bluuebunny/crossref_metadata_2025 huggingface dataset:
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Encephalitis Is a Cytokine Release Syndrome: Evidences From Cerebrospinal Fluid Analyses
Authors: Pilotto Andrea , Masciocchi Stefano , Volonghi Irene , De Giuli Valeria , Caprioli Francesca , Mariotto Sara , Ferrari Sergio , Bozzetti Silvia , Imarisio Alberto , Risi Barbara , Premi Enrico , Benussi Alberto , Focà Emanuele , Castelli Francesco , Zanusso Gianluigi , Monaco Salvatore , Stefanelli Paola , Gasparotti Roberto , Zekeridou Anastasia , McKeon Andrew , Ashton Nicholas J , BlennoW Kaj , Zetterberg Henrik , Padovani Alessandro
Published: January 2021

Background

Recent findings indicated that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related neurological manifestations involve cytokine release syndrome along with endothelial activation, blood brain barrier dysfunction, and immune-mediated mechanisms. Very few studies have fully investigated the cerebrospinal fluid (CSF) correlates of SARS-CoV-2 encephalitis.

Methods

Patients with polymerase chain reaction (PCR)-confirmed SARS-CoV-2 infection and encephalitis (COV-Enc), encephalitis without SARS-CoV-2 infection (ENC), and healthy controls (HC) underwent an extended panel of CSF neuronal (neurofilament light chain [NfL], T-tau), glial (glial fibrillary acidic protein [GFAP], soluble triggering receptor expressed on myeloid cells 2 [sTREM2], chitinase-3-like protein 1 [YKL-40]) and inflammatory biomarkers (interleukin [IL]-1β, IL-6, Il-8, tumor necrosis factor [TNF] α, CXCL-13, and β2-microglobulin).

Results

Thirteen COV-Enc, 21 ENC, and 18 HC entered the study. In COV-Enc cases, CSF was negative for SARS-CoV-2 real-time PCR but exhibited increased IL-8 levels independently from presence of pleocytosis/hyperproteinorracchia. COV-Enc patients showed increased IL-6, TNF- α, and β2-microglobulin and glial markers (GFAP, sTREM2, YKL-40) levels similar to ENC but normal CXCL13 levels. Neuronal markers NfL and T-tau were abnormal only in severe cases.

Conclusions

SARS-CoV-2-related encephalitis were associated with prominent glial activation and neuroinflammatory markers, whereas neuronal markers were increased in severe cases only. The pattern of CSF alterations suggested a cytokine-release syndrome as the main inflammatory mechanism of SARS-CoV-2-related encephalitis.
Trust-aware Task Allocation in Collaborative Crowdsourcing Model
Authors: Donglai Fu , Yanhua Liu
Published: January 2021

Task allocation plays a vital role in crowd computing by determining its performance. The power of crowd computing stems from a large number of workers potentially available to provide high quality of service and reduce costs. An important challenge in the crowdsourcing market today is the task allocation of crowdsourcing workflows. Task allocation aims to maximize the completion quality of the entire workflow and minimize its total cost. Trust can affect the quality of the produced results and costs. Selecting workers with high levels of trust could provide better solution to the workflow and increase the budget. Crowdsourcing workflow needs to balance the two conflicting objectives. In this paper, we propose an alternative greedy approach with four heuristic strategies to address the issue. In particular, the proposed approach aims to monitor the current status of workflow execution and use heuristic strategies to adjust the parameters of task allocation. We design a two-phase allocation model to accurately match the tasks with workers. T-Aware allocates each task to the worker that maximizes the trust level, while minimizing the cost. We conduct extensive experiments to quantitatively evaluate the proposed algorithms in terms of running time, task failure ratio, trust and cost using a customer objective function on WorkflowSim, a well-known cloud simulation tool. Experimental results based on real-world workflows show that T-Aware outperforms other optimal solutions on finding the tradeoff between trust and cost, which is 3 to 6% better than the best competitor algorithm.
Continual Leakage-Resilient Hedged Public-Key Encryption
Authors: Huang Meijuan , Yang Bo , Zhou Yanwei , Hu Xuewei
Published: January 2021

Hedged public-key encryption (HPKE), introduced by Bellare et al. (ASIACRYPT 2009), provides useful security when the per-message randomness fails to be uniform due to faulty implementations or adversarial actions. The HPKE scheme achieves IND-CPA (chosen plaintext attack) security when the randomness they used is of high quality, but, when the randomness is poor quality, rather than breaking completely, it achieves a weaker but a useful notion of security called IND-CDA (chosen distribution attack) as long as the message and randomness together have sufficient min-entropy. However, little research on HPKE in the presence of key leakage was done. In this paper, we study HPKE featuring key leakage-resilience and formulate appropriate security notion for key leakage-resilient HPKE. We work in the continual key leakage model where the secret key is refreshed periodically and an adversary can learn arbitrary but bounded leakage on the secret key between the updates. We present two generic constructions of continual leakage-resilient HPKE in the standard model by using a continual leakage-resilient all-but-one lossy trapdoor function. Finally, we give an instantiation of leakage-resilient HPKE under the linear assumption in bilinear groups.
Association between β-blocker dose and cardiovascular outcomes after myocardial infarction: insights from the SWEDEHEART registry
Authors: Mars Katarina , Wallert John , Held Claes , Humphries Sophia , Pingel Ronnie , Jernberg Tomas , Olsson Erik M G , Hofmann Robin
Published: January 2021

Aims

Dose-dependent effects of β-blockers on survival and cardiovascular outcomes after myocardial infarction (MI) are not well understood. We investigated the long-term risk of cardiovascular events in patients with different doses of β-blockers after MI.

Methods and results

This was a nationwide observational study linking morbidity, mortality, socioeconomic, and medication data from Swedish national registries. Between 2006 and 2015, 97 575 unique patients with first-time MI were included. In total, 33 126 (33.9%) patients were discharged with ≥50% of the target β-blocker dose and 64 449 (66.1%) patients with <50% of the target β-blocker dose used in previous randomized trials. The primary composite endpoint was re-infarction or all-cause death within 1 year from discharge. Multivariable adjusted 1-year follow-up estimates using mixed effects Cox regression [HR (95% CI)] showed that patients treated with ≥50% of the target dose had a similar risk of the composite endpoint [1.03 (0.99–1.08)] and a somewhat higher risk when stroke, atrial fibrillation, or heart failure hospitalization were added to the composite endpoint [1.08 (1.04–1.12)], compared with patients on <50% of the target β-blocker dose. Results remained similar up to 5 years of follow-up and consistent across relevant patient subgroups, including patients who developed heart failure during the index hospitalization.

Conclusions

In contrast to doses of β-blockers used in previous trials, ≥50% of the target β-blocker dose was not associated with superior cardiovascular outcomes up to 5 years as compared with <50% of the target dose. Contemporary randomized clinical trials are needed to clarify the optimal dose of β-blockers after MI.
Hospitalization-related economic impact of patients with cardiogenic shock in a high-complexity reference centre
Authors: Collado Elena , Luiso Daniele , Ariza-Solé Albert , Lorente Victoria , Sánchez-Salado José Carlos , Moreno Ramon , Alsina Maria , Tapia Javier , González-Costello José , Comin-Colet Josep
Published: January 2021

Aims 

Cardiogenic shock (CS) is associated with high mortality. Current guidelines strongly recommend centralizing the care of these patients in high-complexity centres. We described the hospitalization-related economic cost and its main determinants in patients with CS in a high-complexity reference centre.

Methods and results 

This is a single-centre, retrospective study. All patients with CS (2015–17) were included. Hospitalization-related cost per patient was calculated by analytical accountability method, including hospital stay-related expenditures, interventions, and consumption of devices. Expenditure was expressed in 2018 euros. All-cause mortality during follow-up was registered. Ratio of cost per life-year gained (LYG) was also calculated. A total of 230 patients were included, with mean age of 63 years. In-hospital mortality was 88/230 (38.3%). Hospital stay was longer in patients surviving after the admission (21.7 vs. 7.5 days, P < 0.001). Total economic cost for the overall cohort was 3 947 118€ (mean/patient 17 161€). Most of this cost was attributable to hospital stay (81.1%). The rest of the expenditure was due to in-hospital procedures (13.1%) and the use of devices (5.8%). Most of hospital stay-related costs (79.8%) were due to Critical Care Unit stay. Mean follow-up was 651 days. Total LYG was 409.77 years for the whole series. The observed ratio of cost per LYG was 9632.52 €/LYG.

Conclusions 

Management of CS in a reference centre is associated to a significant economic cost, but with a low ratio of cost per LYG. Most of this cost is attributable to hospital stay, specifically in critical care units.
Role of perilipin 2 in microvascular obstruction in patients with ST-elevation myocardial infarction
Authors: Russo Michele , Montone Rocco A , D’Amario Domenico , Camilli Massimiliano , Canonico Francesco , Santamaria Claudia , Iannaccone Giulia , Pedicino Daniela , Pidone Chiara , Galli Mattia , Trani Carlo , Severino Anna , Liuzzo Giovanna , Niccoli Giampaolo , Crea Filippo
Published: January 2021

Aims

Coronary microvascular obstruction (MVO) occurs frequently in patients with ST-elevation myocardial infarction (STEMI) after percutaneous coronary intervention (PCI). However, mechanisms are multiple and not yet fully understood. Perilipin 2 (PLIN2) is involved in lipid metabolism of macrophages resident in atherosclerotic plaques, along with a role in enhancing plaque inflammation. We studied the association between PLIN2 and MVO in STEMI patients undergoing primary PCI, and we assessed the role of PLIN2 to predict major adverse cardiovascular events (MACEs).

Methods and results

STEMI patients undergoing primary PCI were enrolled. PLIN2 was evaluated in peripheral blood monocytes; MVO was assessed using coronary angiogram. MACEs, as a composite of cardiac death, non-fatal myocardial infarction, re-admission for heart failure, and target vessel revascularization were investigated at follow-up. Among 100 STEMI patients, 33 (33.0%) had MVO. Patients with MVO had higher levels of PLIN2 (1.03 ± 0.28 vs. 0.90 ± 0.16, P = 0.019). Age [odds ratio (OR) (95% confidence interval, CI), 1.045 (1.005–1.087), P = 0.026] and PLIN2 [OR (95% CI), 16.606 (2.027–136.030), P = 0.009] were associated with MVO at univariate analysis, although only PLIN2 [OR (95% CI), 12.325 (1.446–105.039), P = 0.022] was associated with MVO at multivariate analysis. After a mean follow-up of 182.2 ± 126.6 days, 13 MACEs occurred. MVO [hazard ratio (HR) (95% CI), 6.791 (2.053–22.462), P = 0.002], hypercholesterolaemia [HR (95% CI), 3.563 (1.094–11.599), P = 0.035], and PLIN2 [HR (95% CI), 82.991 (9.857–698.746), P < 0.001] were predictors of MACEs at univariate analysis, although only PLIN2 [HR (95% CI), 26.904 (2.461–294.100), P = 0.007] predicted MACEs at multivariate analysis.

Conclusions

In STEMI patients undergoing primary PCI, PLIN2 was independently associated with MVO and was an independent predictor of MACEs at follow-up, suggesting to further explore PLIN2 as a target for future cardioprotection therapies.
The value of urinary sodium assessment in acute heart failure
Authors: Tersalvi Gregorio , Dauw Jeroen , Gasperetti Alessio , Winterton Dario , Cioffi Giacomo Maria , Scopigni Francesca , Pedrazzini Giovanni , Mullens Wilfried
Published: January 2021

Acute heart failure (AHF) is a frequent medical condition that needs immediate evaluation and appropriate treatment. Patients with signs and symptoms of volume overload mostly require intravenous loop diuretics in the first hours of hospitalization. Some patients may develop diuretic resistance, resulting in insufficient and delayed decongestion, with increased mortality and morbidity. Urinary sodium measurement at baseline and/or during treatment has been proposed as a useful parameter to tailor diuretic therapy in these patients. This systematic review discusses the current sum of evidence regarding urinary sodium assessment to evaluate diuretic efficacy in AHF. We searched Medline, Embase, and Cochrane Clinical Trials Register for published studies that tested urinary sodium assessment in patients with AHF.
The addition of echocardiographic parameters to PESI risk score improves mortality prediction in patients with acute pulmonary embolism: PESI-Echo score
Authors: Burgos Lucrecia M , Scatularo Cristhian E , Cigalini Ignacio M , Jauregui Juan C , Bernal Maico I , Bonorino José M , Thierer Jorge , Zaidel Ezequiel J ,   the Argentine Council of Cardiology Residents, Argentina
Published: January 2021

Aims

Pulmonary embolism severity index (PESI) has been developed to help physicians make decisions about the treatment of patients with pulmonary embolism (PE). The combination of echocardiographic parameters could potentially improve PESI’s mortality prediction. To assess the additional prognostic value of tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) when combined with the PESI score in patients with PE to predict short-term mortality.

Methods and results

A multicentric prospective study database of patients admitted with PE in 75 academic centres in Argentina between 2016 and 2017 was analysed. Patients with an echocardiogram at admission with simultaneous measurement of TAPSE and PASP were included. PESI risk score was calculated blindly and prospectively, and in-hospital all-cause mortality was assessed. Of 684 patients, 91% had an echocardiogram, PASP and TAPSE could be estimated simultaneously in 355 (57%). All-cause in-hospital mortality was 11%. The receiver operating characteristic analysis showed an area under the curve (AUC) [95% confidence interval (CI)] of 0.76 (0.72–0.81), 0.74 (0.69–0.79), and 0.71 (0.62–0.79), for the PESI score, PASP, and TAPSE parameters, respectively. When PESI score was combined with the echocardiogram parameters (PESI + PASP-TAPSE = PESI-Echo), an AUC of 0.82 (0.77–0.86) was achieved (P = 0.007). A PESI-Echo score ≥128 was the optimal cut-off point for predicting hospital mortality: sensitivity 82% (95% CI 67–90%), specificity 69% (95% CI 64–74%). The global net reclassification improvement was 9.9%.

Conclusions

PESI-Echo score is a novel tool for assessing mortality risk in patients with acute PE. The addition of echocardiographic parameters to a validated clinical score improved the prediction of hospital mortality.
Incidence of major adverse cardiac events following non-cardiac surgery
Authors: Sazgary Lorraine , Puelacher Christian , Lurati Buse Giovanna , Glarner Noemi , Lampart Andreas , Bolliger Daniel , Steiner Luzius , Gürke Lorenz , Wolff Thomas , Mujagic Edin , Schaeren Stefan , Lardinois Didier , Espinola Jacqueline , Kindler Christoph , Hammerer-Lercher Angelika , Strebel Ivo , Wildi Karin , Hidvegi Reka , Gueckel Johanna , Hollenstein Christina , Breidthardt Tobias , Rentsch Katharina , Buser Andreas , Gualandro Danielle M , Mueller Christian ,   for the BASEL-PMI Investigators, Marbot Stella Joan , Walter Michael , Freese Thomas , Nestelberger Jasper , Boeddinghaus Jeanne , du Fay de Lavallaz Raphael , Twerenbold Patrick , Badertscher Luca , Koechlin Tobias , Zimmermann Valentina , Troester Eleni , Michou Stefan , Osswald Esther , Seeberger Manfred , Seeberger Daniel , Rickli Desiree , Wussler Julia , Dinort Alexandra , Prepoudis Kathrin , Meissner Gregor , Fahrni Raban , Jeger Christoph , Kaiser Laura , Infanti
Published: January 2021

Aims

Major adverse cardiac events (MACE) triggered by non-cardiac surgery are prognostically important perioperative complications. However, due to often asymptomatic presentation, the incidence and timing of postoperative MACE are incompletely understood.

Methods and results

We conducted a prospective observational study implementing a perioperative screening for postoperative MACE [cardiovascular death (CVD), acute heart failure (AHF), haemodynamically relevant arrhythmias, spontaneous myocardial infarction (MI), and perioperative myocardial infarction/injury (PMI)] in patients at increased cardiovascular risk (≥65 years OR ≥45 years with history of cardiovascular disease) undergoing non-cardiac surgery at a tertiary hospital. All patients received serial measurements of cardiac troponin to detect asymptomatic MACE. Among 2265 patients (mean age 73 years, 43.4% women), the incidence of MACE was 15.2% within 30 days, and 20.6% within 365 days. CVD occurred in 1.2% [95% confidence interval (CI) 0.9–1.8] and in 3.7% (95% CI 3.0–4.5), haemodynamically relevant arrhythmias in 1.2% (95% CI 0.9–1.8) and in 2.1% (95% CI 1.6–2.8), AHF in 1.6% (95% CI 1.2–2.2) and in 4.2% (95% CI 3.4–5.1), spontaneous MI in 0.5% (95% CI 0.3–0.9) and in 1.6% (95% CI 1.2–2.2), and PMI in 13.2% (95% CI 11.9–14.7) and in 14.8% (95% CI 13.4–16.4) within 30 days and within 365 days, respectively. The MACE-incidence was increased above presumed baseline rate until Day 135 (95% CI 104–163), indicating a vulnerable period of 3–5 months.

Conclusion

One out of five high-risk patients undergoing non-cardiac surgery will develop one or more MACE within 365 days. The risk for MACE remains increased for about 5 months after non-cardiac surgery.

Trial registration

https://www.clinicaltrials.gov. Unique identifier: NCT02573532.
Safety of dexmedetomidine in the cardiac intensive care unit
Authors: Adie Sarah K , Farina Nicholas , Abdul-Aziz Ahmad A , Lee Ran , Thomas Michael P , Konerman Matthew C
Published: January 2021

Aims

Dexmedetomidine is one of the sedative agents recommended by the Society of Critical Care Medicine as a preferred option over benzodiazepines in critically ill, mechanically ventilated patients. Little data exists describing sedation in the cardiac intensive care unit (CICU). The purpose of this study was to determine the prevalence of adverse events in CICU patients treated with dexmedetomidine.

Methods and results

This was a retrospective cohort analysis of patients >18 years old admitted to the University of Michigan CICU from June 2014 to October 2019 who received dexmedetomidine therapy. The primary outcome was the composite of adverse events including bradycardia, hypotension, increasing vasopressor/inotrope requirements, and asystole. Secondary outcomes included individual components of the primary outcome. Patients that experienced adverse events were compared to those that did not experience adverse events to identify risk factors for adverse events. A total of 197 patients were included. There were 116 adverse events in 106 patients. Hypotension was the most common adverse event, making up 60.3% of adverse events reported. Increased vasopressor requirement and bradycardia both occurred in 22 patients (18.9%). Asystole occurred in two patients. B-type natriuretic peptide (BNP) levels were significantly higher in those experiencing an adverse event (848 pg/mL vs. 431 pg/mL; P = 0.03).

Conclusions

Patients admitted to the CICU experienced a high rate of adverse events with dexmedetomidine use. Those experiencing adverse events were more likely to have a higher BNP. Future studies should explore the safety of alternative sedative agents to ascertain safe pharmacological options for patients admitted to the CICU.
Cardiogenic shock due to predominantly right ventricular failure complicating acute myocardial infarction
Authors: Josiassen Jakob , Helgestad Ole Kristian L , Møller Jacob E , Schmidt Henrik , Jensen Lisette O , Holmvang Lene , Ravn Hanne B , Hassager Christian
Published: January 2021

Aims

The objective was to describe patient characteristics, interventions, and outcome in acute myocardial infarction complicated by cardiogenic shock (AMICS), due to predominantly right ventricular (RV) failure after revascularization, in comparison with patients suffering from left ventricular (LV) failure as these patients remain sparsely characterized.

Methods and results

From 2010 to 2017, consecutive AMICS patients admitted to either of two tertiary heart centres, covering 3.9 million citizens, corresponding to two-thirds of the Danish population, were identified and individually reviewed through patient records. A total of 1716 AMICS patients were identified, of which 1482 underwent acute revascularization and included for analysis. Hereof, 101 (7%) patients developed cardiogenic shock due to predominantly RV failure, while 1381 (93%) had significant LV involvement. Female sex was the only demographic factor associated with RV failure (35% vs. 25%, P = 0.01). Despite having a preserved LV ejection fraction, patients with predominantly RV failure were comparable to patients with LV involvement, in terms of haemodynamic and metabolic profile, here among variables commonly used in the cardiogenic shock definition including blood pressure (82 mmHg vs. 83 mmHg, P = 0.90) and lactate level (5.7 mmol/L vs. 5.4 mmol/L, P = 0.70). Patients with RV AMICS had significantly lower 30-day mortality than LV AMICS, and this result persisted after multivariable adjustment (RV vs. LV; hazard ratio 0.61, 95% confidence interval 0.41–0.92, P = 0.01).

Conclusion

In contemporary AMICS patients undergoing revascularization, patients with predominantly RV failure had comparable haemodynamics and metabolic derangement on admission compared to patients with LV failure but was associated with female sex and a significantly lower 30-day mortality.
Composition, structure, and function of heart teams: a joint position paper of the ACVC, EAPCI, EACTS, and EACTA focused on the management of patients with complex coronary artery disease requiring myocardial revascularization
Authors: Leonardi Sergio , Capodanno Davide , Sousa-Uva Miguel , Vrints Christiaan , Rex Steffen , Guarracino Fabio , Bueno Héctor , Lettino Maddalena , Price Susanna , Valgimigli Marco , Jeppsson Anders
Published: January 2021

Contemporary cardiovascular medicine is complex, dynamic, and interactive. Therefore, multidisciplinary dialogue between different specialists is required to deliver optimal and patient-centred care. This has led to the concept of explicit collaborations of different specialists caring for patients with complex cardiovascular diseases—that is ‘heart teams’. These teams are particularly valuable to minimize referral bias and improve guideline adherence as so to be responsive to patient preferences, needs, and values but may be challenging to coordinate, especially in the acute setting. This position paper—jointly developed by four cardiovascular associations—is intended to provide conceptual and practical considerations for the composition, structure, and function of multidisciplinary teams. It focuses on patients with complex coronary artery diseases in both elective and urgent setting and provide guidance on how to implement the heart team both in chronic and in acute coronary syndromes patients, including cases with mechanical complications and haemodynamic instability; it also discuss strategies for clear and transparent patient communication and provision of a patient-centric approach. Finally, gaps in evidence and research perspectives in this context are discussed.
Association between cardiac rhythm conversion and neurological outcome among cardiac arrest patients with initial shockable rhythm: a nationwide prospective study in Japan
Authors: Kandori Kenji , Okada Yohei , Okada Asami , Nakajima Satoshi , Okada Nobunaga , Matsuyama Tasuku , Kitamura Tetsuhisa , Narumiya Hiromichi , Iizuka Ryoji
Published: January 2021

Aims

Initial cardiac rhythm, particularly shockable rhythm, is a key factor in resuscitation for out-of-hospital cardiac arrest (OHCA) patients. The purpose of this study was to clarify the association between cardiac rhythm conversion and neurologic prognosis in OHCA patients with initial shockable rhythm at the scene.

Methods and results

The study included adult patients with OHCA due to medical causes with pre-hospital initial shockable rhythm and who were still in cardiac arrest at hospital arrival. Multiple logistic regression analysis was conducted to identify the adjusted odds ratios (AORs) and 95% confidence interval (CI) of cardiac arrest rhythm at hospital arrival for 1-month favourable neurologic status and 1-month survival, adjusted for potential confounders. Of 34 754 patients in the 2014–2017 JAAM-OHCA Registry, 1880 were included in the final study analysis. The percentages of 1-month favourable neurologic status for shockable rhythm, pulseless electrical activity (PEA), and asystole at hospital arrival were 17.4% (137/789), 3.6% (18/507), and 1.5% (9/584), respectively. The AORs for 1-month favourable neurologic status comparing to OHCA patients who maintained shockable rhythm at hospital arrival were PEA, 0.19 (95% CI, 0.11–0.32) and asystole, 0.08 (95% CI, 0.04–0.16), respectively.

Conclusion

Findings showed that the 1-month neurologic outcome in OHCA patients who converted to non-shockable rhythm at hospital arrival was very poor compared with patients who had sustained shockable rhythm. Also, patients with conversion to PEA had better neurologic prognosis than conversion to asystole.
Clinical presentation of patients with prior coronary artery bypass grafting and suspected acute myocardial infarction
Authors: Koechlin Luca , Boeddinghaus Jasper , Nestelberger Thomas , Miró Òscar , Fuenzalida Carolina , Martinez-Nadal Gemma , López Beatriz , Wussler Desiree , Walter Joan , Zimmermann Tobias , Troester Valentina , Lopez-Ayala Pedro , Baumgartner Benjamin , Ratmann Paul David , Diebold Matthias , Prepoudis Alexandra , Huber Jeffrey , Christ Michael , Wildi Karin , Rubini Giménez Maria , Strebel Ivo , Gualandro Danielle M , Martin-Sanchez F Javier , Kawecki Damian , Keller Dagmar I , Reuthebuch Oliver , Eckstein Friedrich S , Reichlin Tobias , Twerenbold Raphael , Mueller Christian ,   for the APACE investigators
Published: January 2021

Aims

Diagnosis of acute myocardial infarction (AMI) can be challenging in patients with prior coronary artery bypass grafting (CABG).

Methods and results

Final diagnoses were adjudicated by two independent cardiologists using the universal definition of AMI among patients presenting to the emergency department (ED) with suspected AMI. Diagnostic accuracy of 34 chest pain characteristics (CPCs) and four electrocardiogram (ECG) signatures stratified according to the presence or absence of prior CABG were prospectively quantified. Among 4015 patients (no prior CABG: n = 3686; prior CABG: n = 329), prevalence of AMI and unstable angina were higher in patients with prior CABG (35% vs. 18%; 26% vs. 8%; both P < 0.001). Three CPCs (9%) and two electrocardiographic findings (50%) showed a different diagnostic performance (interaction P < 0.05) with loss of diagnostic value in patients with prior CABG. The diagnostic accuracy as quantified by the area under the curve (AUC) of the integrated clinical judgement was moderate to good in patients with prior CABG, and significantly lower compared to patients without prior CABG [AUC 0.80 (95% confidence interval (CI) 0.75–0.84) vs. AUC 0.87 (95% CI 0.86–0.89); P = 0.004]. Time to discharge from the ED was significantly longer in patients with prior CABG [359 (215–525) min vs. 300 (192–435) min; P < 0.001]. Key findings were confirmed in a large independent external validation cohort (n = 13 653).

Conclusions

Patients with prior CABG presenting with suspected AMI have a high prevalence of AMI and unstable angina and lower diagnostic accuracy of CPCs and the ECG, possibly justifying liberal use of early coronary angiography in these vulnerable patients.

ClinicalTrials.gov registry

Number NCT00470587.
Mortality risk stratification using artificial intelligence-augmented electrocardiogram in cardiac intensive care unit patients
Authors: Jentzer Jacob C , Kashou Anthony H , Lopez-Jimenez Francisco , Attia Zachi I , Kapa Suraj , Friedman Paul A , Noseworthy Peter A
Published: January 2021

Aims

An artificial intelligence-augmented electrocardiogram (AI-ECG) algorithm can identify left ventricular systolic dysfunction (LVSD). We sought to determine whether this AI-ECG algorithm could stratify mortality risk in cardiac intensive care unit (CICU) patients, independent of the presence of LVSD by transthoracic echocardiography (TTE).

Methods and results

We included 11 266 unique Mayo Clinic CICU patients admitted from 2007 to 2018 who underwent AI-ECG after CICU admission. Left ventricular ejection fraction (LVEF) data were extracted for patients with a TTE during hospitalization. Hospital mortality was analysed using multivariable logistic regression. Mean age was 68 ± 15 years, including 37% females. Higher AI-ECG probability of LVSD remained associated with higher hospital mortality [adjusted odds ratio (OR) 1.05 per 0.1 higher, 95% confidence interval (CI) 1.02–1.08, P = 0.003] after adjustment for LVEF, which itself was inversely related with the risk of hospital mortality (adjusted OR 0.96 per 5% higher, 95% CI 0.93–0.99, P = 0.02). Patients with available LVEF data (n = 8242) were divided based on the presence of predicted (by AI-ECG) vs. observed (by TTE) LVSD (defined as LVEF ≤ 35%), using TTE as the gold standard. A stepwise increase in hospital mortality was observed for patients with a true negative, false positive, false negative, and true positive AI-ECG.

Conclusion

The AI-ECG prediction of LVSD is associated with hospital mortality in CICU patients, affording risk stratification in addition to that provided by echocardiographic LVEF. Our results emphasize the prognostic value of electrocardiographic patterns reflecting underlying myocardial disease that are recognized by the AI-ECG.
Five-year risk of heart failure and death following myocardial infarction with cardiogenic shock: a nationwide cohort study
Authors: Lauridsen Marie Dam , Rorth Rasmus , Butt Jawad Haider , Kristensen Soren Lund , Schmidt Morten , Moller Jacob Eifer , Hassager Christian , Torp-Pedersen Christian , Gislason Gunnar , Kober Lars , Fosbol Emil Loldrup
Published: January 2021

Aims

More patients survive myocardial infarction (MI) with cardiogenic shock (CS), but long-term outcome data are sparse. We aimed to examine rates of heart failure hospitalization and mortality in MI hospital survivors.

Methods and results

First-time MI patients with and without CS alive until discharge were identified using Danish nationwide registries between 2005 and 2017. One-, 5-, and 1- to 5-year rates of heart failure hospitalization and mortality were compared using landmark cumulative incidence curves and Cox regression models. We identified 85 865 MI patients of whom 2865 had CS (3%). Cardiogenic shock patients were of similar age as patients without CS (median age years: 68 vs. 67), and more were men (70% vs. 65%). Cardiogenic shock was associated with a higher 5-year rate of heart failure hospitalization compared with patients without CS [40% vs. 20%, adjusted hazard ratio (HR) 2.90 (95% confidence interval (CI) 2.67–3.12)]. The increased rate of heart failure hospitalization was evident after 1 year and in the 1- to 5-year landmark analysis among 1-year survivors. All-cause mortality was higher at 1 year among CS patients compared with patients without CS [18% vs. 8%, adjusted HR 3.23 (95% CI 2.95–3.54)]. However, beyond the first year, the mortality for CS was not markedly different compared with patients without CS [12% vs. 13%, adjusted HR 1.15 (95% CI 1.00–1.33)].

Conclusion

Among MI hospital survivors, CS was associated with a markedly higher rate of heart failure hospitalization and 1-year mortality compared with patients without CS. However, among 1-year survivors, the remaining 5-year mortality was similar for MI patients with and without CS.
Development and validation of a novel prediction score for cardiac tamponade in emergency department patients with pericardial effusion
Authors: Duanmu Youyou , Choi Daniel S , Tracy Sam , Harris Owen M , Schleifer Jessica I , Dadabhoy Farah Z , Wu Justina C , Platz Elke
Published: January 2021

Aims

Determining which patients with pericardial effusion require urgent intervention can be challenging. We sought to develop a novel, simple risk prediction score for patients with pericardial effusion.

Methods and results

Adult patients admitted through the emergency department (ED) with pericardial effusion were retrospectively evaluated. The overall cohort was divided into a derivation and validation cohort for the generation and validation of a novel risk score using logistic regression. The primary outcome was a pericardial drainage procedure or death attributed to cardiac tamponade within 24 h of ED arrival. Among 195 eligible patients, 102 (52%) experienced the primary outcome. Four variables were selected for the novel score: systolic blood pressure < 100 mmHg (1.5 points), effusion diameter [1–2 cm (0 points), 2–3 cm (1.5 points), >3 cm (2 points)], right ventricular diastolic collapse (2 points), and mitral inflow velocity variation > 25% (1 point). The need for pericardial drainage within 24 h was stratified as low (<2 points), intermediate (2–4 points), or high (≥4 points), which corresponded to risks of 8.1% [95% confidence interval (CI) 3.0–16.8%], 63.8% [95% CI 50.1–76.0%], and 93.7% [95% CI 84.5–98.2%]. The area under the curve of the simplified score was 0.94 for the derivation and 0.91 for the validation cohort.

Conclusion

Among ED patients with pericardial effusion, a four-variable prediction score consisting of systolic blood pressure, effusion diameter, right ventricular collapse, and mitral inflow velocity variation can accurately predict the need for urgent pericardial drainage. Prospective validation of this novel score is warranted.
The cardiac arrest centre for the treatment of sudden cardiac arrest due to presumed cardiac cause: aims, function, and structure: position paper of the ACVC association of the ESC, EAPCI, EHRA, ERC, EUSEM, and ESICM
Authors: Sinning Christoph , Ahrens Ingo , Cariou Alain , Beygui Farzin , Lamhaut Lionel , Halvorsen Sigrun , Nikolaou Nikolaos , Nolan Jerry P , Price Susanna , Monsieurs Koenraad , Behringer Wilhelm , Cecconi Maurizio , Van Belle Eric , Jouven Xavier , Hassager Christian , Sionis Alessandro , Qvigstad Eirik , Huber Kurt , De Backer Daniel , Kunadian Vijay , Kutyifa Valentina , Bossaert Leo
Published: January 2021

Approximately 10% of patients resuscitated from out-of-hospital cardiac arrest (OHCA) survive to hospital discharge. Improved management to improve outcomes are required, and it is proposed that such patients should be preferentially treated in cardiac arrest centres (CACs). The minimum requirements of therapy modalities for the CAC are 24/7 availability of an on-site coronary angiography laboratory, an emergency department, an intensive care unit, imaging facilities, such as echocardiography, computed tomography, and magnetic resonance imaging, and a protocol outlining transfer of selected patients to CACs with additional resources (OHCA hub hospitals). These hub hospitals are regularly treating a high volume of patients and offer further treatment modalities. This consensus document describes the aims, the minimal requirements for therapeutic modalities and expertise, and the structure, of a CAC. It represents a consensus among the major European medical associations and societies involved in the treatment of OHCA patients.
In-hospital outcomes of catheter-directed thrombolysis in patients with pulmonary embolism
Authors: Hobohm Lukas , Schmidt Frank P , Gori Tommaso , Schmidtmann Irene , Barco Stefano , Münzel Thomas , Lankeit Mareike , Konstantinides Stavros V , Keller Karsten
Published: January 2021

Aims

Catheter-directed treatment of acute pulmonary embolism (PE) is technically advancing. Recent guidelines acknowledge this treatment option for patients with overt or imminent haemodynamic decompensation, particularly when systemic thrombolysis is contraindicated. We investigated patients with PE who underwent catheter-directed thrombolysis (CDT) in the German nationwide inpatient cohort.

Methods and results

Data from hospitalizations with PE (International Classification of Disease code I26) between 2005 and 2016 were collected by the Federal Office of Statistics in Germany. Patients with PE who underwent CDT (OPS 8-838.60 or OPS code 8-83b.j) were compared with patients receiving systemic thrombolysis (OPS code 8-020.8), and those without thrombolytic or other reperfusion treatment. The analysis was not prespecified; therefore, our findings can only be considered to be hypothesis generating. We analysed data from 978 094 hospitalized patients with PE. Of these, 41 903 (4.3%) patients received thrombolytic treatment [systemic thrombolysis in 4.2%, CDT in 0.1% (1175 patients)]. Among patients with shock, CDT was associated with lower in-hospital mortality compared to systemic thrombolysis [odds ratios (OR) 0.30 (95% 0.14–0.67); P = 0.003]. Intracranial bleeding occurred in 14 (1.2%) patients who received CDT. Among haemodynamically stable patients with right ventricular dysfunction (intermediate-risk PE), CDT also was associated with a lower risk of in-hospital mortality compared to systemic thrombolysis {OR 0.55 [95% confidence interval (CI) 0.40–0.75]; P < 0.001} or no thrombolytic treatment [0.45 (95% CI 0.33–0.62); P < 0.001].

Conclusion

In the German nationwide inpatient cohort, based on administrative data, CDT was associated with lower in-hospital mortality rates compared to systemic thrombolysis, but the overall rate of intracranial bleeding in patients who received CDT was not negligible. Prospective controlled data are urgently needed to determine the true value of this treatment option in acute PE.
Current status and needs for changes in critical care training: the voice of the young cardiologists
Authors: Czerwińska-Jelonkiewicz Katarzyna , Montero Santiago , Bañeras J , Wood A , Zeid A , De Rosa S , Guerra F , Tica O , Serrano F , Bohm A , Ahrens I , Gierlotka M , Masip J , Bonnefoy E , Lettino M , Kirchhof P , Sionis A ,   Young National Ambassadors (YNA) of Acute Cardiovascular Care Association (ACVC), European Society of Cardiology (ESC)
Published: January 2021

Aims

The implementation of the 2013 European Society of Cardiology (ESC) Core Curriculum guidelines for acute cardiovascular care (acc) training among European countries is unknown. We aimed to evaluate the current status of acc training among cardiology trainees and young cardiologists (<40 years) from ESC countries.

Methods and results

The survey (March–July 2019) asked about details of cardiology training, self-confidence in acc technical and non-technical skills, access to training opportunities, and needs for further training in the field. Overall 614 young doctors, 31 (26–43) years old, 55% males were surveyed. Place and duration of acc training differed between countries and between centres in the same country. Although the majority of the respondents (91%) had completed their acc training, the average self-confidence to perform invasive procedures and to manage acc clinical scenarios was low—44% (27.3–70.4). The opportunities for simulation-based learning were scarce—18% (5.8–51.3), as it was previous leadership training (32%) and knowledge about key teamwork principles was poor (48%). The need for further acc training was high—81% (61.9–94.3). Male gender, higher level of training centres, professional qualifications of respondents, longer duration of acc/intensive care training, debriefings, and previous leadership training as well as knowledge about teamwork were related to higher self-confidence in all investigated aspects.

Conclusions

The current cardiology training program is burdened by deficits in acc technical/non-technical skills, substantial variability in programs across ESC countries, and a clear gender-related disparity in outcomes. The forthcoming ESC Core Curriculum for General Cardiology is expected to address these deficiencies.
Left Impella®-device as bridge from cardiogenic shock with acute, severe mitral regurgitation to MitraClip®-procedure: a new option for critically ill patients
Authors: Vandenbriele Christophe , Balthazar Tim , Wilson James , Adriaenssens Tom , Davies Simon , Droogne Walter , Dubois Christophe , Caetano Ana Francisca , Goetschalckx Kaatje , Jacobs Steven , Janssens Stefan , Ledot Stephane , Meyns Bart , Soliman-Aboumarie Hatem , Verbrugghe Peter , Price Susanna
Published: January 2021

Aims

Patients presenting with cardiogenic shock (CS) related to acute, severe mitral regurgitation (MR) are often considered too ill for immediate surgical intervention. Therefore, other less invasive techniques for haemodynamic stabilization should be explored. The purpose of this exploratory study was to investigate the feasibility and outcomes in patients with CS due to severe MR by using a novel approach combining haemodynamic stabilization with left Impella-support plus MR-reduction using MitraClip®.

Methods and results

We analysed whether a combined left Impella®/MitraClip®-procedure in a rare population of CS-patients with acute MR requiring mechanical ventilation is a feasible strategy to recovery in patients who had been declined cardiac surgery. Six INTERMACS-1 CS-patients with acute MR were studied at two tertiary cardiac intensive care units. The mean EURO-II score was 39 ± 19% and age 66.8 ± 4.9 years. All patients had an initial pulmonary capillary wedge pressure >20 mmHg and pulmonary oedema necessitating invasive ventilation. Cardiac output was severely impaired (left ventricular outflow tract velocity time index 9.8 ± 1.8 cm), requiring mechanical circulatory support (MCS) (Impella®-CP; mean flow 2.9 ± 1.8 L per minute; mean support 9.7 ± 6.0 days). Despite MCS-guided unloading, weaning from ventilation failed due to persisting pulmonary oedema necessitating MR-reduction. In all cases, the severe MR was reduced to mild using percutaneous MitraClip®-procedure, followed by successful weaning from invasive ventilation. Survival to discharge was 86%, with all surviving and rare readmission for heart failure at 6 months.

Conclusions

A combined Impella®/MitraClip®-strategy appears a novel, feasible alternative for weaning CS-patients presenting with acute, severe MR. Upfront Impella®-stabilization facilitates safe bridging to Mitraclip®-procedure and the staged approach facilitates successful weaning from ventilatory support.
Influence of age and shock severity on short-term survival in patients with cardiogenic shock
Authors: Jentzer Jacob C , Schrage Benedikt , Holmes David R , Dabboura Salim , Anavekar Nandan S , Kirchhof Paulus , Barsness Gregory W , Blankenberg Stefan , Bell Malcolm R , Westermann Dirk
Published: January 2021

Aims

Cardiogenic shock (CS) is associated with poor outcomes in older patients, but it remains unclear if this is due to higher shock severity. We sought to determine the associations between age and shock severity on mortality among patients with CS.

Methods and results

Patients with a diagnosis of CS from Mayo Clinic (2007–15) and University Clinic Hamburg (2009–17) were subdivided by age. Shock severity was graded using the Society for Cardiovascular Angiography and Intervention (SCAI) shock stages. Predictors of 30-day survival were determined using Cox proportional-hazards analysis. We included 1749 patients (934 from Mayo Clinic and 815 from University Clinic Hamburg), with a mean age of 67.6 ± 14.6 years, including 33.6% females. Acute coronary syndrome was the cause of CS in 54.0%. The distribution of SCAI shock stages was 24.1%; C, 28.0%; D, 33.2%; and E, 14.8%. Older patients had similar overall shock severity, more co-morbidities, worse kidney function, and decreased use of mechanical circulatory support compared to younger patients. Overall 30-day survival was 53.3% and progressively decreased as age or SCAI shock stage increased, with a clear gradient towards lower 30-day survival as a function of increasing age and SCAI shock stage. Progressively older age groups had incrementally lower adjusted 30-day survival than patients aged <50 years.

Conclusion

Older patients with CS have lower short-term survival, despite similar shock severity, with a high risk of death in older patients with more severe shock. Further research is needed to determine the optimal treatment strategies for older CS patients.
Recognition of acute myocardial infarction caused by spontaneous coronary artery dissection of first septal perforator
Authors: Sharkey Scott W , Alfadhel Mesfer , Thaler Christina , Lin David , Nowariak Meagan , Cavalcante João L , Henry Timothy D , Saw Jacqueline
Published: January 2021

Aims 

Spontaneous coronary artery dissection (SCAD) diagnosis is challenging as angiographic findings are often subtle and differ from coronary atherosclerosis. Herein, we describe characteristics of patients with acute myocardial infarction (MI) caused by first septal perforator (S1) SCAD.

Methods and results 

Patients were gathered from SCAD registries at Minneapolis Heart Institute and Vancouver General Hospital. First septal perforator SCAD prevalence was 11 of 1490 (0.7%). Among 11 patients, age range was 38–64 years, 9 (82%) were female. Each presented with acute chest pain, troponin elevation, and non-ST-elevation MI diagnosis. Initial electrocardiogram demonstrated ischaemia in 5 (45%); septal wall motion abnormality was present in 4 (36%). Angiographic type 2 SCAD was present in 7 (64%) patients with S1 TIMI 3 flow in 7 (64%) and TIMI 0 flow in 2 (18%). Initial angiographic interpretation failed to recognize S1-SCAD in 6 (55%) patients (no culprit, n = 5, septal embolism, n = 1). First septal perforator SCAD diagnosis was established by review of initial coronary angiogram consequent to cardiovascular magnetic resonance (CMR) demonstrating focal septal late gadolinium enhancement with corresponding oedema (n = 3), occurrence of subsequent SCAD event (n = 2), or second angiogram showing healed S1-SCAD (n = 1). Patients were treated conservatively, each with ejection fraction >50%.

Conclusion 

First septal perforator SCAD events may be overlooked at initial angiography and mis-diagnosed as ‘no culprit’ MI. First septal perforator SCAD prevalence is likely greater than reported herein and dependent on local expertise and availability of CMR imaging. Spontaneous coronary artery dissection events may occur in intra-myocardial coronary arteries, approaching the resolution limits of invasive coronary angiography.