).

During a median follow-up of 16 months (IQR 15–51), 65 patients (24,2%) had the primary outcome.

After adjusting for ischemic heart disease, sex and use of allopurinol, uric acid levels superior to 7 mg /dl on admission is a predictor of poor outcomes in HFrER (HR 1.83, 95% CI: 1,89-3,08; p<0,023).

Conclusion

Patients with uric acid levels superior or equal to 7 mg/dl on admission had a higher risk of death, HF hospitalizations or emergency department admission during follow-up in HFC. UA might be considered a HF prognostic marker.
Gender differences in elderly patients admitted to a coronary care unit
Authors: Olivares Martinez B , Garcia Del Rio M , Gomez Gonzalez A , Altarejos Salido F , Martinez Nunez R , Garcia Rubira JC
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Gender differences in cardiovascular diseases have been widely observed, and these affect both their management and prognosis.

Purpose

This study aims to evaluate if such differences also exist in elderly patients who were admitted at our Coronary Care Unit (CCU).

Methods

Retrospective cohort of patients older than or equal to 80 years old who were admitted to a CCU in 2018-2019. We performed a descriptive analysis by gender, comparing comorbidities, causes of admission, complications, intrahospital mortality and after discharge, as well as readmissions.

Results

148 patients ≥80 years old were admitted at our CCU. 50% were women, with similar median age (men 83.58± SD 3.65 years; women 84.45±SD 2.94) and Charlson index (6.08±SD 1.70; women 6.54±SD 1.78).

We observed a higher proportion of men with previous ischemic heart disease (46% vs. 22%, p=0.002). The rest of comorbidities were however similar, and hypertension and dyslipidemia were the most frequent ones. Concerning causes of admission at the CCU, Acute Coronary Syndrome (39% vs. 41% women) and Acute Heart Failure (18% vs. 23% women, p>0.05) were the most common.

Complications were also similar between both groups (acute kidney injury and heart failure were the most common). We didn’t observe either any differences in vasoactive drugs requeriments, need of ventilatory support and interventional procedure rates. Men had a higher proportion of severe left ventricular systolic dysfunction at discharge (41% vs. 13%, p<0.001), although there weren’t any differences in intrahospital mortality (22% vs. 28% in women, p>0.05).

During follow-up (median 41.57 weeks, IQR 20.71-63.86) there was a tendency towards higher mortality in men (25% compared to 13%, p=0.12). Readmissions however were similar in both groups (37% in men and 30% women, p>0.05).

Conclusions

We didn’t observe any significant gender differences concerning interventional procedures, complications and intrahospital mortality in patients ≥80 years old admitted at our CCU. Even though severe left ventricular systolic dysfunction at discharge was more common in men, mortality and readmissions were similar during follow-up.
Relationship of plasma ST2 level with anatomical features of coronary artery lesion in patients with NSTEMI
Authors: Maslovskyi VI , Mezhiievska IA , Ivanov VP
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Objective

Relationship determining of ST2 plasma level and comparing it in patients with NSTEMI, determining of ST2 plasma level gradations.

Methods

We studied 90 patients with NSTEMI aged of 35 to 79 years (mean 60.7 ± 0.8, median - 61, interquartile range 54 and 69). Plasma ST2 level was determined and analyzed in the NSTEMI group of patients, the gradations of the stimulating growth factor level (ST2) and the correlation with the character of coronary artery lesions were highlighted. The degree of damage to the coronary arteries was determined by the SYNTAX score. All of research corresponding to the principles of the Declaration of Helsinki of the World Medical Association.

Results

Using the variational statistics method, the ST2 level gradations group were selected. Thus, the relatively low level (RL) corresponded to less than 25, and the relatively high (RH) level of ST2 to more than 75 persons in the group, respectively. For patients in the main group, these levels were < 26 and > 56 ng / ml, respectively. Instead, the relatively moderate (or intermediate) ST2 level (RM) for these patients was 26-56 ng/ml (Fig. 1). Analysis of the anatomical damage of the coronary arteries showed a reliable relationship of a relatively high level of ST2 with atherosclerotic lesion of the left coronary artery (LCA) trunk, while a relatively moderate level of ST2 was determined in the case of lesions of the circumlex branch (CB) of LCA (Fig. 2). The highest degree of coronary artery stenosis was determined in patients with relatively high ST2 levels, while relatively low ST2 levels were observed in the absence of hemodynamically significant stenosis (Fig. 2).

Conclusion

1. There are 3 groups of levels of stimulating growth factor in patients with NSTEMI: relatively low level (<26 ng / ml), relatively moderate level (26-56 ng / ml), relatively high level (> 56 ng / ml).

2. A relatively high level of ST2 was observed in the lesion of the LСA trunk, while a relatively moderate level of ST2 was determined in the case of the CB LCA lesion.

3. The level of ST2 with high probability allows to predict the severity and character of the lesion of the coronary arteries.
The impact of coronary chronic total occlusion angioplasties on left ventricular function
Authors: Costa H , Santo ME , Fernandes R , Mota T , Palmeiro H , Bispo J , Guedes J , Carvalho D , Mimoso J , Vinhas H , Jesus I
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Coronary chronic total occlusions (CTO) are relatively common findings in the context of coronary angiography. The indication for revascularization of this type of lesions remains controversial. The recommendations of international cardiology societies consider the treatment of CTO by percutaneous coronary intervention (PCI) in selected patients, but this technique is not yet widely used in this context.

Objectives

Analyze the impact of CTO PCI on left ventricular function (LVEF), measured by the recovery of LVEF (positive variation-PV). Also analyze the profile of patients with greater cardiac functional benefit.

Methods

Observational and retrospective study with descriptive and comparative analysis of patients undergoing CTO PCI, between 1 January 2019 and 31 December 2020. Descriptive analysis was carried out regarding the demographic and clinical characteristics. Chi-Square test was used for categorical variables and the T-Student test for numerical variables, with a significance level of 95%. CHIAD algorithm was applied to identify patient profiles, whose dependent variable was LVEF variation, and fixed 15 parent nodes and 5 children nodes. For statistical analysis, SPSS 24.0 was used.

Results

N177 patients were identified, with a mean age of 65.4 years (standard deviation of 11.1), 51% were female. The most frequent location of CTO was the right coronary (RCA) in 41.2%. The mean LVEF was 46.9% with standard deviation 9.9. 61.5% of patients had PV, on average rising 14% (p=0,000). The patients who benefited the most were those with LVEF <49% (81.8% of PV - p = 0.000), compared to those with LVEF [49%-58%] (41.7% of PV - p=0.000) and LVEF> 58% (30.8 % of PV - p=0.00). In the multivariate analysis in a logic of dependency and profiles, patients with LVEF <49% (81.8% PV - p=0.000), who didn´t develop HF symptoms at 180D (85.7% PV - p=0.001) and angor at 30D (90.5% PV - p = 0.020) were those with the highest PV of LVEF.

Conclusion

This analysis highlights the experience of the angiography laboratory. In this pool, the RCA was the most affected by CTO. Most patients had LVEF recovery, rising by an average of 14%. Lower LVEF patients appear to have greater potential for left ventricular recovery. The analysis suggests that benefit were greater in patients with medium range or reduced LVEF that didn´t develop post-procedure HF symptoms and angina.
Prognosis impact of ticagrelor vs clopidogrel based DAPT discontinuation after acute coronary syndrome. Insights from the multicenter CREA ARIAM Andalucia registry
Authors: Hernandez Meneses BG , Padilla-Rodriguez G , Carmona-Carmona J , Hidalgo-Urbano R , Almendro-Delia M , Garcia-Rubira JC
Published: May 2022

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): The study project was financially supported by a non-conditional grant by Astrazeneca.

Background/Introduction

Premature cessation of dual antiplatelet therapy (DAPT) after acute coronary syndrome (ACS) has been associated with increased risk of major adverse cardiovascular events (MACE)

Purpose

To assess the relationship between premature DAPT discontinuation versus therapy continuation and outcomes in ACS patients discharged on ticagrelor or clopidogrel.

Methods

Prospective, observational, multicentre all-comers registry of ACS patients who were intended to receive 12-month DAPT with ticagrelor or clopidogrel. Adherence was defined by the medication possession ratio metric (MPA, proportion of days of medication supply within a time interval). Categories for DAPT cessation included: physician-recommended discontinuation, brief interruption (invasive procedures), or disruption due to non-compliance or because of bleeding. Fully-adjusted Cox models with time-varying covariates to account for informative censoring, were used to examine the effect of DAPT cessation on MACE (a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, definite stent thrombosis, or target-lesion revascularization). Moderation analysis was also performed to assess for potential exposure-adherence interaction.

Results

Among 2070 patients included (mean age 63 years, 73% men), 150 (7.3%) prematurely discontinued DAPT, median (IQR) 214 (101-236) days. Significantly more clopidogrel than ticagrelor users discontinued medication (9.5% vs 5%, respectively; P = .001), though timing of cessation was similar in both groups. At 1 year, MPR was slightly higher, but not significantly different, in the clopidogrel group than in the ticagrelor group (70±30 vs 64±29; P = .06). Overall, physician-guided discontinuation and bleeding were the main reasons for DAPT cessation. These were observed with a similar rate in both groups, while non-compliant disruption was more common among ticagrelor- than clopidogrel-treated patients (8% vs 2%, respectively; P for trend .04). After adjustments, DAPT cessation was associated with significantly increased risk of MACE (adjusted HR 2.94; 95% CI 1.82 – 4.74; P < .0001), regardless of the P2Y12 inhibitor (P interaction = 0.665). Non-compliance related cessation resulted in higher risk of MACE (HR 6.04, 95%CI 2.15 – 16.95; P = .001).

Conclusion(s)

Overall, approximately 7% of patients discontinued DAPT. Early cessation of either ticagrelor- or clopidogrel-based DAPT portended to a near 3-fold increased risk of MACE. Disruption due to non-compliance resulted in higher risk for ischemic events. These data warrant efforts to focus on patient education in subgroups at high risk of non-compliance.
First-line treatment with oral anticoagulant predicts survival in acute cardiac patients with heparin-induced thrombocytopenia
Authors: Szyda L , Klosinska M , Mrozowska-Peruga E , Nowakowska M , Poninska N , Wiklo K , Kasprzak JD
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Heparin-induced thrombocytopenia (HIT) is a rare immune-mediated disorder related to the use of unfractionated heparin and low-molecular-weight heparin. Although thrombocytopenic, HIT is a paradoxical prothrombotic state associated with increased risk of vascular thrombosis and death. Non-heparin anticoagulants, parenteral and oral, are recommended for the treatment of HIT. As heparin is commonly used and thrombocytopenia is frequent in critically ill cardiac patients, HIT constitute a relevant clinical issue in the intensive cardiac care unit. Despite this, the incidence of HIT as well as factors influencing clinical outcomes in acute cardiac patients with HIT are unknown and have not been investigated so far.

Purpose

The purpose of our study was to evaluate the incidence of HIT in the population of cardiac patients and to determine if any predictor of survival for acute cardiac patients with HIT can be found.

Methods

We retrospectively collected data of all patients with HIT who were hospitalized in our intensive cardiac care unit in 2016 - 2021. We had used functionalized latex immunoassay to confirm the diagnosis of HIT in all patients. The choice of the non-heparin anticoagulant, oral or parenteral, for the first-line treatment of HIT had been left to clinical judgment of the physician. We performed statistical analysis including clinical and laboratory variables to find the predictors of survival in critically ill cardiac patients with HIT.

Results

Among 22 483 patients hospitalized in 2016 - 2021 in our department of cardiology 12 were diagnosed with HIT (incidence 1 : 1874). 5 of them were treated with parenteral non-heparin whereas 7 with oral anticoagulant as first-line treatment. 4 patients with HIT died during the index hospitalization. All of them were treated with parenteral non-heparin anticoagulant. 7 of 8 survivors were treated with oral anticoagulant as primary drug. First-line treatment with oral anticoagulant was the predictor of survival (p=0,0152) in our study group. There was no other neither clinical nor laboratory factor influencing outcomes in critically ill cardiac patients with HIT (Table 1).

Conclusion

First-line treatment with oral anticoagulant was the only one predictor of survival in acute cardiac patients with HIT. Oral anticoagulants may be preferred for the treatment of HIT in this population.
Acute hemodynamic effect of ketone bodies in patients with decompensated heart failure
Authors: Sramko M , Melenovsky V , Kleissner M , Benak A , Holek M , Pazdernik M , Kautzner J
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Chronically failing heart increases utilization of ketone bodies as an energy substrate.

Purpose

This study investigated feasibility, safety and acute hemodynamic effect of exogenous ketosis induced by administration of beta-hydroxybutyrate (OHB) in patients with decompensated heart failure and low cardiac output syndrome.

Methods

Patients with acutely decompensated heart failure with reduced ejection fraction (HFrEF), who were on inotropic support for at least 24 hours (milrinone 0.5±0.1 ug/kg/min), were given oral solution of OHB (25g of OHB monoester in 65 ml of solution; H.V.M.N Ketone Ester, H.V.M.N, USA) in 3-hour intervals up to a total dose of 75g. Serum concentration of OHB and invasive hemodynamics (Swan-Ganz catheter with continuous thermodilution) were measured repeatedly before and during 24 hours after administration of OHB. The primary endpoint was the maximum change in cardiac index (CI).

Results

The study included 8 patients with decompensated HFrEF (male/female gender: 6/2; age: 58 ± 6 years; left ventricular ejection fraction: 19 ± 5%; non-ischemic/ischemic cardiomyopathy: 7/1). The baseline OHB concentration was 0.4 ± 0.2 mmol/L (normal range: 0 - 0.6 mmol/L). Mild ketosis (1.8 ± 0.6 mmol/L) was induced in all patients within one hour after administration of OHB. The maximum OHB concentration (2.5 ± 0.8 mmol/L) was reached after a median of 5 hours (IQR, 2 to 7 hours). No complications occurred except of temporary dyspepsia in one patient. Within 3 hours after administration of OHB, the CI increased from the baseline by 39 ± 25% (CI 3.4 ± 0.8 vs. 2.5 ± 0.5 L/min/m2; absolute increase of 1.0 ± 0.6 L/min/m2, p = 0.003). The maximum increase of CI reached 52 ± 20% (1.2 ± 0.4 L/min/m2 from the baseline, p <0.001) and it was observed after a median of 5 hours (IQR 3 to 8 hours). After 24 hours, CI returned to the baseline values (p = 0.4). The increase of CI was nor related to changes in the heart rate (at baseline vs. at the maximum CI: 101 ± 5 vs. 103 ± 6 beats/min, p = 0.5).

Conclusion

Induction of mild ketosis by administration of OHB on top of established inotropic therapy caused a significant temporary increase in myocardial contractility. This novel therapeutic concept might be a promising adjunction to the inotropic support in patients with decompensated HFrEF.
Ten years of experience in pre-transplant patients from an advanced heart failure center - when is the best time to step in?
Authors: Martinho A , Alves T , Rodrigues C , Girao A , Pais J , Fernandes L , Franco F , Costa S , Lourenco C , Prieto D , Goncalves L
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) profiles provide important prognostic information for patients with advanced heart failure (AHF) hospitalized for clinical worsening.

Purpose

Assess the prognosis and fate of patients with Advanced HF (AHF), in INTERMACS I-IV, admitted to an Advanced Heart Failure Unit during 10-years.

Methods

Retrospective, single-center study with AHF’ patients admitted for acute HF during January 2010 and December 2020 in an Advanced Heart Failure Care Unit (AHFCU), who required inotropic therapy (INTERMACS I-IV) and were candidates for heart transplant (<65 years). We assessed the baseline characteristics at the time of admission and the long-term outcomes: death, alive with optimized medical therapy (OMT) and device or transplantation, according to INTERMACS profiles.

Results

For 10 years, 175 patients who met the inclusion criteria were admitted to the AHFC, mostly men (66.2%) and ischemic (30%), with a mean age of 52±10 years. At admission the patients had a mean Left Ventricle Ejection Fraction (LVEF) of 27±10% and a median NT-proBNP of 7230 pg/ml (IQR 3801 to 19882). During the 10-years on focus, 42% patients were transplanted (n=73), 38% (n=66) remained alive with optimized MT and device and 20% (n= 36) died. In-hospital mortality was significant different between profiles (p=0.001), 55% in INTERMACS I patients, 25% in II, and 17% in III-IV. Most transplanted patients (63%) were in INTERMACS IV, 16.4% in III, 12.3% in II and only 11% (n=8) in INTERMACS I (p=0.043).

Conclusion

Our results reinforce the importance of early action in these patients, using INTERMACS profile to prognostic stratification, who is important to identify the ideal time for referral to an appropriate centre, to properly convey expectations to patients and families, and to plan treatment and follow-up strategies (transplant, circulatory mechanical support, or palliative care).
Artificial intelligence model for prediction of cardiogenic shock in patients with acute coronary syndrome
Authors: Bohm A , Jajcay N , Jankova J , Petrikova K , Bezak B
Published: May 2022

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Education, Science, Research and Sport of the Slovak Republic VEGA

Background

Cardiogenic shock (CS) is a serious life-threatening condition affecting almost 10% of patients suffering from acute coronary syndrome (ACS). Despite recent treatment improvements such as mechanical circulatory support devices (MCS), mortality remains 50%. It is hypothesized that early implantation of MCS before hemodynamic deterioration could prevent CS. Therefore, knowing which ACS patient will progress into CS would be of paramount importance.

Purpose

We aimed to develop a model based on machine learning algorithms for CS prediction in patients with ACS.

Method

Over 40 000 patients from critical care units of the Beth Israel Deaconess Medical Center database were extensively analyzed and sorted. Patients suffering from acute coronary syndrome undergoing cardiac catheterizations were selected and divided into two groups based on the development of CS. Patients in CS at the time of admission were excluded. The study population consisted of 3056 patients who didn’t develop CS and of 176 patients who did develop CS. Important information was also extracted manually from textual summaries of hospital stays. Potentially relevant clinical variables for shock prediction were selected using supervised feature selection, and missing values were supplemented using imputation methods. Seven well-known and established machine learning algorithms were used. Based on preliminary evaluation of classifier performance (AUC on random train-test split with 30% test data), we selected two best-performing algorithms: Logistic Regression and Gaussian Process classifier with Radial Basis Function (RBF) kernel. Both models were subsequently validated using Repeated Stratified K-Fold cross-validation with 5 folds and 20 repeats each.

Results

Age, heart rate, mean arterial pressure, respiratory rate, oxygen flow (liters per minute), peripheral oxygen saturation, blood glucose, pain type, heart rhythm and ectopy frequency were chosen as input variables. Both models showed good discrimination. The Logistic Regression model scored AUC of 0.76 ± 0.04. The Gaussian Process classifier with Radial Basis Function (RBF) kernel scored AUC of 0.77 ± 0.03.

Conclusion

According to our knowledge this is the first study that uses machine learning algorithms to predict CS in patients with ACS based on easily obtainable clinical variables. Further explorations and refinement of used imputation, feature selection, machine learning techniques and validation on an external cohort might result in even better performance of the proposed prediction models. Furthermore, these prediction models could be transformed into a simple predictive scoring system available in clinical practice.
Patient delay in patients with st-elevation myocardial infarction
Authors: Hendin KS , Egholm G , Lassen JF
Published: May 2022

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Snedkermester Sophus Jacobsen og hustru Astrid Jacobsens fond

Background/Introduction

Rapid revascularisation therapy (primary percutaneous intervention (PCI)) is widely established as the most important factor in preventing myocardial damage after ST-Elevation Myocardial Infarction (STEMI)(1,2). Current ESC (European Society of Cardiology) guidelines recommends fast revascularisation therapy within 120 minutes of symptom onset(3). Despite this, previous studies have shown patient delay times above 120 minutes in more than 50% of patients(2,4). Reducing patient delay is therefore an important factor in the endeavour of decreasing myocardial damage and for prediction of outcome following STEMI. However, most knowledge on this field originates from registry-based studies(4). Previous studies conducted in Denmark, rely on data from danish quality databases containing data such as delay times, cardiac risk factors and procedure specific information. The few studies on this field using patient reported data, have focused on subpopulations or sex differences(5).

Purpose

The purpose of this study was to investigate the patient reported delay in STEMI patients and to compare the registered delay times to the physician reported delay in databases.

Methods

This single center study includes interviews of 129 patients hospitalized for STEMI between April and October 2021. The patients participated in semi-structured patient interviews conducted within 30 days of hospitalization. The main focus of the interviews was time of symptom onset and time of first medical contact, but other factors such as symptom presentation and perception, lifestyle choices and care seeking behaviour were also investigated. The patient reported delay times were then compared with the delay time registered in danish quality databases, using descriptive analysis and double-sided T-test.

Results

148 patients were included to the study. Upon contact, 19 were lost to follow up. 16 patients had missing delay times in the database. The final study cohort consisted of 113 patients (93 men and 20 women) aged 30-94 years (mean: 62,7 years).

We observed that on average patient reported delay times were 5 hours longer than the physician reported delay times in the databases, P=0.0080. The disagreement in delay times ranged from -25 hours to 159 hours.

Conclusions

We found a substantially longer delay time when comparing patient reported delay times with physician reported delay times. This is of high clinical importance in relation to proper prediction of outcomes, and to ensure the aiming of future information campaigns to populations most at need. As quality measures in this field relies on database registrations, it is imperative to address this discrepancy in order to improve patient delay times.
Allopurinol pretreatment effects on coronary blood flow and revascularization outcomes in acute STEMI patients underwent emergency percutaneous coronary intervention
Authors: Kermani-Alghoraishi M , Sanei H , Heshmat-Ghahdarijani K , Sadeghi M , Shirvani E
Published: May 2022

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Isfahan University of Medical Sciences, Isfahan, Iran.

Introduction

Todays, acute ST-segment elevation myocardial infarction (STEMI) is considered as a most important component of acute coronary syndrome. In this regards, reperfusion therapy with percutaneous coronary intervention (PCI) is the most effective treatment for establishing coronary blood flow; which despite reperfusion of ischemic myocardium, it can also induce secondary injury as myocardial ischemia-reperfusion injury. The generation of reactive oxygen species by activation of xanthine oxidase (XO) enzymatic system is one of the major causes of ischemia-reperfusion injury in the ischemic myocardium and allopurinol, a XO inhibitor, has an inhibitory role on free radical productions in STEMI patients.

Purpose

In this study, we aimed to assess impact of allopurinol pre-treatment on revascularization outcomes, according to Thrombolysis in Myocardial Infarction (TIMI) flow and ST segment elevation recovery as well as clinical finding and major cardiac events incidence in STEMI patients underwent emergency PCI.

Methods

In this randomized double blind clinical trial, we enrolled 90 patients with acute STEMI in two equal groups. Allopurinol group received 600 mg allopurinol loading dose before the emergency PCI and the control group received the same shape medication as a placebo. Both groups also received the standard pretreatment protocol for PCI in acute STEMI setting. TIMI flow, ECG changes, Troponin level and major cardiac events (MACE) occurrence including death, myocardial infarction and ischemic stroke after 1 month follow up were assessed. In case group, allopurinol 100 mg daily and matched placebo pill for control group was continued for one month in addition to standard medications.

Results

Finally, 81 patients with acute STEMI has completed the study. The mean age of study population was 59.52 (11.31) and 61.3 (9.25) in case and control groups respectively (p = 0.49). Troponin level 48 hour after the PCI had not significant difference between the groups (p = 0.25). ECG ST-elevation regression also had not significant difference between the groups [75.0%1 vs 67.10% in case and control groups, respectively (p = 0.21)]. TIMI flow had improved in allopurinol group rather than placebo (p = 0.02). PCI success rate was 78.6% and 61.5% in allopurinol and control group respectively (p = 0.09). MACE and other clinically outcomes in follow up period were similar between groups (p > 0.05).

Conclusions

This study indicated that allopurinol pre-treatment loading dose could improve minimally revascularization outcomes based on TIMI flow in the patients undergoing primary or rescue PCI in acute STEMI setting.
Creation and validation of a biochemical scoring system and smartphone application to predict 30 day mortality in patients requiring left-sided Impella monotherapy
Authors: Tindale A , Cretu I , Tan S-T , Monteagudo Vela M , Panoulas V
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Objectives

To create and validate a simple biochemical scoring system and smartphone application that can estimate 30-day mortality in patients requiring left-sided Impella implantation as standalone mechanical circulatory support (MCS).

Methods

Initially, we retrospectively analysed 79 consecutive patients who required left-sided Impella MCS monotherapy. Regression analysis was used to elucidate significant associations between biochemical markers before Impella implantation and all-cause mortality at 30 days. Using these factors, a simple additive scoring system was create. The scoring system was then validated using prospectively collected data from our sister institution. This validated scoring system was then used to create a smartphone application that was formally evaluated by cardiologists.

Results

The BALLAR scoring system was created. Patients are assigned points based upon biochemical markers. These are summed and the final points tally provides an estimate of 30-day mortality. The points are assigned as follows:

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

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

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

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

The total score can be used to estimate the probability of death at 30 days. A score less than 6 predicts a 30-day mortality of under 5%, whereas a score over 11 predicts a greater than 95% chance of death within 30 days.

This scoring system was initially validated using prospectively collected data from 10 patients our sister institution, where it predicted 30-day mortality in all of these patients. A smartphone application was then created which received universally positive feedback for ease of use by cardiologists and trainees at our institution.

Conclusion

The simple heuristic predicted 89% of 30-day deaths in our cohort. All the misclassifications were in the intermediate probability range (scores 5-11). Applied to a small external validation cohort, the predictive accuracy was 100%. This simple scoring system gives an effective estimate of the probability of death at 30 days in our cohort of patients and is now the basis for a novel smartphone application.