bluuebunny/crossref_metadata_2025_split huggingface dataset:
IABP and VA-ECMO is associated with better outcome than VA-ECMO alone in the treatment of cardiogenic shock in STEMI
Authors: Van Den Brink F , Zivelonghi C , Vossenberg T , Sjauw K.D , Bleeker G , Winia V , Ten Berg J.M 
Published: November 2020

Abstract

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

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

Results
Between 2011 and 2018 18 patients with STEMI underwent VA-ECMO +/− IABP treatment for cardiogenic shock. The majority was male (78% (14/18)) with a median age of 59 (47–75) years. All patients were in Killip class IV. VA-ECMO alone was performed in 61% (11/18) and VA-ECMO and IABP was performed in 39% (7/18). A cardiac arrest was observed 91% (10/11) of the patients in the VA-ECMO alone group vs 71% (5/7) in the VA-ECMO+IABP group (p=0.52).
The VA-ECMO+IABP group had more complex coronary anatomy, i.e. a higher amount of left main (LM) disease, LM + 3 vessel disease, and three vessel disease when compared to the ECMO alone group (ECMO+IABP 87% vs ECMO alone 18% vs p=0.03). The Syntax score was higher in the ECMO+IABP group (ECMO alone 22±14 vs ECMO+IABP 32±13). The SAVE score did not differ between the groups (ECMO alone −5.9±2.4 vs ECMO+IABP −6.1±2.6 p=0.88) and has a predicted survival of 25–35%.
Survival in the VA-ECMO+IABP group was 100% (7/7), survival in the VA-ECMO group was 55% (6/11) (p=0.035). Good neurological outcome was achieved in more patients in the ECMO+IABP group (ECMO alone 45% vs ECMO+IABP 100% p=0.037). There was no difference in leg ischemia between the VA-ECMO alone group vs the ECMO+IABP group (27% (2/11) vs 0% (0/7) p=0.55) or in bleeding complications (18% (2/11) vs 43% (3/7) p=0.28)

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

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

Abstract

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

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

Methods
This is a retrospective study with data from a national multicentre registry. We have included 3.296 patients with STEMI. Zwolle score was calculated for each patient. It is defined as shown in figure 1.
Δ-Cr was defined as maximum serum creatinine minus admission serum creatinine. A Δ-Cr≥0.3 was assigned 2 points in the Modified Zwolle Score, after interpretation of odds ratio via multivariate analysis.
For prediction quality assessment, we have performed ROC curve analysis with both scoring systems versus 30-day mortality. Regarding survival analysis, we have performed Kaplan-Meier curves with Log-rank analysis. We have also registered complications during hospital stay.

Results
The sample mean age is 63±14, and it is composed by 76.8% of males. The majority of patients presented Killip Class I (87.3%). The STEMI was anterior in 49.7% of patients and inferior in 49.8% of patients. The mean admission time was 5 days. Intrahospital mortality was 3% and 30-day mortality was 4%.
The mean ZS was 3.1±2.8 points, the mean MZS was 3±2.1 points and the mean Δ-Cr was 0.2±0.6mg/dL.
The ROC curve analysis between ZS and early mortality revealed a c-statistic of 0.810 (CI 0.796–0.823), whereas the ROC curve between MZS and early mortality revealed a c-statistic of 0.853 (95% CI: 0.841–0.865). The ROC curves comparison showed superiority of the MZS c-statistic, with a difference between AUC of 0.043 (p&lt;0.001, 95% CI: 0.024–0.063).
Regarding low-risk patients, 30-day mortality was 3.3% using ZS (0–2 points) and 2.4% using modified ZS (0–2 points). Fifty patients (1.5%) died between 3rd and 10th day after ACS: original ZS low-risk criteria registered 0.09% and modified ZS low-risk criteria 0.06% fatalities. Kappa coefficient for intergroup concordance was good (0.73).

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

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

Abstract

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

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

Results
During the period studied, 115 pts were diagnosed of MINOCA, with only one case of in-hospital death. At discharge, DAPT AAS were prescribed in 61%, and a second antiplatelet therapy (clopidogrel, ticagrelor or prasugrel) in 36% of pts. Only 63% of MINOCA pts were on betablockers at discharge, while 61% were on ACEi or ARB and 39% with both of them. Regarding other cardiovascular treatment nitrates were prescribed in 10% of MINOCA pts, calcium channel blocker (CCB) in 15% and nondihydropyridine-CCB in 5%. Statins were used in 61% of pts.
We completed the follow up of 97 of the 114 MINOCA pts discharged (85%). After one year of follow up, MACE occurred in 10 pts (10%). This events were less frequent among MINOCA pts treated with betablockers (3,3% vs 22,2%, p 0,005) and with ACEi/ARB (5,1% vs 18,4%, p 0,045). There were a significant difference in MACE between MINOCA pts who takes both betablockers and ACEi/ARB and those without these treatments (2.9% vs 40%, p 0,001). On the other hand, the use of nitrates and CCB were associated with a significant increase of MACE (5,7% vs 50%, p&lt;0,001; 7,3% vs 26,7%, p&lt;0,045). The use of statins or DAPT was not related with MACE in MINOCA pts.

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

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

Abstract

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

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

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

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

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

Abstract

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

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

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

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

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

Abstract

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

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

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

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

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

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

Abstract

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

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

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

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

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

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

Abstract

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

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

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

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

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

Abstract

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

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

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

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

Funding Acknowledgement
Type of funding source: Public Institution(s). Main funding source(s): NESTOR program for geriatric research, the Netherlands Heart Foundation, the Netherlands Organization for Scientific Research, the Health Research and Development Council (28-2975 and 97-1-364), and the Municipality of Rotterdam