bluuebunny/crossref_metadata_2025 huggingface dataset:
Vasodilators for acute heart failure. A systematic review of randomized clinical trials with meta-analysis and trial sequential analysis
Authors: El Chaidi N , Lukoschewitz J , Overgaard Olesen A S , Dahlgaard Hove J , Hassager C , Jakobsen J C , Seven E , Grand J
Published: May 2024

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Danish Cardiovascular Academy Novo Nordisk Foundation.

Background

Acute heart failure (AHF) is an increasing public health concern with limited evidence for current treatments, such as vasodilators. Recent studies have shown mixed results regarding the efficacy of vasodilation in AHF, leading to downgraded recommendations in European Society of Cardiology (ESC) 2021 guidelines.

Method

We conducted a systematic review of randomized clinical trials (RCTs) to assess vasodilator therapy's effectiveness in managing AHF. The search for relevant studies was conducted without restrictions across the major databases: Medline, Embase, Latin American and Caribbean Health Sciences Literature (LILACS), Web of Science, and the Cochrane Central Register of Controlled Trials. The study protocol was published and registered at PROSPERO, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. We included RCTs that compared vasodilators to standard care, placebo, no-intervention, or co-interventions. Our primary outcome was all-cause mortality, while secondary outcomes included serious adverse events (SAEs), tracheal intubation and length of hospital stay. Systolic blood pressure difference was an exploratory outcome. We assessed the risks of bias in individual trials using the Cochrane Collaboration risk of bias tool.

Results

We included 46 RCTs comprising 28,374 patients with AHF. Meta-analysis and Trial Sequential Analysis showed that vasodilators did not reduce the risk of all-cause mortality (risk ratio (RR) = 0.96, 95% CI: 0.90 to 1.03; I2 = 0%; P = 0.26). However, meta-analysis showed evidence of a beneficial effect of vasodilators in reducing the need for tracheal intubation (RR = 0.82, 95% CI: 0.68 to 0.99; I2 = 55.05%; P = 0.04). No evidence of a difference was seen in the risk of SAEs (RR = 1.01, 95% CI: 0.97 to 1.06; I2 = 0%; P = 0.50) or length of hospital stay (Mean difference (MD) = -0.28, 95% CI: -0.73 to 0.16; I2 = 69.84%; P = 0.28). Finally, a significant decrease in systolic blood pressure (MD = -6.26, 95% CI: -8.06 to -4.46; I2 = 90.51%; P < 0.01) was demonstrated.

Conclusion

In patients hospitalised with AHF, vasodilator therapy did not result in a reduction of all-cause mortality, SAEs or length of hospital stay. However, the need for tracheal intubations was significantly decreased.Forest plot of all-cause mortalityForest plot of Tracheal intubation
The prevalence of pleural effusion in patients with heart failure and preserved ejection fraction using chest ultrasonographic assessment
Authors: Maadarani O , Bigdelu L E I L A , Bitar Z O H E I R
Published: May 2024

Funding Acknowledgements

None.

Background

The incidence of pleural effusions (PEs) radiologically in acute decompensated heart failure was estimated by 50 %( 1).The prevalence of PEs using chest ultrasound in patients with heart failure with preserved ejection fraction (HFpEF) was not studied before.

Aim

Determine the prevalence and severity of PE using bedside chest ultrasound in patients with HFpEF.

Method

We prospectively evaluated 85 patients admitted to the coronary care unit with acute pulmonary edema. 27 patients had LVEF below 50% and they were excluded. We used bedside ultrasonography to document the presence of pleural effusions and estimate the amount using Goecke 2 formula.

Results

58 patients were recruited with estimated LVEF above 50% and median age of 73 years (Table 1). Pleural effusion was detected by chest ultrasound in 54 patients (94%) with 91% being bilateral and of moderate amount. The mean value of E/A and E/E’ ratio was 1.92 and 19.9 respectively where mean deceleration time (DT) was 171 ms , however, these parameters were not related to severity of pleural effusion (P= 0.52, 0.98 and 0.7 respectively) ( Table 2). The N-terminal pro-brain-type natriuretic peptide (NT-proBNP) was significantly higher in patients with pleural effusion (P = 0.046).

Conclusion

PEs are present on chest ultrasound in 94% of patients with HFpEF and mainly bilateral. The degree of PEs were moderate and was not related to the LV indices of HFpEF.
Ten-year prognosis of acute atrial fibrillation in ST-elevation myocardial infarction: recurrence and stroke risk
Authors: Martinez Membrive M J , Subirana Cachinero I , Fadeuilhe Grau E , Rueda Sobella F , Carreras Mora J , Oliveras Vila T , Giralt Borrell T , Labata Salvador C , El Ouaddi N , Montero Aradas S , Elosua Llanos R , Ribas Barquet N , Bayes Genis A , Garcia Garcia C
Published: May 2024

Funding Acknowledgements

None.

Background

Atrial fibrillation (AF) often complicates ST elevation acute myocardial infarction (STEMI), with associated risks including stroke and mortality. Anticoagulation therapy for these patients and AF prognosis remains controversial. The aim was to evaluate long-term prognosis of STEMI patients complicated with AF in the acute phase.

Methods

We performed a prospective register involving 4,184 patients admitted for STEMI to the intensive cardiac care unit of two tertiary centres from 2007 to 2015. Patients with pre-existing permanent AF were excluded. Out of these, 269 (6.4%) patients developed AF within the first 48 hours after STEMI and were matched with a control group based on age and left ventricular ejection fraction (LVEF).

Results

After matching, a total of 470 patients were included (n=235, AF-STEMI; n=235, control group). Mean age 69.0 years, and 31.7% women. No differences were found in gender, cardiovascular risk factors or ischemic heart disease. AF-STEMI patients experienced more sustained ventricular tachycardia (12.8% vs. 4.7%; p=0.003), advanced atrioventricular block (13.2% vs. 6.0%; p=0.012), heart failure (28.5% vs. 18.7%; p=0.017), and cardiogenic shock (17.4% vs. 8.5%; p=0.006). In-hospital mortality was also higher in AF-STEMI patients (11.9% vs 7.2%, p=0.008). After 10-years follow-up, the AF-STEMI group had remained with higher mortality (50.5% vs. 36.2%; p=0.003) and a greater recurrence of AF (44.2% vs. 14.7%; p<0.001), without differences in stroke incidence (10.1% vs. 9.3%).

Conclusion

Patients with AF complicating STEMI have higher rates of heart failure, cardiogenic shock, and in-hospital mortality. After a 10-years follow up, they exhibit a high risk of AF recurrence, with no significant differences in stroke incidence.Kaplan Meier curves
Gender-based differences in clinical profile, management and mortality in cardiogenic shock. Prognostic accuracy of CardShock vs IABP Score, the Shock-CAT study
Authors: Garcia-Garcia C , Andrea R , Sanz E , Sanchez-Salado J C , Aboal J , Pueyo P , Buera I , Sionis A , Lopez T , Ruiz M , Ariza A , Tomas C , Baneras J , Elouaddi N , Rueda F
Published: May 2024

Funding Acknowledgements

None.

Background

Mortality in cardiogenic shock (CS) remains very high. Gender could influence in aetiology, management, outcomes and risk stratification predictors.

Purpose

The aim is to analyse differences in clinical profile, management, in-hospital prognosis and mortality risk in CS patients depending on sex and compare the prognostic accuracy of CardShock and IABP scores between sexes in a Mediterranean cohort.

Method

Shock-CAT study was a multicentre, prospective, observational study conducted between December 2018 and December 2019 in eight public University hospitals in Spain, including CS patients of different aetiologies. Data on clinical presentation, biomarkers, management, including mechanical cardiac/circulatory support (MCS) were analysed comparing women and men. Cardshock and IABP score have been compared to assess 90-days mortality risk between sexes.

Results

A total of 382 CS patients (p) were included: women 24.9% (n=95 p) and men 75.1% (n=287p). Women were older than men (68.9 vs 64.1 years, P=0.004). CS due to acute coronary syndrome (ACS) was more frequent in men (66.6% vs 43.2%), and myocarditis (1.7 vs 6.3%), stress cardiomyopathy (0.3% vs 8.4%) and severe aortic stenosis (2.4% vs 6.3%) were more prevalent in women, all p<0.001. Cardiac arrest was more prevalent in men than women (38.4% vs 25.3%, p=0.020). MCS was implanted in 35.3% of patients, without gender differences (men 36.6%, women 31.6%, p=0.376). Even though there was a non-significant trend to lower use in women of IABP (31.1% vs 26.5%), Impella (13.5% vs 7.4%) or ECMO (10.4% vs 7.4%). Risk scores were similar between sexes: Cardshock (men:4.32 vs 4.40 women, p=0.674) and IABP score (men: 2.31 vs 2.04 women, p=0.190). There were no differences between men and women in in-hospital mortality (32.4% vs 34.7%, p=0.675) or 6-months mortality (41.5% vs 40%, p=0.989). Receiver-operating characteristic curves demonstrated that IABP shock score had superior prognostic power for predicting 90-days mortality when compared with Cardshock score in men (area under the curve -AUC- 0.72 vs 0.64) respectively, p=0.009, although both scores were similar in women (AUC 0.70 vs 0.72, p=0.635), Figures 1-2.

Conclusions

Women with CS were older than men and had less ACS and cardiac arrest at admission. There is a non-significant lower use of mechanical assistance devices in women, although in-hospital or 6-months mortality were similar in both sexes. IABP score provided better 90-days mortality risk prediction than CardShock score in men, but both scores were similar in women with cardiogenic shock.Men ROC Curves 90-days MortalityWomen ROC Curves 90-days Mortality
Attention to STEMI patients in our region: what is the adherence to the quality indicators from a population perspective?
Authors: Legarra P , Jimenez O , Iniesta I , Ibanez E , Delfrade J , Borderias T , Segur M , Villabona C , Martinez J , Munarriz A , Alcasena M S , Moreno C
Published: May 2024

Funding Acknowledgements

None.

Introduction

The use of quality indicators (QI) proposed by the Association for Acute Cardiovascular Care (ACVC) for processes carried out in cardiology services represents an excellent internal quality control of their operation.

Purpose

The aim is to assess adherence to the main QI in the care of acute ST-elevation myocardial infarction (STEMI) in our region, according to data from the population-based registry of myocardial infarction in that area.

Methods

Evaluation of adherence to the main QI proposed by the ESC Association for ACVC, by retrospective analysis (data from in-hospital and out-of-hospital care) of patients with STEMI from our regional Infarction Registry attended between 2017 and 2020, in both tertiary and secondary hospitals of the public and private care network, providing data with a population-based character.

Results

QI were analysed in 1355 patients categorised as STEMI in our regional Infarction Registry between 2017 and 2020. 71% of patients were male. The number of STEMI per year ranged from 358 in 2019 to 316 in 2020. Primary percutaneous coronary intervention (PCI) was performed in 87% of patients. In 53% the first medical contact occurs in out-of-hospital care, while 25% occur in emergency departments (ED) of PCI capable hospitals and 12% in emergency departments of non-PCI hospitals. Forty-two percent of patients firstly attended out-of-hospital or in non-PCI centres achieve revascularisation in less than 90 minutes, but less than 30% of patients seen in PCI centres achieve revascularisation in less than 60 minutes. Radial access was used in 92% of cases. LVEF was assessed during admission in 98% and LDL-cholesterol was determined in 87%. Ninety-one per cent of patients were discharged on dual antiplatelet therapy, 96% on statins and a large proportion of patients with left ventricular dysfunction received angiotensin-converting enzyme inhibitors (78%) and beta-blockers (88%).

Conclusion

There is good overall adherence to major QI related to care of patients with STEMI in our region. However, there are indicators that could be optimised, particularly those related to timely primary reperfusion. Networked care thanks to the local Infarction Code means a significant reduction in reperfusion times, avoiding unnecessary referrals to Emergency Departments.
Patients with scheduled heart valve interventions are at very high risk for acute heart failure during prolonged waiting time
Authors: Andress S , Felbel D , Rottbauer W , Imhof A , Stephan T
Published: May 2024

Funding Acknowledgements

None.

Background

Postponement of non-emergency cardiac interventions is associated with increased rates of emergency hospitalizations. Affected patients show signs of acute heart failure during the waiting time. Since this worse outcome has been proven to persist even long post-procedure, patients at risk must be identified in advance.

Purpose

This study sought to identify predictors associated with acute heart failure during prolonged waiting time in cardiac patients scheduled for non-emergency interventions.

Methods

A retrospective, observational cohort study was conducted that included consecutive patients whose non-emergency cardiac intervention was postponed during the first Covid-19 related lockdown between March 19th and April 30th, 2020. The endpoint was heart failure at admission to the procedure performed, indicated by a NT-proBNP level > 900 pg/ml. Cox regression analysis was performed to identify characteristics of patients who met the endpoint.

Results

After postponing their non-emergency cardiac intervention for an average of 23 days, 89 of 178 postponed patients (59 %) at a mean age slightly above 70 years had a NT-proBNP level > 900 pg/ml. Cox regression analysis showed the criterion "planned heart valve procedure" to independently predict achievement of the endpoint (p < 0.001, OR 12.040, 95 % CI 3.423 – 42.353). Subgroup analysis (n = 49) showed that especially patients with atrioventricular valve regurgitation are at risk with an endpoint rate of 94.74 % compared to 69.00 % in patients undergoing aortic valve replacement (p = 0.008). Moreover, the intervention of the affected patients was performed more frequently as emergency hospitalization (p = 0.005) and lasted longer (p < 0.001). This was accompanied by worse cardiac status at the time of admission including worse NYHA class, higher biomarker levels and lower cardiac function (each p < 0.001). Additionally, worse outcome as demonstrated by higher rates of emergency hospitalization and death persisted even 12, 24 and 36 months after the procedure (each p < 0.001).

Conclusion

Patients scheduled for heart valve interventions and particularly due to atrioventricular valve regurgitation are at high risk of heart failure in case of prolonged waiting time. Therefore, this population does not appear to be suitable for postponement but, in contrast, seems to require acute cardiovascular care.
The prognostic value of HEART score in patients with known heart failure evaluated at the emergency department for acute chest pain
Authors: Abuhannaneh M , Alrawashdeh M , Atoum H , Faramand Z , Al-Zaiti S
Published: May 2024

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Heart Lung and Blood Institute (United States).

Background

Chest pain is a common and concerning symptom in emergency care, often necessities further risk stratification for adverse cardiovascular events on short-term follow up. Patients with known heart failure (HF) constitutes a unique sub-population that would greatly benefit from short-term risk stratification to guide appropriate clinical interventions and optimize resource allocation. HEART (History, ECG, Age, Risk factors, Troponin) is a well-validated risk score that has been shown to outperform other clinical risk scores in patients with chest pain. It remains unknown if HEART score can be safely used in patients with known HF presenting to the emergency department with chest pain.

Purpose

We sought to evaluate the prognostic value of HEART score in patients with known HF compared to their counterparts.

Method

This was a prospective observational cohort study of consecutive adult patients evaluated at the emergency department for non-traumatic chest pain. HEART score was computed from charts by independent physician reviewers. The primary study outcome was major adverse cardiac events (MACE) defined as acute coronary syndrome, invasive revascularization, reinfarction, death, cardiac arrest, ventricular tachyarrhythmia, or acute exacerbation within 30 days of indexed admission. Outcomes were adjudicated by two independent reviewers (Kappa = 0.908). Classification performance between groups was compared using area under receiver operator characteristic curve (AUROC), sensitivity, and negative predictive value (NPV).

Results

Our cohort included 4,132 patients (age 59±16, 47% female, 33% Black). Overall, 921 patients (22.3%) experienced 30-day MACE. The classification performance of HEART score in those without HF (n = 3,329, 81%) was AUROC of 0.831 (95% CI 0.813-0.848), compared to only 0.633 (95% CI 0.592-0.673) in those with known HF (n = 803, 19%) (z score = 8.771, p < 0.001, Figure). The sensitivity and NPV of HEART score among those without HF were 87.4% and 95.3%, compared to 81.2% and 73.3%, respectively, among those with known HF.

Conclusion

Our findings suggest that the prognostic value of HEART score for predicting 30-day MACE is inferior and suboptimal in patients with known HF evaluated for chest pain at the emergency department compared to their counterparts. These findings emphasize the need for more tailored risk assessment and management strategies in this specific patient population. Further research is warranted to better understand the limitations and potential enhancements of the HEART score in patients with HF.Classification Performance of HEART score
Comparison of the clinical chemistry score to other biomarker algorithms for rapid rule-out of acute myocardial infarction and risk stratification
Authors: Yildirim M , Salbach C , Milles B R , Reich C , Frey N , Giannitsis E , Mueller-Hennessen M
Published: May 2024

Funding Acknowledgements

None.

Background

The clinical chemistry score (CCS) comprising high-sensitivity (hs) cardiac troponins (cTn), glucose and estimated glomerular filtration rate has been previously validated with superior accuracy for detection and risk stratification of acute myocardial infarction (AMI) compared to hs-cTn alone.

Methods

The CCS was directly compared to other biomarker-based algorithms for rapid rule-out and prognostication of AMI including the hs-cTnT limit-of-blank (LOB, <3 ng/L) or limit-of-detection (LOD, <5 ng/L) and the dual marker strategy (DMS) (copeptin <10 pmol/L and hs-cTnT ≤14 ng/L) in 1506 patients presenting to the emergency department (ED) with symptoms suggestive of acute coronary syndrome. Negative predictive values (NPV) and sensitivities for rule-out of AMI were assessed and outcomes included rates of the combined end-point of all-cause mortality, myocardial re-infarction and stroke within 12 months.

Results

NPVs of 100% (98.3-100%) could be found for a CCS=0, hs-cTnT LoB and hs-cTnT LoD with rule-out efficacies of 11.1%, 7.6% and 18.3% as well as specificities of 13.0% (9.9-16.6%), 8.8% (7.3-10.5%) and 21.4% (19.2-23.8%), respectively. A CCS≤ 1 achieved a rule-out in 32.2% of all patients with a NPV of 99.6% (98.4-99.9%) and specificity of 37.4% (34.2-40.5%) compared to a rule-out efficacy of 51.2%, NPV of 99.0 (98.0-99.5) and specificity of 59.7% (57.0-62.4%) for the DMS. Rates of the combined end-point of death/AMI within 30 days ranged between 0.0% and 0.5% for all fast-rule-out protocols.

Conclusions

The CCS enables a reliable rule-out of AMI with low outcome rates in short and long-term follow-up for a specific population of ED patients. However, compared to a single or dual biomarker strategy, the CCS rule-out is attenuated by a loss of specificity and lower efficacy. Thus, the clinical benefit of the CCS in clinical practice seems to be negligible.
The lipid profile of the young patient with ischemic heart disease. Do these patients meet the goals?
Authors: Pelaz Sanchez M , Barea Gonzalez C , Arroyo Monino D F , Garcia Gonzalez N , Garcia Rubira J C
Published: May 2024

Funding Acknowledgements

Type of funding sources: Public hospital(s). Main funding source(s): Hospital Universitario Virgen Macarena

Introduction

Ischemic heart disease is becoming increasingly common in young individuals, with dyslipidemia being an important risk factor for developing acute coronary syndrome (ACS). Recently, new analytical parameters of the lipid profile have been described, which are associated with a higher cardiovascular risk.

Purpose

The aim of the study was to analyse characteristics, lipid profile and, whether LDL goals are achieved in young patients with ACS admitted to our Coronary Care Unit (CCU).

Methods

Retrospective cohort of all patients with ACS minor than 45 years admitted to a CCU between January 2010 and February 2023. The LDL goals were established according to the European clinical practice guidelines (<70 mg/dL or <55 mg/dL after 2019).

Results

A total of 287 patients were included, with 82.6% being male and an average age of 41 years. 77% were smokers and 9% were ex-smokers. The prevalence of classic cardiovascular risk factors at admission was as follows: dyslipidemia 105 (37%), overweight 74 (26%), obesity 70 (25%), hypertension 87 (30%), and diabetes 29 (10%). Lipid profile’s results are showed in picture 1. Smoking, gender, as well as obesity or overweight were not significantly associated with a worse lipid profile. Significant differences were also not found based on the extent of coronary involvement (analyzing the number of affected vessels or the presence of coronary occlusion) or the reason for admission (NSTEMI vs. STEMI).

As for secondary prevention, 70% of patients completed the cardiac rehabilitation program. The percentage of patients who achieved the LDL goal was 62.4% at 6 months (with an average of 61 mg/dL) and 52.4% at one year (with an average of 72 mg/dL). The majority of patients (74%) who did not meet the goals at 6 months still did not achieve them at one year. A higher initial LDL-C level was associated with a lower likelihood of achieving the goals at 6 months and one year, although it did not reach statistical significance at one year (p = 0.05 and 0.08, respectively). No other predictors of success were found, although participation in a Cardiac Rehabilitation Program was associated with a non-significant trend towards goal attainment, likely due to the small sample size (45% vs. 65%, p = 0.09).

Conclusion

Young patients with ACS have a good short-term and long-term prognosis, which is why secondary prevention becomes particularly important. However, a significant percentage of patients still do not achieve the recommended LDL-C goals, leaving room for improvement in reducing morbidity and mortality in this population. Larger patient series are needed to gain a better understanding of this population.Table 1.Lipid profile'sLDL and Lipoprotein (a) at admission
Independent predictors of MACE in patients with cancer
Authors: Kalogera V , Benetos G , Nikolopoulou L , Solomou E , Vakka A , Drakopoulou M , Tsioufis K , Toutouzas K
Published: May 2024

Funding Acknowledgements

None.

Background/Introduction

Cardiovascular disease and cancer are the leading causes of death worldwide. Both disease entities share common risk factors. More importantly, the main cause of death after disease progression is cardiovascular disease in patients with cancer. Despite the recent advancements in the field of cardio-oncology, the main prognostic factors of major adverse cardiovascular events (MACE) remain elusive.

Purpose

To investigate prognostic factors of MACE in a single center cardio-oncology registry.

Methods

Consecutive patients referred to the cardio-oncology outpatient clinic of a tertiary center for cardiologic consultation were included. All patients were followed up clinically or by telephone. Data from national records were also used.

Results

In total, 115 patients were included in the analysis. Of them, 60 (52.2%) were female and the majority of study population suffered from breast cancer (27%). Thirteen patients (11.3%) had hematologic malignancies and the rest solid tumors. Chemotherapy was received by a total of 94 patients (81,7%). The mean follow -up duration was 446 days. During follow up, 32 MACEs (27.8%) occurred. Death from any cause occurred in 21 patients (including 2 cardiac deaths), hospitalization due to heart failure in 6, myocardial infarction in 2, pulmonary embolism in 3 and stroke in 1 patient. In multivariate logistic regression analysis, diabetes mellitus was an independent predictor of MACE, after adjustment for cardiovascular risk factors and body mass index (OR=3.37, 95% CI 1.14-9.99). In Kaplan Meier plots patients with diabetes mellitus showed higher incidence of MACE (log rank p=0.03).

Conclusions

In the present single center study, diabetes mellitus emerged as an independent predictor of MACE. This finding confirms the important and primary role of cardio-oncology units in the strict management of cardiovascular risk factors, leading to improved prognosis of this patient-population.Kaplan Meier Curve
McConnell's sign predicts normotensive shock in patients with acute pulmonary embolism
Authors: Zhang R Z , Rhee A R , Grossman K G , Arushi Singh A S , Nayar A N , Elbaum L E , Greco A G , Postelnicu R P , Alviar C A , Bangalore S B
Published: May 2024

Funding Acknowledgements

None.

Background

Patients with intermediate-risk acute pulmonary embolism (PE) have mortality rates ranging from 3-15%, with incidence of normotensive shock occurring in up to 30% of patients.1-3 Existing risk models often fall short in accurately identifying those at heightened risk of normotensive shock and those who might derive benefit from advanced therapeutic interventions including catheter based therapies. Diagnosis of normotensive shock typically necessitates invasive right heart catheterization, however, McConnell's sign has been associated with higher risk PEs.4 Consequently, our objective was to assess the relationship between McConnell's sign, a readily available bedside point-of-care tool, and its predictive value in identifying normotensive shock in patients diagnosed with acute intermediate-risk PE.

Methods

All patients with intermediate-risk PE who underwent percutaneous mechanical thrombectomy (MT) between August 2020 and April 2023 at a large academic public hospital were included in the study. Normotensive shock was defined as patients with systolic blood pressure (SBP) ≥ 90mmHg in the absence of vasopressor support with pre-procedural invasive measures of CI £ 2.2 L/min/m2 and clinical evidence of hypoperfusion (i.e. elevated lactate, oliguria). The primary outcome was the association between McConnell’s sign and normotensive shock.

Results

A total of 49 patients with intermediate-risk PE underwent MT, 9 patients had incomplete data, resulting in a final cohort of 40 patients (mean age: 57 ± 13 years; 45% female). A total of 29/40 (72.5%) patients had McConnell’s sign. Patients with McConnell’s sign had higher rates of obesity (59% vs 18% p=0.02), higher heart rate (114 vs 99 beats/min, p=0.008), higher rates of elevated lactate (86% vs 55%, p=0..038), lower cardiac index (1.9 vs 3.1 L/min/m2, p=0.003), and higher rates of normotensive shock (76% vs 27%, p=0.005). There was no statistically significant difference in age, sex, race, rates of saddle emboli, left ventricular ejection fraction, pulmonary artery systolic pressure, presenting blood pressure, sPESI and composite pulmonary embolism shock score scores in patients with or without McConnell’s sign. In patients with normotensive shock, 22/25 (88%) had McConnell’s sign and only 53.3% had McConnell’s sign without shock (Figure 1). Patients with McConnell’s sign had an increased odds (OR 8.38, CI: 1.73-40.53; p=0.008, AUC 0.70, 95% CI: 0.56-0.85) of normotensive shock.

Conclusion

This is the first study to suggest that McConnell’s sign can effectively identify those in the intermediate-risk group who are at risk for normotensive shock. Further studies are needed to validate this non-invasive technique that can be rapidly performed at bedside with high reproducibility and whether it can help risk-stratify patients who may benefit from advanced PE therapies.
Body mass index and long-term survival following acute pulmonary embolism: insights from machine learning models
Authors: Pavlov M , Novak A , Radonic V , Letilovic T , Hadzibegovic I , Jurin I
Published: May 2024

Funding Acknowledgements

None.

Introduction

Body mass index (BMI) has been associated with long-term survival in the setting of acute pulmonary embolism (PE) [1,2]. The non-linear pattern of this association proves to be challenging for frequentist statistical analyses. Contemporary machine learning models offer superior handling capabilities of datasets with non-linear data distributions.

Purpose

To examine the predictive power of BMI expressed as a continuous variable in a dataset of patients with pulmonary embolism (PE) using the extreme gradient boosting (XGBoost) machine learning framework.

Methods

All consecutive patients with confirmed PE admitted to the two tertiary teaching Clinical Hospitals in the metropolitan area from November 2013 until November 2018 were included in the study. The diagnosis was established by multislice computed tomography angiography. Machine learning models were investigated using the LightGBM variant of XGBoost. We allocated 80% of the dataset for model training and the remaining 20% for testing. Two models were tested: (1) a model with 20 variables tailored according to the Cox proportional hazards model in the initial publication; (2) a model with 11 independent predictors of outcome.

Results

The study population is described in detail in previous publications [1,2]. In brief, a total of 761 patients were included in the study. The population was predominantly female (57.4%), aged 73 (61-81). The median overall follow-up was 675 days (114-1331). There were 335 (44.0%) cases of death recorded at follow-up. A Cox proportional hazards model with 19 covariates significantly predicted death during follow-up (χ2 = 595.5, p<0.001). The first BMI quartile was an independent predictor of death (hazard ratio 1.66, 95% confidence interval 1.31-2.10). However, when expressed as a continuous variable, BMI failed to enter the model.

In both XGBoost models, BMI expressed as a continuous variable proved to be a feature with high predictive power, second only to pulmonary embolism severity index score (Figure 1 and 2). The models showed high accuracy, with an area under curve of 0.840 and 0.864 respectively.

Conclusion

In the XGBoost analysis, a machine learning framework with superior handling of non-linear data, BMI expressed as a continuous variable emerged as the second strongest predictor of outcome among 761 PE patients.Figure 1Figure 2
Oxygen delivery and consumption in comatose out-of-hospital cardiac arrest patients are affected by blood pressure targets
Authors: Schneekloth S , Moeller J E , Beske R P , Grand J , Schmidt H , Kjaergaard J , Hassager C
Published: May 2024

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Grosserer L. F. Foghts Fond

Background

Hemodynamic instability is common after resuscitated out-of-hospital cardiac arrest (OHCA). Preventing inadequate oxygen delivery (DO2) to the cells and thus not meeting oxygen demand is crucial to prevent further organ dysfunction. Additionally, oxygen uptake in the cells may be impaired. Oxygen consumption (VO2; the amount of oxygen consumed by the body per minute) could thus also be affected in OHCA.

Purpose

This study aimed to describe the effect of different mean arterial blood pressure (MAP) and partial arterial oxygen pressure (PaO2) targets on DO2 and VO2.

Methods

This post-hoc study is based on the BOX trial, a 2x2 factorial design that randomized OHCA patients to a MAP of either 63 mmHg (MAP63) or 77 mmHg (MAP77) and a partial pressure of arterial oxygen of 9 to 10 kPa or a liberal oxygen target of a PaO2 of 13 to 14 kPa at two cardiac centers in Denmark. Pulmonary artery catheters were placed to evaluate cardiac output and collect mixed venous blood samples at prespecified time points. Oxygen blood contents were calculated for arterial (CaO2) and mixed venous blood (CvO2) as Hgb (mg/dl) x 10 x 1.39 x Saturation O2 (proportion) + 0.0225 x PaO2. DO2 = CO x CaO2, and VO2 = CO x (CaO2-CvO2).

Results

This study included 715 patients (90% of the total cohort with a pulmonary catheter) for analysis. A restrictive or liberal oxygen supplement did not affect DO2 or VO2 during the initial 48 hours. The MAP77 group exhibited on average 11% higher DO2 (95%CI: 6%-15%) and on average a 6% higher VO2 in the first 48 hours (95%CI: 3%-10%) compared to the MAP63 group (see Figure 1).

Conclusion

Targeting a PaO2 of either 9 to 10 kPa or 13 to 15 kPa resulted in no significant changes in the provision of oxygen to the cells, nor did it increase the consumption of oxygen. In contrast, targeting a MAP of 77 mmHg resulted in an increase in both the provision of oxygen and consumption of oxygen compared to a MAP target of 63 mmHg.Figure 1
All lactate are not equal substudy of the BOX trial
Authors: Paulin Beske R , Moeller J E M , Schmidt H S , Kjaergaard J K , Hassager C H
Published: May 2024

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): The BOX trial was supported by a grant (NNF17OC0028706) from the Novo Nordisk Foundation. Dr. Hassager's work is funded by a grant (R186-2015-2132) from the Lundbeck Foundation.

Background

Lactate levels following out-of-hospital cardiac arrest (OHCA) are associated with arrest duration (time to ROSC) and mortality. However, given the complexity of lactate generation and clearance, lactate levels assessed at hospital arrival represent not only time to ROSC but also the quality of resuscitation, circulatory stability following ROSC, dose of epinephrine administered, kidney, liver, and mitochondrial function in the early post-cardiac arrest phase. Accordingly, we describe the lactate levels at hospital arrival according to time to ROSC and one-year mortality.

Method

In this sub-study of the randomized clinical BOX trial, blood lactate levels were measured immediately at hospital arrival. Time to ROSC was registered in the medical records. Patients were divided into two groups according to median time to ROSC (≤ 18 min or > 18 min). The primary outcome was one-year mortality.

Results

The study included 768 (97% of the randomized population) patients of which 386 (50%) patients had ≤ 18 min and 382 (50%) patients had > 18 min to ROSC. The median age (64 (54-73) years) and sex distribution (81% men) was similar in both groups. One-year mortality was 76 (20%) and 199 (52%) in the ≤ 18 min and > 18 min to ROSC groups respectively. Mean lactate levels were 3.8 mmol/L (95%CI: 3.5-4.1) and 5.9 mmol/L (95%CI: 5.4-6.2), respectively. Lactate levels differed significantly between one-year survivors and non-survivors in the patients with ≤ 18 min to ROSC (mean difference: 1.9 mmol/L, 95%CI: 1.0 - 2.8) but not for patients with > 18 min to ROSC (mean difference: 0.6 mmol/L, 95%CI: -0.1-1.3), Figure 1. Further, lactate’s ability to predict one-year mortality was fair in the ≤ 18 min group with an Area Under Receiver Operating Characteristic Curve (AUC) of 0.68 (95%CI: 0.62-0.75) but poor for the > 18 min groups with an AUC of 0.55 (95%CI: 0.50-0.61) (DeLong's test for two ROC curves, p = 0.004), Figure 2.

Conclusion

Lactate's predictive value for one-year mortality decreases with increasing time to ROSC in OHCA. This highlights the importance of individualized clinical approaches based on lactate dynamics in OHCA patients.Figure 1Figure 2
Clinical impact of a cardiac intensivist in an adult cardiac care unit from the RESCUE registry
Authors: Bae D , Lee S Y , Yang J H , Gwon H C
Published: May 2024

Funding Acknowledgements

None.

Purpose

Dedicated intensive care unit (ICU) physician staffing is assocated with a reduction in ICU mortality rates in general medical and surgical ICUs. However, limited data area available on the role of cardiac intensivist in the cardiac intensive care unit (CICU). We investigated the association of cardiac intensivist-directed care with clinical outcomes in adult patients admitted to the CICU.

Methods

The SMART-RESCUE study is a multicenter, retrospective and prosective registry of patients that presented witth cardiogenic shock (CS). Between January 2014 and December 2018, 1,247 patients with CS were enrolled from 12 major centers in Korea. The study population was divided into 2 groups, according to the presence of a cardiac intensivist. The primary outcome was in-hospital mortality.

Results

THe analysis with SMART-RESCUE registry included 1,247 patients with CS (n=552 in the group with cardiac intensivist and n=695 in the group without cardiac intensivist) (Table 1). The in-hospital survival rate was significant higher in the group with intensivist than that in the group without intensivist (72.1% vs 59.2%, p < 0.001) (Figure 1). Cardiac intensive care with cardiac intensivist was associated with a reduction in risk-adjusted in-hospital mortality (adjusted odds ratio for in hospital death, 0.53; 95% confidence interval: 0.401 to 0.704; p < 0.001). Survival analysis also revealed significantly higher death free survival in te group with intensitivst. In multivariable analysis, cardiac intensivist, chronic kidney disease, ECMO-cardiopulmonary resuscitation, ST elevation myocardial infarction presentation and vasotrope-inotrope score were selected to be significant prognostic predictors for death in the CICU.

Concluison: The presence of a dedicated cardiac intensivist was associated with a reduction in hospital mortality rates in patients with cardiovascular disease who required critical care.
The influence of perceived stress in acute coronary syndromes presentation
Authors: Figueiredo M , Paula S O F I A , Santos M A R I A N , Coelho M A R I A N , Lopes A R T U R , Almeida S A M U E L , Almeida L U R D E S
Published: May 2024

Funding Acknowledgements

None.

Introduction

Acute coronary syndrome (ACS) is the result of a complex pathophysiological process, influenced by multiple factors, including stress. The 10-item Perceived Stress Scale (PSS-10) is a validated instrument to estimate stress levels in clinical practice and may be useful in the assessment of ACS (Figure 1).

Purpose

We aimed to assess if perceived stress had influence on the presentation of an ACS as a ST-elevation myocardial infarction (STEMI) or a non-ST-elevation myocardial infarction (NSTEMI), at admission, during hospitalization for this event, and at follow-up.

Methods

Single-center prospective study engaging patients hospitalized for ACS from 20/03/2019 to 31/03/2020. The PSS-10 was completed during the hospitalization period. Patients were divided into two groups, according to the type of ACS: group A – STEMI patients - and group B - NSTEMI patients. Follow-up of these patients (regarding death, readmissions for cardiac causes and readmissions for other causes) was carried out until December 11, 2022. Logistic regression was performed to assess if stress was a predictor of NSTEMI.

Results

A total of 166 patients were included: 52 in group A and 94 in group B. In group A, mean age was 63 ± 18 years and 34.60% were women, while in group B mean age was 66 ± 20 years, and 38.70% were female. Group B presented more with preserved ejection fraction (79.30% vs 60.40% in group A, p=0.018). There were no other statistically significant differences regarding clinical presentation, or intrahospital complications between the two groups. PSS-10 score in group A was 17.17 ± 8.62, while group B scored 20.83 ± 6.10 (p=0.039). The follow-up of these two groups did not show significant differences in terms of death (7.70% in group A vs 16.10% in group B, p=0.149), readmissions for other causes (19.20% in group A vs 28.00% in group B, p=0.243) or readmissions for cardiac causes (group A 9.60% and group B 22.60%, p=0.051). Logistic regression revealed that perceived stress was a predictor of NSTEMI (odds ratio (OR) 1.006, p=0.025, confidence interval (CI) 1.001-1.011). There were no statistically significant differences in follow-up between the two groups.

Conclusions

This is the first prospective study carried out in the Portuguese population regarding this thematic, which showed that perceived stress was a predictor of NSTEMI and can influence patients with ACS manifestations.Figure 1
Bioresorbable vascular scaffolds - a single center experience
Authors: Rocha De Almeida A , Carias De Sousa M , Congo K , Neves D , Lino L
Published: May 2024

Funding Acknowledgements

None.

Background/Introduction

Bioresorbable vascular scaffolds (BVS) were considered promising alternatives to drug-eluting stents in percutaneous coronary interventions (PCI). They would restore the normal vasomotor tone and allow positive remodeling, reducing the trigger for inflammation and facilitating further interventions. Although randomized trials showed beneficial outcomes up to 1 year of follow-up, longer-term results have been disappointing, with increased rates of events, leading to its discontinuation.

Purpose

This study aims to evaluate our center’s 5-year follow-up of the BVS implantations, in terms of safety and efficacy.

Methods

Retrospective cohort of 46 patients submitted to PCI with a BVS was evaluated. The outcomes assessed were composite endpoint of death, myocardial infarction (MI), and revascularization (DMR), target vessel failure (TVF) and cardiovascular death, and each endpoint individually. Data analysis was done with SPSS software.

Results

The cohort was a total of 46 patients, with a mean age 69,5±1,5 years, and 23,9% women (n=11). The mean follow-up time was 5,6±0,2 years. BVS were implanted 74% (n=34) of the times in acute coronary syndromes, and 68% (n=31) were PCI on previous stent failure. Total of 24% (n=11) had an episode in the follow-up. Regarding each individual outcome, there was 9% (n=4) of MI, 0% (n=0) of cardiovascular deaths and 15,2% (n=7) of BVS re-stenosis requiring revascularization. Only 4% (n=2) of patients had complete BVS resorption on reassessment coronary angiography.

Conclusions

In the 5-year follow-up, there was a high rate of events, with 24% (n=11) of events, of which the most common was BVS re-stenosis, with 15,2% cases (n=7), and MI in 9% (n=4). Despite theoretical benefits with the resorption of BVS, it was only verified in 4% of the cases (n=2). According to the recent data, from the longer-term follow-up, BVS have been associated with a higher number of events, with the intended benefit not being verified.
Impact of acute aortic pathology care process reengineering on mortality of type A acute aortic syndrome
Authors: Ramos Gonzalez-Cristobal I , Ferrera C , Vilacosta I , Guerrero A , Gutierrez F , Gonzalez Del Castillo J , Dominguez M J , Alvarez E , Fernandez F , Martinez I , Cobiella J , Noriega F J , Viana-Tejedor A , Perez Villacastin J , Maroto-Castellanos L
Published: May 2024

Funding Acknowledgements

None.

Introduction

Type A Acute aortic syndrome (AAS) is a life-threatening disease. Although emergent surgery is the treatment of choice, these procedures are highly complex and require a high level of expertise. Process reengineering has demonstrated prognostic benefit in acute cardiovascular pathology.

Purpose

The aim of the present work is to assess whether the reorganization of AAS care has an impact on patient prognosis.

Methods

The "Aorta Code" (AC) is a protocol for AAS-patients’ care within a network of 4 hospitals with a tertiary hospital as a referral center. A common diagnostic algorithm was specifically designed and periodical training programs were carried out in the different emergency departments at the 4 hospitals. Once activated, the out of hospital emergency service immediately transfers the patient to the Acute Cardiovascular Care Unit at the referral center. An Aortic Dissection Team was responsible for patients’ care. Only two cardiac surgeons and two vascular surgeons performed all AAS surgeries. All patients with AAS were prospectively and consecutively collected and patients with type A AAS were selected for analysis. Expected 30-day mortality was calculated using the GERAADA score.

Results

From April-2019 to April-2023, 113 patients with AAS were included. Of them, 75.9% (83) were type A. 12% (10) of the patients died before reaching the operating theatre. In 9% (8) of the sample, surgery was rejected due to comorbidities and unacceptable surgical risk, of whom 4 patients died. Mean age was 66.7±13.7 years and 71% were males. Patients with type A AAS presented a significant burden of pre-surgical complications: severe aortic regurgitation (35.6%), cardiac tamponade (26.8%), shock (32.9%), cardiorespiratory arrest (8.5%), need for intubation (26.8%), acute renal failure (27%), peripheral malperfusion (12.7%) and myocardial ischemia (9.52%).

Although the AC included a high risk AAS population, the process reorganization, and concentration of patients’ care in an experienced medical and surgical team resulted in a significant reduction of surgical mortality of patients with type A AAS compared to the expected mortality based on risk (figure).

Conclusion

AAS process reengineering and concentration of AAS management in an experienced medical-surgical team is associated with an improvement in the expected prognosis and mortality.Pre-surgical type A AAS complications.