bluuebunny/crossref_metadata_2025 huggingface dataset:
Prediction of in-hospital mortality in patients with acute pulmonary embolism requiring invasive mechanical ventilation: comparation of risk scores
Authors: Devesa Neto V , Correia J , Fiuza J , Pereira J G
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

High-risk pulmonary embolism (PE) is a life-threatening disorder associated with high mortality and morbidity. Multiple scores are used to predict in-hospital mortality of patients admitted to intensive care units. The purpose of this study is to assess which risk score is best at predicting in-hospital mortality in a specific population of patients requiring invasive mechanical ventilation.

Methods

Retrospective analysis of 33 patients admitted for high-risk pulmonary embolism requiring invasive mechanical ventilation in a general intensive care unit during a period of 15 years. Clinical, analytical, and imaging parameters were evaluated. The PESI, Apache II, SAPS II, and SOFA scores were obtained at ICU admission. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the predictive value of each score for in-hospital mortality.

Results

Mean age was 59,1±16 years; 55% were men. 27% presented with a cardiorespiratory arrest at admission. Mean values risk scores were: PESI 138±51, Apache II 23±9, SAPS II 49±23, and SOFA 8±3. In-hospital mortality was 45,4%. The mean duration of hospitalization was 14,8±17,9 days. Mean pulmonary systolic arterial pressure was 51,5±14,63mmHg. Mean values of maximum troponin I and d-dimers were 2,97±7,99 and 6603±5541 ng/mL, respectively. ROC curve analysis revealed that Apache II (AUC 0,752; p=0,02; CI 95% 0,58;0,92), SAPS II (AUC 0,718; p=0,04; CI 95% 0,52;0,91) and PESI (AUC 0,754; p=0,02; CI 95% 0,6;0,91) had best predictive performance for in-hospital mortality compared to SOFA (AUC 0,641; p=0,2; CI 95% 0,42;0,9). The following cut-off values were obtained: PESI of 130 (sensitivity (S)≈85% and specificity (E)≈53%), Apache II of 26 (S≈62% and E≈77%), and SAPS II of 52 (S≈69% and E≈70%).

Conclusion

In this population, PESI, Apache II, and SAPS II scores were better predictors of in-hospital compared to SOFA score.
Impact of care bundles on the occurrence and outcomes of acute kidney injury among myocardial infarction patients
Authors: Shacham Y , Khoury S , Frydman S , Banai S , Banai A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Among Patients with myocardial infarction hospitalized patients, deterioration of renal function resulting in acute kidney injury (AKI) is an important complication, associated with increased length of hospital stay, morbidity and mortality. Given large variation in care for AKI patients and poor outcomes of AKI, the interest in implementing care bundles for AKI is growing. Several reports suggested that compliance with AKI bundles among hospitalized patients resulted in better kidney and patient outcomes non, however, included acute cardiac patients.

Purpose

We investigated the effect of AKI care bundle (AKI-CB ) utilization on the incidence and renal outcomes of AKI in a large cohort of myocardial infarction patients treated percutaneous coronary intervention (PCI).

Methods

We Included ST elevation myocardial infarction (STEMI) patients admitted to the cardiac intensive care unit following PCI between January 2008- December 2020. From January 2016 AKI- CB was implemented in our cardiac intensive care unit. AKI-CB consisted of simple standardized investigations and interventions, reminding clinicians of the importance of early AKI detection, management, via strict monitoring of serum creatinine and urine analysis, planning investigations and treatment and guidance about seeking nephrologist advice. .Patients' records were evaluated for the occurrence of AKI, its severity, AKI recovery, length of hospital stay and long term mortality before and after the implementation of AKI-CB.

Results

2646 patients were included (1945 patients in the years 2008-2015 and 705 patients in the years 2016-2020). Overall, 232 AKI episodes occurred within the study period (232/2646, 8.7%). Implementation of care bundles resulted in a decrease in the occurrence of AKI from 190/1945 ( 10%) to 42/705 (6%); P<0.001, with a trend for lower AKI score>1 (20% vs. 25% ; p=0.07), higher AKI recovery ( 62% vs. 45% , p=0.001) and reduction in the length of hospital stay ( 5.2± 6 days vs. 5.9 ± 5 days ; p=0.02). Over a median follow up period of 48 month, mortality was significantly lower following implementation of AKI-CB ( 3.7% vs. 5.8%,p=0.002,figure 1). Using a multivariable regression model, the use of care bundles resulted in a 45% decrease in the relative risk for AKI (HR 0.55, 95% CI 0.37-0.82, p=0.003; figure 2).

Conclusion

Among STEMI patients, compliance with AKI-CB was independently associated with a decrease in AKI occurrence and better renal outcomes following an AKI event. Further interventions are required to improve utilization of the AKI-CB.
Hemodynamic changes associated to increments of PEEP in mechanically ventilated patients admitted into the cardiac intensive care unit
Authors: Angeles Sistac D , Robles Conde I , Bragagnini W , Vila Perales M , Rodriguez Sotelo L , Pena Ortega P , Padilla Lopez M , Sionis A , Duran Cambra A
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Current evidence suggests that incremental levels of PEEP generate an increase in right intracavitary pressures, diminishing venous return and consequently lessening left ventricular preload and stroke volume, resulting in a significant decrease of cardiac output. Nonetheless, most studies regarding these interactions have been done in patients requiring mechanical ventilation for non-cardiac disorders or in animals. We studied the effects of incremental levels of PEEP on cardiac intracavitary pressures and hemodynamics in mechanically ventilated patients admitted into the Cardiac Intensive Care Unit.

Purpose

We aimed to model how increments in PEEP alter cardiac output and other hemodynamic variables in patients with cardiac disfunction.

Methods

We included 14 mechanically ventilated patients admitted into a Cardiac Intensive Care Unit from 2018 to 2020. Data on intracavitary pressures and hemodynamics were recorded via Swan-Ganz catheterization and echocardiographic imaging. We documented measurements for all variables of interest at three different levels of PEEP: 5cmH2O, 10cmH2O and 15cmH2O. We conducted general descriptive statistics, mean comparison tests for paired data and linear regression models with Stata version 12.0 (StataCorp LP, College Station, TX).

Results

7 (50%) patients admitted in the study had cardiogenic shock, 11 (79%) patients were mechanically ventilated in a volume-controlled setting and 3 (21%) were on pressure support ventilation. Seven (50%) patients needed vasoactive drugs during the study. Only 1 (7%) patient required an intra-aortic balloon pump. Seven (50%) patients had a visual left ventricular ejection fraction lesser than 40% and 3 (21%) had a moderate-severe mitral regurgitation. Paired mean testing by groups associated to gains of PEEP revealed statistically significant increments in Mean Pulmonary Artery Pressure (mPAP), Pulmonary Capillary Wedge Pressure (PCWP) and Central Venous Pressure (CVP). Inversely, increments of PEEP were linked to significant decrements in Cardiac Output (CO) [Figure 1 & Table 1].

Conclusions

In mechanically ventilated patients admitted into the Cardiac Intensive Care Unit, rises in PEEP are associated to increments in intracavitary cardiac pressures, and inversely, with decrements in cardiac output. Although our findings are statistically significant, we have yet to clarify whether these are clinically meaningful, specifically within PEEP increments of 5 to 10cmH2O, the usual range in clinical practice.
Predictors of acute kidney injury in patients with acute decompensated heart failure upon admission at a cardiac intensive care unit
Authors: Carvalho M , Goncalves C , Cabral M , Vazao A , Lopes S , Santos L , Morais J
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiorenal syndrome (CRS) type 1 is characterized as the development of acute kidney injury (AKI) and dysfunction in the patient with acute cardiac illness, most commonly acute decompensated heart failure (ADHF). Acute kidney injury (AKI) is associated with a worse overall prognosis in patients hospitalized with acute decompensated heart failure.

Objective

To assess the predictors of AKI in patients with acute decompensated heart failure with reduced ejection fraction upon admission to the cardiac intensive care unit.

Methods

A retrospective single-center observational study analyzed 105 patients admitted to a cardiac intensive care unit. between January 2022 and August 2022. The definition of AKI is based on KIDIGO (Kidney disease: Improving global outcomes). We compared clinical characteristics, echocardiographic parameters, selected biomarkers and outcomes between patients with and without AKI. A logistic regression analysis was performed, looking for independent predictors of AKI in this population.

Results

Of the 105 patients, 45 (42.9%) presented with AKI. These patients were older (median age: 74 vs. 58 years, p=0,009), lower body mass index (median: 26.4 vs.29.8 kg/m2, p=0,038). Moreover, AKI was associated with an increased all-cause mortality rate and longer hospitalization. In addition, arterial hypertension (odds ratio [OR]: 1.69; 95% confidence interval [CI]: 1.25-2.57; p=0.015), age ≥ 73 years (OR 2,1: 95% CI: 1.73-3.5, p=0,036), previous diagnosis of coronary heart disease (OR 1.35: 95% CI: 1.0-2.2, p=0.021), diabetes mellitus (OR 1.27: 95% CI: 0.91-1.93, p=0.230), left ventricular ejection fraction <35% (OR 2.2: 95% CI 1.0-­2.7, p=0,003) at admission were significant predictors of AKI.

Conclusion

This study suggests cardiovascular comorbidities, older age, lower ejection fraction were predictors of AKI in patients upon admission of patients hospitalized with ADHF in the cardiac intensive care unit.
Sex differences in acute hemodynamic response in comatose survivors of OHCA
Authors: Bo Kunkel J , Grand J , Eifer Moeller J , Schmidt H , Hassager C , Kjaergaard J
Published: May 2023

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Novo Nordisk Fonden

Background

In critically ill patients with cardiogenic shock, neurohormonal activation is higher in females compared with males. Whether this is the case in patients resuscitated from out of hospital cardiac arrest (OHCA) is not known and whether sex-based differences relate to achieving mean-arterial-pressure (MAP)-target has not previously been described.

Methods

This was an investigator-initiated, randomized, controlled study of targeted MAP (63 vs 77 mmHg) and PaO2 (9-10 vs 13-14 kPa) interventions in 789 comatose OHCA (of presumed cardiac origin) patients. Patients underwent serial hemodynamic assessments with pulmonary artery catheter at time of insertion, 6 h, 12 h, 24 h, 36 h and 48 h. Among parameters recorded were heart rate (HR), cardiac output (CO) and central venous pressure (CVP), from which cardiac index (CI) and systemic vascular resistance index (SVRI) were derived. Patient characteristics included sex for stratification, age, time to return of spontaneous circulation (ROSC) and initial electrocardiographic (ECG) rhythm.

Results

Hemodynamic parameters from 729 patients were analysed, of which 138 (19%) were female and 591 (81%) were male. Both groups had a median age of 64 years, with median time-to-ROSC of 19 minutes in females versus 18 minutes in males. In females versus in males, SVRI and HR were higher (fig.1,2). There were no differences among sexes with regards to CI, MAP, or dose of noradrenaline. At 12 hours, median SVRI in females was 755 dyn·s/cm5·m2 (inter-quartile ratio, IQR 569-931) versus 554 dyn·s/cm5·m2 (IQR 441-684) in males (P<0.0001). At the same point in time, median HR was 71 beats/minute (bpm) in females (IQR 59-82) versus 62 bpm (IQR 54-74) in males (P<0.0001). Lastly, 12-hour median CI was 1.82 L/min/m2 (IQR 1.54-2.40) in females versus 1.95 L/min/m2 (IQR 1.63-2.43) in males (P=0.1303).

Conclusions

Female comatose OHCA patients had higher SVRI and HR during the first 48 hours of ICU admission, without difference in MAP or vasopressor requirement. Sex specific physiological mechanisms may be involved in maintaining vascular resistance.
Total body water and acute kidney injury in myocardial infarction
Authors: Tapia K , Barbosa B , Croissant Y , Costa D , Acosta M F , Gregorietti V , Muzzio M , Coronel R
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Acute kidney injury (AKI) in patients with myocardial infarction (MI) is associated with higher morbidity and mortality and a higher incidence of MACE. The cardiorenal syndrome is a disorder between the heart and the kidney, where the primary dysfunction of one organ results in secondary dysfunction and damage to the other. There are multiple mechanisms involved in its pathogenesis, related to hemodynamic changes that lead to venous congestion, greater volume overload, and impaired renal function. Echocardiographic parameters of congestion have been related to AKI in MI.

Our objective was to assess hydration estimated by bioimpedance analysis (BIA) as a marker of congestion and its association with AKI.

Methods

Observational study in patients admitted to a CCU for MI and treated with PCI. Body composition was assessed with tetrapolar bioimpedance analysis obtained at 50 kHz. AKI was defined as a 1.5-fold increase in serum creatinine from baseline level within 24–48 hours. Mayor adverse cardiovascular events (MACE) during hospitalization were defined as type IV infarction, heart failure, stroke, or death.

Results

A total of 94 patients were included. The median age was 58 years (IQR 53 – 63), and 89% were male. 53% had STEMI, 32% hypertension, 23% diabetes, and the median creatinine on admission was 0.9 mg/dl (IQR 0.75 – 1.05). AKI occurred in 9 patients (9.7%). Patients with AKI had a higher incidence of MACE (66.7% versus 29.8%, p = 0.02). Total body water (TBW) was higher on admission in patients who suffered AKI, compared to those who did not (76.8% versus 75.5%, p = 0.0008). There was no significant difference in TBW between patients who developed heart failure compared to those who did not (75.3% versus 75.8%, p = 0.39).

Conclusion

Among patients with MI undergoing PCI, hydration status estimated by BIA, as a noninvasive parameter to estimate congestion, was associated with a higher risk of developing AKI.
Machine learning prediction of in-hospital mortality and external validation in patients with cardiogenic shock: the RESCUE score
Authors: Cha J H , Choi K H , Gwon H C , Yang J H
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Despite the introduction of mechanical circulatory support (MCS), short-term mortality rates in cardiogenic shock (CS) remain high. Prior CS risk scores have limited reliability because of selected derivation cohorts or inadequate validation.

Purpose

The aim of this study is to develop and validate externally the risk prediction model for in-hospital mortality in CS patients using machine learning (ML) algorithms.

Methods

1247 patients of all-cause CS from the RESCUE registry (Retrospective and Prospective Observational Study to Investigate Clinical Outcomes and Efficacy of Left Ventricular Assist Device for Korean Patients with CS) between January 2014 and December 2018 were analyzed. Patients were randomly divided into two groups for training and testing at a ratio of 7 to 3. Risk prediction models were estimated with the logistic regression analysis and four ML algorithms: Least absolute shrinkage and selection operator analysis (LASSO), Support vector machine (SVM), Extreme Gradient Boosting (XGB), and Random Forest classifier. Internal validation with the RESCUE registry and external validation with the single center CS registry including 678 patients were performed.

Results

All four ML models made an agreement with the seven important variables associated with mortality as follows; age, vasoactive inotropic score, left ventricular ejection fraction, lactic acid, cardiac arrest at presentation, requiring continuous renal replacement therapy, and mechanical ventilator. The logistic regression analysis was performed with the risk factors which were derived by ML models. The logistic regression model named RESCUE score showed the predictive performance with an area under the curve (AUC) of 0.86 [95% CI 0.83-0.88] for in-hospital mortality. External validation showed excellent discrimination with an AUC of 0.80 [95% CI 0.76-0.84]. Decision curve analysis indicated that the nomogram conferred high clinical net benefit.

Conclusion

The RESCUE score using advanced machine learning techniques has excellent predictive performance for the in-hospital mortality of CS regardless of the underlying cause. This model may be useful as a tool to estimate the risk stratification of CS patients.
Inotropes and vasopressor use in non-ischemic cardiogenic shock: a single-center retrospective study
Authors: Erba M , Battistini L , Bianciardi C , Fiocco E , Rossi F , Labella N , Colombo C N J , Tavazzi G
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Cardiogenic shock (CS) is a syndrome due to primary cardiac dysfunction leading to multiorgan failure and death in up to 50% of cases. Recently an increased prevalence of non-ischemic CS have been reported. Treatment bundles include inotropes and/or vasopressors; however, indications regarding use of vasoactive drugs in CS are characterized by very low evidence (class IIb - level C)(1,2).

Purpose

We sought to describe the population of non-ischemic CS in our center, focusing on clinical, hemodynamic and pharmacological data in the first 24 hours (including Maximum Vasoactive Inotropic Score – VISMAX) and to investigate any effect of vasoactive drugs on mortality.

Methods

We carried out a monocentric retrospective study including adult patients admitted to ICU for non-ischemic CS from January 2011 to December 2020.

Results

60 patients were included (40% female; 68.5±12.5 y.o). Median duration of ICU stay was 5 [3-10] days; 27 (45%) patients died in ICU. 41 (68,3%) patients had history of arterial hypertension and 33 (55,9%) had known heart failure (in 20 patients due to ischemic cause); 29 (50,9%) patients were previous treated with beta-blockers. No difference in clinical history data were found between dead and survivors. At index event, mean blood pressure (MBP) was 76±25 mmHg, heart rate (HR) was 103±34 bpm and serum lactate were 4,3 [2,2-13,3] mmol/L among overall population. Patients who died had significantly lower MBP (68,7±29,5 vs 81,6±19,9 mmHg; p <0,05), while no difference in arterial lactate and HR was found between those who died and survivors. Vasoactive drugs were administered in 42 (70%) patients during the first 24 hours. Maximum dosages (mcg/kg/min) of inotropes and vasopressors were: epinephrine 0.10 [0,08-0,17], dobutamine 4.75 [3,5-5,0], norepinephrine 0.3 [0,15-0,48] and dopamine 3,56±1,43. VISMAX In the overall population was 20,0 [8,0-38,0]. Despite not significant, we observed higher VISMAX in the first 24 hours in patients who died (24,5 [9,7-55,9] vs 17 [7,4-26,0] p=0,05); this could be due to difference, although not significant, in norepinephrine dose, as other vasoactive drugs levels were similar (Figure 1). At logistic regression no effect of vasoactive drug and VISMAX on ICU mortality was found (p > 0.05 for all).

Conclusions

Adrenergic inotropes are reported to be related with increase mortality, although the time duration and dosages used in literature are mostly unknown or very high(3,4). In our cohort of ADHF-CS, those drugs at lower dosages, without differences between died and survivors patients, did not demonstrate any effect on mortality.
Coronary angiographic and culprit lesion characteristics in patients resuscitated from out-of-hospital cardiac arrest
Authors: Schneider R , Bal Z , Zander C , Achenbach S
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Emergent coronary angiography is recommended in patients with return of spontaneous circulation (ROSC) after out of hospital cardiac arrest (OHCA) of suspected cardiac origin. The aim of this study was to analyze the prevalence of coronary artery disease (CAD), characteristics of the culprit lesions in case of acute coronary syndrome (ACS) and the success of percutaneous coronary intervention (PCI) in patients resuscitated from OHCA due to a shockable rhythm, i.e. ventricular fibrillation (VF) and ventricular tachycardia (VT).

Methods

We analyzed the data of 150 patients in whom coronary angiography was performed in the setting of ROSC after OHCA. Patients were categorized to have non obstructive CAD or obstructive CAD. Patients with obstructive CAD were classified as acute myocardial infarction (ST-elevation myocardial infarction (STEMI), Non-ST-elevation myocardial infarction (NSTEMI)) and chronic coronary syndrome. The culprit vessel was identified by means of electrocardiographic findings, echocardiography and coronary angiography. Coronary angiograms and all clinical data were reviewed in consensus by two experienced interventional cardiologists. Successful PCI was defined as angiographic restoration of TIMI III flow.

Results

Significant CAD was ruled out in 27 patients (18.0%). Obstructive CAD with at least one coronary artery stenosis was found in 123 patients (82.0%). According to clinical and angiographic findings, ACS was found in 105/150 patients (70.0%). Of the 105 patients with ACS, 53 (35.3%) presented with STEMI and 52 (34.7%) presented with NSTEMI. 18/123 patients (14.6%) showed chronic coronary syndrome. Among the patients with obstructive CAD, 1-vessel CAD was found in 32 patients (26.0%), 2-vessel CAD in 44 patients (35.8%), 3-vessel CAD in 47 patients (38.2%). 41 (33.3%) of the patients with CAD showed a chronic total occlusion (CTO) of at least one vessel. In patients presenting with ACS, the most common culprit vessels were LAD (37.4%) and CX (23.6%), followed by RCA (11.4%) and LM (2.4%). In 22.8% of the patients, the culprit vessel could not be unambiguously identified. In 82.9% of the patients with ACS/CAD, PCI was performed. TIMI flow after intervention was TIMI III in 92.1%, TIMI II in 3.9%, TIMI I in 2.0% and TIMI 0 in 2.0%.

Conclusion

In patients resuscitated from OHCA due to VF/VT, multivessel disease is common. Most frequently, culprit lesions are located in the LAD and CX. PCI in OHCA patients can be performed at a high success rate.
Relevance of age and hypertension for blood pressure targets in comatose survivors of cardiac arrest
Authors: Byrne C , Kjaergaard J , Moeller J E , Schmidt H , Hassager C
Published: May 2023

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): The Novo Nordisk Foundation.

Background

Baseline arterial blood pressure (BP) is influenced by age. Therefore, age and previous hypertension may alter the appropriate BP target after out-of-hospital cardiac arrest (OHCA).

Purpose

To examine whether the optimal BP target after OHCA is affected by age and a history of arterial hypertension.

Methods

The Blood Pressure and Oxygenation Targets in Post Resuscitation Care (BOX) trial was a randomized, controlled, double-blind trial comprising 789 comatose patients ≥18 years of age, resuscitated after OHCA of presumed cardiac cause. Patients were randomized to a mean arterial BP target of either 63 mm Hg (low BP target group) or 77 mm Hg (high BP target group). The primary outcome was a composite of death from any cause or hospital discharge with severe cerebral disability within one year. The relationship between age or prevalent hypertension and clinical outcomes was evaluated using Cox proportional-hazards regression. Age was stratified into quartiles. We further determined if the effects of BP target varied across the age spectrum (and according to prevalent hypertension).

Results

Three-hundred and ninety-three patients were assigned to the high BP target group and 396 to the low BP target group. In all, 204 (25.9%), 201 (25.5%), 186 (23.6%), and 198 (25.1%) were ≤54, 55-64, 65-72, and ≥73 years. Mean age was similar between the two study groups (high BP target 63 ± 13 years versus low BP target 62 ± 14 years; P = 0.60). A total of 176 (45%) patients in the high BP target group and 186 (47%) patients in the low BP target group had known hypertension. At 90 days, 133 patients (34%) in the high BP target group and 127 patients (32%) in the low BP target group had experienced the primary outcome. The risk of the primary outcome increased with higher age (Figure 1). Hazard ratios of the primary outcome according to BP targets within each age quartile (with low BP target as reference) were as follows: ≤54: 1.71; 95% confidence interval [CI], 0.99 to 2.95; P = 0.054, 55-64: 0.92; 95% CI, 0.57 to 1.49; P = 0.73, 65-72: 1.12; 95% CI, 0.73 to 1.74; P = 0.59 and ≥73: 0.88; 95% CI, 0.60 to 1.27; P = 0.48 (Figure 2). The hazard ratio of the primary outcome was 0.99; 95% CI, 0.72 to 1.37; P = 0.97 in patients without prevalent hypertension, and 1.14; 95% CI, 0.83 to 1.54; P = 0.42 in patients with prevalent hypertension.

Conclusions

In patients resuscitated after OHCA, there was a significant association between age and the primary composite outcome of death, severe disability, or coma. The effect of BP target on the primary outcome did not appear to differ according to age groups or prevalent hypertension. Therefore, age and prevalent hypertension should not influence the choice of BP targets after OHCA.
Association of early surgery and mortality in patients with native or prosthetic valve endocarditis
Authors: Tao M , Manikantan P , Despotidis G , Alkhalil A , Parikh P , Pyo R
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Infective endocarditis (IE) is a disease associated with high risk of morbidity and mortality. Recent studies suggests that surgery during index hospitalization may be performed without increased risk of mortality. However, differences in this association in patients with native valve IE and prosthetic valve IE remain unclear.

Purpose

The purpose of this meta-analysis is to explore differences in the association between early surgery and mortality in patients with native valve IE and prosthetic valve IE.

Methods

We performed a literature search for studies reporting an association between early surgery and study endpoints in patients with either native valve IE or prosthetic valve IE. The primary endpoint was in-hospital mortality. The secondary endpoints was long-term mortality. The search included the following databases: Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar. The search was not restricted to time or publication status. Studies reporting mixed native and prosthetic valve populations were excluded.

Results

A total of 10 studies with 5493 participants (2505 with early surgery vs 2988 with conventional therapy) were included. The mean duration of follow-up was 55 months (ranging between 12 to 120 months). Early surgery in patients with native valve IE was associated with lower risk of in-hospital mortality (OR 0.48, 95% CI 0.28, 0.83; p<0.01). Early surgery in patients with native valve IE was associated with lower risk of long-term mortality, however this effect was primarily driven by a single study (OR 0.26, 95% CI 0.08, 0.83; p=0.02). Early surgery in patients with prosthetic valve IE was not significantly associated with risk of in-hospital mortality, however there is a trend toward lower risk (OR 0.77, 95% CI 0.58, 1.02; p=0.07). There was not enough studies reporting long-term outcomes to assess the association between early surgery and long-term mortality in patients with prosthetic valve IE

Conclusions

Early surgery is associated with lower risk of in-hospital mortality in patients with native valve IE and is not associated with increased risk of mortality in patients with prosthetic valve IE. Further high-quality studies are needed to elucidate the association between early surgery and long-term outcomes in both patients with native valve IE and prosthetic valve IE.
Cardiac Magnetic Resonance in myocarditis: besides the diagnosis?
Authors: Rocha Carvalho P , Carvalho C , Bernardo M , Moreira I , Silveira I , Ferreira C , Fontes P , Moreira J I
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Patients with acute myocarditis (AM) can be at increased risk of adverse cardiac events after the index episode. Beyond its undoubted role in diagnosis, Cardiac Magnetic Resonance (CMR) can also provide additional prognostic information and contribute to the patients risk stratification.

Methods

Retrospective study with patients admitted with the clinical suspicion of myocarditis in our center from February/2018 to September/2021, in whom CMR was performed. A total of 48 patients were included and divided into two groups based on the number of segments with late gadolinium enhancement (LGE). The threshold (> or < than 5 segments) was determined according to ROC curve analysis. The primary outcome was a composite of all-cause mortality, heart failure and myocarditis recurrence.

Results

We included 48 patients (95,8% males; mean age 37,0±16,1 years old), 93,8% presenting with chest pain and 63,2% presenting with st-segment elevation on electrocardiogram. During hospitalization, 3 patients needed ionotropic support, 7 had supraventricular tachycardia, 9 non-sustained ventricular tachycardia, 1 sustained ventricular tachycardia, 1 needed extracorporeal membrane oxygenation and 9 had heart failure.

CMR (performed 6 days (median) after admission) showed LGE in 45 patients (93,8%) and mean left ventricular ejection fraction (LVEF) of 55,5±8,7%.

Both groups had similar age (35,0±13,7 vs 38,5±17,6 years, p=0,45), cardiovascular risk factors, st-segment elevation at admission (61,9% vs 63,0%, p=0,38), pro-BNP levels at admission [286 (IQR 144-699) mg/dl vs 522 (IQR 222-1253) mg/dl, p = 0,20] and peak C-reactive protein [5,7 (IQR 4-12) vs 5,2 (IQR 2,6-12,5),p=0,77].

Patients with LGE in ≥5 segments (56,3%) had lower LVEF (53,2±9,6 vs 58,2±6,6, p=0,02), had more non-sustained ventricular tachycardia episodes (29,6% vs 4,8%, p=0,03), incidence of heart failure during hospitalization (25,9% VS 9,6%, p=0,19) and higher peak troponin levels [1,54 (IQR0,64-2,45) vs 0,594 (IQR 0,374-1,07), p=0,002].

During a median follow-up of 21,5 (IQR 8–35,2) months, 11 patients (22,9%) experienced the primary outcome (6 for heart failure, 4 for AM recurrence, 1 death).

The incidence of the primary endpoint increased by 1,20 (95% CI 1,08-1,60) for each segment involved. Patients with ≥ 5 segments had a higher incidence of this outcome (25,7 vs 5,1 per 100 patient/year, log rank p=0,02).

After adjusting for possible cofounders, LGE≥ 5 segments on CMR was an independent predictor of all-cause mortality, heart failure and myocarditis recurrence (HR 7,22, 95% CI 1,33-39,16).

Conclusion

In this study, LGE involving 5 or more segments by LGE was correlated with adverse cardiovascular events among patients with suspected myocarditis. These data suggest that cardiac resonance imaging might add value to currently existing diagnostic tools for risks assessment in AM.
Predicting heart failure during hospitalization in myocarditis
Authors: Rocha Carvalho P , Carvalho C , Bernardo M , Moreira I , Ferreira C , Silveira I , Fontes P , Moreira J I
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Currently, there is little evidence available regarding their predictive potential of Monocyte-to-lymphocyte ratio (MLR) in patients diagnosed with myocarditis.

Purpose

We aimed to investigate if MLR can predict heart failure during hospitalization in patients with clinical suspicious of acute myocarditis.

Methods

Retrospective study with patients admitted with the clinical suspicion of myocarditis in our center from February/2016 to September/2021. A total of 74 patients were included and divided into two groups based on MLR. ROC-analysis was conducted and AUC was calculated for the prediction of heart failure during hospitalization (0.82). Optimal cut-off for MLR was calculated by means of the Youden Index (MLR ≥ 0,817 (sens.: 73%, spec.: 80%). The primary outcome was heart failure during hospitalization.

Results

We included 74 patients (90,5% males; mean age 37,1±15,1 years old), 96,8% presenting with chest pain and 68,9% presenting with ST-segment elevation on electrocardiogram. During hospitalization, 4 patients needed ionotropic support, 7 had supraventricular tachycardia, 14 non-sustained ventricular tachycardia, 2 sustained ventricular tachycardia, 1 needed extracorporeal membrane oxygenation and 11 had heart failure.

Both groups had similar age (39,0±16,9 vs 36,5±16,7 years, p=0,59), previous history of myocarditis (8,9% vs 5,6%, p=0,65), smoking history (16,7% vs 33,9%, p=0,34), diabetes mellitus (7,1% vs 2,6%, p=0,24), dyslipidemia (33,3% vs 19,6%,p=0,23), arterial hypertension (11,1% vs 14,3%,p=0,73), ST-segment elevation on admission (72,7% vs 63,8%, p=0,45), pro-BNP levels on admission [522 (IQR 222-1253) mg/dl vs 495 (IQR 222-970) mg/dl, p = 0,46].

Patients with MLR ≥ 0,817 (24,3%) had lower Left ventricular ejection fraction on admission (45,9%±14,1% vs 53,3%±8,4, p=0,008), high Peak C-reactive protein [13 (IQR 4,5-22) vs 4,5 (IQR 4-6,1), p=0,001] and peak troponin levels [1,98 (IQR 0,98-2,81) vs 0,87 (IQR 0,55-1,74), p=0,007] were higher in this group.

Throughout a median hospital stay of 4 days (IQR 3,5–7), 11 patients (17,7%) experienced the primary outcome.

After adjusting for possible cofounders, MLR ≥ 0,817 was an independent predictor of heart failure during hospitalization (HR 6,83, 95% CI 1,55-30,01, p=0,011).

Conclusion

MLR in our population, was a predictive factor for heart failure during hospitalization in patients with acute myocarditis. MLR could facilitate an early risk stratification and clinical management in these patients.
Use of advanced therapies for pulmonary embolism among pregnant or postpartum women
Authors: Farmakis I , Barco S , Giannakoulas G , Keller K , Valerio L , Konstantinides S V , Hobohm L
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary embolism (PE) in pregnancy can be a devastating event with a high case-fatality rate. Information on treatment of acute PE during pregnancy or the puerperium is limited.

Purpose

To investigate the use of advanced therapies and associated outcomes in maternal-associated PE.

Methods

The Nationwide Inpatients Sample (NIS) of years 2016-2018 was accessed to select hospitalizations among pregnant or postpartum women with a main discharge diagnosis code of acute PE (ICD-10 O88.2 or the combination I26 and O09). High-risk PE was defined as hospitalizations with an additional diagnosis of shock, cardiac arrest, cardiopulmonary resuscitation, or use of vasopressors. Systemic thrombolysis, catheter-directed thrombolysis, catheter-based thrombectomy, surgical embolectomy, and extracorporeal membrane oxygenation (VA-ECMO) were considered as advanced therapy. We investigated the prevalence of in-hospital fatality, abortive outcome, pre-term deliveries, caesarean sections, and bleedings.

Results

During the period from 2016 to 2018, an estimated 11,986,555 maternal-related hospitalizations and an estimated 1,129,935 PE-related hospitalizations were identified. Of them, an estimated 7,595 (0.06% of all maternal-related hospitalizations and 0.67% of all PE-related hospitalizations) were characterized as PE hospitalizations during pregnancy (48% of all) or the puerperium (52% of all), while 2.2% of them fulfilled the criteria of high-risk PE. Patients with high-risk PE showed higher prevalence of chronic arterial hypertension, heart failure, ischemic heart disease, and post-partum infections compared to not-high risk patients (Figure 1). The median length of stay in the hospital was 3 days; patients with high-risk PE had significantly greater length of stay with a median of 8 days (p<0.001). In general, in 2.6% of all pregnant or postpartum women with PE advanced therapies were used, whereas in high-risk PE patients advanced therapy was performed in 27% (p<0.001) (Figure 2). Case fatality rate was <0.1% among not-high-risk and 36% among high-risk patients (p<0.001). Case fatality rate was 0.3% among women ≤24 years, 0.9% among women 25-40 years, and 2.8% among women ≥40 years. Caesarean section (33% vs 16%, p=0.008), and bleeding (24% vs 12%, p=0.031) were more prevalent among high-risk vs not high-risk PE hospitalizations, whereas an abortive outcome was not (3% vs 1.5%, p=0.5).

Conclusion(s)

Case fatality in pregnant or postpartum women with high-risk PE was high, but lower than in the general population. The utilization of advanced therapies is low among pregnant or postpartum women with PE and hemodynamic instability.
Multidisciplinary Pulmonary Embolism Response Team (PERT) a propensity score matched single centre experience from Germany
Authors: Sagoschen I , Scibior B , Farmakis I T , Munzel T , Keller K , Konstantinides S , Hobohm L
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Over the last years, the concept of multidisciplinary pulmonary embolism response teams (PERTs) has emerged to encounter the increasing variety and complexity in the management of acute pulmonary embolism (PE).

Purpose

To investigate the composition and added clinical value of PERT in our city.

Methods

Over a 5-year period (01/2017-09/2022), patients with confirmed PE were enrolled in a prospective single-centre cohort study (PERT). We investigated the composition of PERT and compared, after propensity score matching, patients with acute PE prior and after the formation of PERT at our institution. The primary outcome was in-hospital PE-related mortality before and after the formation of PERT.

Results

During the period from 2017 to 2022, 88 patients with acute PE with a PERT decision were registered. Of those, 13 (14.8%) patients died during the in-hospital stay. Patients evaluated by a PERT had a mean age of 68 years; among these 48.9% were females, and 21.7% suffered from malignancy. Right ventricular dysfunction was present in 84.9% of the patients. In total, 42.0% were classified as intermediate-risk PE and 11.6% as high-risk PE. First PERT contact originated mostly by emergency departments (33.3 %) and intensive care unit (30.0%), followed by chest pain unit (21.3%) and regular ward (12.0%) (Figure 1a). The participation rate of specialties demonstrated that cardiologists (100%) or cardiac/vascular surgeons (98.6%) were included in almost all PERT activations followed by radiologist (95.9%) or anesthesiologist (87.8%). Further disciplines were present in few cases as summarized in Figure 1b. When comparing patients characteristics of the pre-PERT era with the PERT era, more patients were classified as sPESI ≥1 and as high-risk according to ESC 2019 guidelines in the pre-PERT era (78.4% and 18.2%) opposed to the PERT era (71.6 and 11.4%) (Figure 2). A considerable higher all-cause mortality (31.8% vs. 14.8%) and PE-related mortality rate (22.7% vs. 13.6%) was observed in patients in the pre-PERT era compared to the PERT era. After propensity matching (1:1) by including parameters as age, sex, sPESI and ESC risk classes, an univariate regression analyses demonstrated, that the PE management based on a PERT-decision was associated with lower risk of all-cause mortality (OR, 0.37 [95%CI 0.18-0.77]; p=0.009) and PE-related mortality (OR, 0.54 [95%CI 0.24-1.18]; p=0.121) compared to patients without a PERT-decision.

Conclusion

PERT implementation tended to reduce the mortality rate in patients with acute PE. Large prospective studies are needed to further explore the impact of PERTs on clinical outcomes.
Role of serial troponin measurements in risk stratification of acute pulmonary embolism
Authors: Besis G , Khan Z , Candilio L , Kotecha T
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Introduction

Many parameters are used to help in risk stratification of pulmonary embolism. Troponin levels are one of them but currently are used as a dichotomous value ( positive or negative ). We sought to retrospectively analyse and correlate serial troponin measurements with important clinical and radiological parameters.

Purpose

To investigate the association of serial troponin measurements to important clinical and radiographic parameters

Methods

We retrospectively analysed all patients with a diagnosis of pulmonary embolism during 2019 in our centre. Using the electronic patient records, data regarding serial troponin measurements, echocardiographic and CT derived RV strain, catheter directed thrombolysis, intravenous thrombolysis, in hospital and 30 days mortality were collected.

Results

35 patients from a total of 138 cases of confirmed pulmonary embolism, had serial troponin measurements. This small cohort was divided in patients with reducing levels of troponin and in those with increasing with time values of troponin. The group of patients with reducing levels of troponin had no in hospital or 30 days mortality, whereas 68% of patients with rising troponin levels had either thrombolysis or catheter directed thrombolysis during their hospital admission. A significant percentage of both groups had CT evidence of RV strain.

Conclusion

This is a small retrospective analysis of the potential association of serial troponin measurements with risk stratification of patients with acute pulmonary embolism. Due to the retrospective nature of the analysis the results should be viewed as hypothesis generating only.
Modeling of main arteries restenosis in experimental cardiology
Authors: Germanova O , Germanov V , Galati G
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Purpose

To perform the model of main arteries restenosis and to study the arterial hemodynamics using the original device for modeling of intra-arterial circulation.

Materials and methods

We used an original device developed by us for modeling of intra-arterial circulation. The main part of the device is a prototype of human arterial vessel - rotameter glass tube 365 mm length, with inlet diameter more than outlet (20 mm vs 16.5 mm). An aqueous solution of glycerin is introduced inside closed system had the same viscosity as the human blood. Flexible silicone tubes are connected with rotameter and electric pump with various modes of work (imitation of pulse waves in regular rhythm (RR), extrasystoles (ES), atrial fibrillation (AF)). We hermetically installed in the rotameter imitation of arterial stent – metal construction with spiral oriented parts 68 mm long. Plastic diaphragms 15 mm long with stenosis of the internal lumen of 50%, 70%, and 90% were alternatively put inside the tube to study intra-arterial hemodynamics. 5 mm long silk thread was alternately installed inside the tube, an intravascular piezoelectric crystal pressure sensor connected to an oscilloscope was injected with a dye - clerical ink.

Results

When imitating AF after the long pause the speed of fluid flow through the diaphragms increased in comparison with the RR with the pendency: if longer pause was than more speed increased.

So, with a stenosis of 50%: the speed with a RR was 2.09 m/s, with AF after the pause <1 s speed was 3.36 m/s, AF after the pause >1, but <2 s speed was 4.97 m/s, AF after the pause >2 s speed was 5.88 m/s; with 70% stenosis: the speed with a RR was 3.24 m/s with AF after the pause <1 s speed was 3.96 m/s, AF after the pause >1, but <2 s speed was 5.87 m/s, AF after the pause >2 s speed was 7.83 m/s; with 90% stenosis, the speed at RR 8.96 m/s, with AF after the pause <1 s speed was 9.46 m/s, AF after the pause >1, but <2 s speed was 11.17 m/s, AF after the pause >2 s speed was 13.45 m/s.

The pressure measured by piezoelectrical probe increased proportionally to the speed. We observed the appearance of reflected, standing waves in the edge zones of the diaphragm and stent and a turbulent flow of liquid behind the diaphragm and stent.

Conclusion

These changes in hemodynamics are characterized by proposed concept of "hydraulic shock". Intense mechanical effect of the pressure waves after the long pauses between cardio cycles in AF in the marginal zones of the diaphragm and intra-arterial stent can cause the further growth, progression of atherosclerosis and restenosis in arterial vessels.
Lipid-lowering therapy after acute coronary syndromes in Europe: can we do better?
Authors: Tsaban G , Vidal Perez R , Krychtiuk K K , Ahrens I , Halvorsen S , Hassager C , Huber K , Schiele F , Sionis A , Claeys M J
Published: May 2023

Funding Acknowledgements

Type of funding sources: None.

Background

Recent guidelines on acute coronary syndromes (ACS) recommend initiating lipid-lowering therapy (LLT) as soon as possible in order to obtain >50% LDL-cholesterol reduction with a low-density-lipoprotein-cholesterol (LDL-c) <1.4 mmol/L.

Aim

To define the current LLT policy in Europe after an ACS and to assess whether in hospital initiation of combination therapy of high potency (HP) statin with or without ezetimibe improves the adherence rate to target LDL-c levels as compared to a step-by-step LLT approach.

Methods and results

Data on LLT and lipid levels during and up to one year after hospitalisation were gathered retrospectively for 286 ACS patients who were admitted in 28 hospitals (70% academic) across 16 European countries between the years 2021 and 2022. Patients (median age 61 years, 75.9% men) were mostly admitted in dedicated cardiology departments/intensive cardiac care units (96.8%). A total 59% had ST-elevation myocardial infarction and 88% were treated with percutaneous coronary intervention. At baseline 69.9% of the patients had dyslipidaemia, 35 (14.6%) were on HP statin, 5 (3.9%) were on ezetimibe, and 6 (2.2%) were on HP statin/ezetimibe combination therapy. The median LDL-c on admission was 3.27 [interquartile range (IQR): 2.4-4.1] mmol/L.

HP statin only was the predominant LLT during hospitalisation (62%) and was primarily initiated within 24h from admission (figure). During hospitalization, HP statin/ezetimibe combination therapy was administered in 24.0% of the cases. Combination therapy in hospital was given more frequently in high income countries (n=8) as compared to middle income countries (34.0% vs 10.8%, p<0.001). After one year, LLT up titration to combination therapy with ezetimibe or with PCSK9 inhibition was observed among 40 patients (14%, to a total of 37.4%) and 3 patients (1.6%), respectively.

At follow-up, median LDL-c level was 1.6 (IQR 1.3-2.0) mmol/L and the median relative LDL-c reduction was 45.4% (IQR 27.2-64.0). Adherence to target LDL-c with > 50% reduction was achieved in 17.8% of the total population, in 22.4% of the high-income countries and in 12.3% of the middle-income countries (p=0.04). Patients treated with combination therapy at discharge had a higher relative LDL-c reduction than those with HP statin therapy only at discharge (median 52.5% vs 43.8%, p=0.007) and had a numerically higher target lipid status (23.9% vs 17.2%, p=0.24)

Conclusions

Despite high rates of high intensity LLT during hospitalisation, target LDL-c with > 50% LDL reduction was achieved only in 17.8%. Greater, yet insufficient, LDL-c reduction was observed when combination therapy of high dose statin with ezetimibe was initiated during the index hospitalisation.