bluuebunny/crossref_metadata_2025_split huggingface dataset:
Ticagrelor monotherapy vs clopidogrel monotherapy in patients with acute coronary syndrome undergoing percutaneous coronary intervention
Authors: Feng W , Chen P.W , Ho M.Y , Su C.H , Huang S.W , Cheng C.W , Yeh H.I , Chen C.P , Huang W.C , Fang C.C , Lin H.W , Lin S.H , Hsieh I.C , Li Y.H 
Published: November 2020

Abstract

Background
P2Y12 inhibitor monotherapy with either clopidogrel or ticagrelor becomes an alternative antiplatelet strategy in patients (pts) undergoing percutaneous coronary intervention (PCI). The purpose of this study was to compare the efficacy and safety of clopidogrel vs. ticagrelor monotherapy in pts with acute coronary syndrome (ACS) undergoing PCI who cannot tolerate aspirin.

Methods and results
From January 1, 2014 to December 31, 2018, a total of 610 ACS pts (mean age 70.4±13.1 years, 72.1% men, 28.5% STEMI) that aspirin was stopped prematurely for various reasons and received either clopidogrel (n=369) or ticagrelor (n=241) monotherapy were included from 8 major hospitals in Taiwan. The duration (median and the 25th and 75th percentile) of aspirin treatment was 9 (1.39–37.00) days in the clopidogrel group and 10 (1.00–55.00) days in the ticagrelor group (p=0.514). Gastrointestinal bleeding (36.9%) was the most common reason to stop aspirin in both groups. The primary endpoint is the composite of all-cause mortality, recurrent ACS or unplanned revascularization, and stroke within 12 months after discharge. The safety endpoint was the major bleeding defined as BARC 3 or 5 bleedings. The covariates were balanced between groups after using inverse probability of treatment weighting. Overall, 84 patients developed events of primary endpoint, with 57 (15.4%) in the clopidogrel group and 27 (11.2%) in the ticagrelor group. After multivariate adjustment in the Cox proportional-hazards models, ticagrelor was associated with a lower risk of primary endpoint compared with clopidogrel (adjusted hazard ratio [aHR] 0.67, 95% CI 0.49–0.93). Among the primary endpoint, ticagrelor significantly reduced the risk of recurrent ACS or unplanned revascularization (aHR 0.46, 95% CI 0.28–0.75). There was no significant difference of all-cause mortality between the 2 groups (aHR 0.92, 95% CI 0.52–1.61). The risk of BARC 3 or 5 bleeding was also similar (aHR 0.71, 95% CI 0.35–1.45).

Conclusions
Among ACS patients undergoing PCI who cannot tolerate aspirin, ticagrelor monotherapy was associated with a significantly lower risk of a composite of cardiovascular events compared to clopidogrel monotherapy. The major bleeding risk was similar between groups.

Funding Acknowledgement
Type of funding source: None
Differences in revascularization strategy and outcomes in ST-elevation and non-ST-elevation myocardial infarction with spontaneous coronary artery dissection
Authors: Inohara T , Alfadhel M , Starovoytov A , John Mancini G.B , Saw J 
Published: November 2020

Abstract

Background
Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction (MI) in young to middle-aged women. However, the role of revascularization for SCAD, especially percutaneous coronary intervention (PCI), remains controversial.

Purpose
To compare revascularization strategies and outcomes in SCAD patients presenting with ST-elevation MI (STEMI) vs. unstable angina or non-STEMI (UA/NSTEMI).

Methods
We analyzed SCAD patients who presented acutely between June 2014 and June 2018 to 22 centers participating in the Canadian SCAD Cohort Study. We compared treatment patterns and clinical outcomes in SCAD patients with an initial clinical presentation of STEMI vs. UA/NSTEMI. We assessed follow-up major adverse cardiovascular event (MACE) rate, a composite of all-cause death, MI, and stroke. The impact of revascularization on MACE was also evaluated according to clinical presentations (STEMI vs. UA/NSTEMI).

Results
Among 750 SCAD patients (mean age 51.7±10.5 years; 88.5% were women), 234 (31.2%) presented with STEMI. In the STEMI group, left anterior descending artery was more commonly involved (62.0% vs. 47.5%, p&lt;0.001) and TIMI 0 flow was more frequently observed (24.8% vs. 7.2%, p&lt;0.001). A total of 27.8% of STEMI patients were treated with revascularization (98.5% PCI), whereas only 8.7% of UA/NSTEMI patients were revascularized (93.3% PCI). For STEMI patients, 93.9% were planned procedures, whereas, for UA/NSTEMI patients, 71.1% were planned revascularization. Successful or partially successful PCI was 65.5% for STEMI and 76.9% for UA/NSTEMI (p&lt;0.001). The median follow-up period was 850 (interquartile range: 619–1096) days. MACE rate was not different between STEMI and UA/NSTEMI (UA/NSTEMI as a reference: hazard ratio [HR] 1.08, 95% confidence interval [CI] 0.70–1.68, p=0.72). Regardless of clinical presentations, revascularization was associated with increased risk of MACE (STEMI: HR 2.57, CI 1.25–5.25, p=0.01; UA/NSTEMI: HR 5.41, CI 3.19–9.19, p&lt;0.001). The association of revascularization and increased risk of MACE was more prominent in UA/NSTEMI than in STEMI (Figure), but it did not reach statistical significant (P for interaction = 0.09).

Conclusions
In SCAD patients, long-term clinical outcome was not different between STEMI and UA/NSTEMI presentations. Revascularization was more frequently performed with STEMI; however, regardless of clinical presentations, revascularization was associated with worse clinical outcomes. Careful patient selection for revascularization is key for SCAD patients and further studies are needed to clarify selection criteria.
Revasc and MACE by presentation

Funding Acknowledgement
Type of funding source: Public grant(s) – National budget only. Main funding source(s): Canadian Institutes of Health Research
Clinical implications of the morphological features of left ventricular intracavitary thrombi after anterior ST elevation myocardial infarction
Authors: Vilardell P , Moral S , Albert X , Bosch D , Morales M , Frigola J.M , Robles R , Pla R , Ramos R , Aboal J , Brugada R 
Published: November 2020

Abstract

Background
Left ventricular thrombi (LVT) after an anterior ST elevation myocardial infarction (STEMI) are usually classified as protruding or laminar according to their morphological characteristics. However, it is unknown whether this morphology has any clinical implication.

Purpose
Determine prognostic between laminar or protruding LVT in the community of anterior STEMI.

Methods
An observational cohort study on patients with LVT after anterior STEMI detected by echocardiography between 2008 and 2019 was conducted. Laminar LVT was defined as those protruding &lt;5mm inside the cavity.

Results
Of 1.215 anterior STEMI patients, 121 (10%) cases presented a LVT: 86 (71%) were protruding and 35 (29%) laminar. Mean follow-up was 323±116 days. No differences in baseline clinical and echocardiographic characteristics were detected between laminar or protruding LVT groups. However, protruding LVT patients were more frequently treated with triple therapy (71% vs 40%; p&lt;0.001). Laminar LVT patients presented a lower stroke rate (3% vs 16%; P=0.042) and embolism-related rate (3% vs 19%; p=0.024) than protruding LVT cases. Kaplan-Meier analysis demonstrated significant differences in embolism-related event rate between the 2 groups (p=0.003) during the follow-up period. Laminar LVT was associated with lower embolism-related events during follow-up independently than left ventricular ejection fraction (LVEF) and age (HR=0.17; 95% CI,0.10–0.29; p&lt;0.001). No differences were observed in laminar LVT patients in embolism-related events during follow-up between those treated with or without triple therapy (7% vs 0%; p=0.400).

Conclusions
Laminar LVT after anterior STEMI presented a lower rate of embolism-related complications during follow-up compared with protruding LVT regardless of LVEF, age and even with a lower rate of triple therapy.
Figure 1. Kaplan-Meier curve showing cumulative probability of embolism-related event rate after anterior STEMI according to LVT morphology at 1 year.

Funding Acknowledgement
Type of funding source: None
Relation of contrast volume to new onset atrial fibrillation in acute coronary syndrome underwent percutaneous coronary intervention
Authors: Cespon Fernandez M , Abu-Assi E , Parada Barcia J.A , Lizancos Castro A , Caneiro Queija B , Torres J , Dominguez R , Galan A , Iniguez Romo A , Raposeiras Roubin S 
Published: November 2020

Abstract

Introduction
There is an important relationship between atrial fibrillation (AF) and contrast induced nephropathy (CIN). Several hypotheses were suggested to explain this unidirectional association between CIN and AF, like influence on renin-angiotensin-aldosterone system and the inflammatory pathway, as well as the use of iodinated contrasts -due to its possible interaction at the thyroid hormone regulation-.

Purpose
The aim of this study was to analyze the relation between contrast volume and the subsequent development of AF in patients with acute coronary syndrome (ACS)

Methods
A total of 6,133 ACS patients underwent PCI between 2010 and 2016 were analyzed. We have excluded 1,896 patients with prior history of AF, without data about contrast volume or with missing data about follow-up. The impact of contrast volume in the development of AF was assessed by Cox regression analysis. Hazard Ratios (HR) with 95% of confidence interval (CI) were reported. Maximum allowable contrast dose (MACD) was defined as 5*body weight/serum creatinine.

Results
From the total study population (4,237 patients, 64.3±12.8 years, 24.2% women), 399 (9.4%) developed AF during a mean follow-up of 3.5±2.4 years. Mean contrast volume used was 199.9±90.3 ml. Contrast volume was not associated with follow-up de novo AF (HR 0.99, 95% CI: 0.99–1.00; p=0.834). However, the ratio between contrast volume used and the maximum allowable contrast dose (CV/MACD) resulted a predictor of follow-up AF (HR 1.18, 95% CI: 1.02–1.37, p=0.027). The cumulative incidence of AF was 2.7 per 100 patients/year in patients with CV/MACD ≤1 and 4.8 per 100 patients/year in patients with CV/MACD &gt;1. After adjusting for those variables associated with follow-up AF in the univariate analysis, the use of a contrast volume higher than MACD resulted an independent predictor of AF (HR 1.40, 95% CI: 1.03–1.89; p=0.032).

Conclusion
Doses of contrast volume higher than the maximum allowable contrast dose were independently associated with higher rates of AF during the follow-up.
Cumulative incidence of AF by groups

Funding Acknowledgement
Type of funding source: None
Hyperthyroidism in Takotsubo syndrome: prevalence, clinical features and long-term outcomes
Authors: Scudiero F , Arcari L , Silverio A , Citro R , Bossone E , Autore C , Muraca I , Chinati P , Sanna G , Piti A , Parodi G 
Published: November 2020

Abstract

Background
Takotsubo syndrome (TTS) is an increasingly recognized form of transient left ventricular dysfunction, often completely reversible. The exact pathogenesis is not fully understood, but central role of adrenergic dysfunction has been widely accepted. A possible link between hyperthyroidism and TTS has been hypothesized, since thyroid and adrenergic systems are in closely connection. Nevertheless, clinical study to define the association between hyperthyroidism and TTS is still lacking.

Purpose
This study aimed to assess prevalence, clinical features and long-term outcomes of hyperthyroidism at presentation in TTS patients.

Methods
Overall, 590 TTS patients from 23 centers were included in this prospective registry. Thyroid profile was available for 314 patients at time of TTS admission. Patients in hypothyroid state (n=32) according to TSH value were excluded. The remaining 282 patients were divided in normal thyroid state and hyperthyroid state according to TSH value, respectively 240 (85%) and 42 (15%) patients.

Results
The median age was 73±10 and the female rate was 93%. TTS related to physical trigger was mostly detected in hyperthyroidism patients (52% vs 30%, respectively in hyperthyroid state and normal thyroid state; p=0.005); while, TTS related to emotional trigger was less common (19%, vs 38%, respectively in hyperthyroid state and normal thyroid state; p=0.016). In TTS unprovoked by a stress factor, there was no statistical difference in thyroid state (29% vs 31%, respectively in hyperthyroid state and normal thyroid state; p=0.690). Follow-up rate was 95% and follow-up length was 41±36 months. At long-term follow-up, mortality rate was 39% and 20% in hyperthyroidism and normal thyroid state, respectively (p=0.008; Figure 1) and adverse event rates (the composite of all-cause death, myocardial infarction and stroke) were 39% and 24% in hyperthyroid state and normal thyroid state, respectively (p=0.034). At multivariable analysis, hyperthyroidism resulted as a strong predictor of mortality (OR 3.82, 95% CI: 1.71–8.50; p=0.001) and of adverse event rates (OR 2.18, 95% CI: 1.19–3.98; p=0.011).

Conclusion
Hyperthyroidism at presentation is relatively common in TTS patients and associated with physical triggers and unfavorable long-term prognosis.
Figure 1. Kaplan-Meier curves

Funding Acknowledgement
Type of funding source: None
Delayed hyperenhancement obtained by non-contrast computed tomography following coronary angiography in patients of extracorporeal cardiopulmonary resuscitation
Authors: Watanabe T , Akasaka T , Sasaki N , Yamamoto K 
Published: November 2020

Abstract

Background/Introduction
Extracorporeal cardiopulmonary resuscitation (ECPR) has been reported to improve survival and neurologic outcome as compared to conventional CPR in refractory cardiac arrest. Although prognostic factors of these patients have been reported, predicting of outcome is difficult in real world. Recently, early evaluation of myocardial viability in acute myocardial infarction by non-contrast computed tomography (CT) post coronary angiography (CAG) has been reported. And myocardial contrast delayed enhancement obtained by this method related to higher risk of cardiac events. However, few studies have reported delayed enhancement on left ventricular wall findings in non-contrast CT after CAG in terms of patients performed ECPR.

Purpose
To investigate the impact of delayed hyperenhancement obtained by non-contrast CT following CAG in patients performed ECPR.

Methods
We investigated 79 patients treated by ECPR for refractory cardiac arrest regardless of whether in-hospital or out-hospital in our institute from Apr 2009 to Feb 2018. Thirty-two in these patients received non-contrast CT following CAG with ECPR were enrolled. All ECPR cases underwent VA-ECMO in the catheter laboratory using percutaneous procedure while maintaining conventional CPR. Non-ECG-gated and non-contrast CT was performed using a 64-row multidetector CT scanner.

Results
Survival rate was 18.8% in this cohort. There was no significant difference between survive and in-hospital death group in terms of patient characteristics, clinical time courses, initial blood samples and procedure characteristics. Only delayed hyperenhancement showed significant difference between 2 groups (p=0.04). All delayed hyperenhancements were detected in only in-hospital death group. Delayed hyperenhancement was detected in 12 cases (37.5%). Initial shockable rhythm was less common in cases with delayed hyperenhancement. Cardiac death tended to be more frequent in patients with delayed hyperenhancement. The major causes of death were bleeding (41.7%) and heart failure (33%).

Conclusion(s)
Delayed hyperenhancement in patients treated ECPR was strong predictor of in-hospital death.
Image of delayed hyperenhancement

Funding Acknowledgement
Type of funding source: None
Mechanical ventilation in cardiac arrest: association between hyperoxia, hypercarbia and positive end-expiratory pressure with mortality
Authors: Alviar Restrepo C , Lui A.Y , Jaramillo-Restrepo V , Celi L , Rico Mesa J.S , Quien M , Vargas A , Aiad N , Alabdallah K , Li B , Major V , Maselli D.J 
Published: November 2020

Abstract

Background
Optimization of mechanical ventilation (MV) in patients with cardiac arrest (CA) may help improve outcomes in these patients. We sought to investigate the association between hyperoxia, PCO2, and positive end-expiratory pressure (PEEP) with mortality in patients with CA.

Methods
Patients admitted to our medical center CICU from 2001 through 2012 (MIMIC-III database) who received MV with available information on MV parameters and had arterial blood gases sampling were included. Hyperoxia was defined as time-weighted mean of PaO2 &gt;120 mmHg and non-hyperoxia as PaO2 ≤120 mmHg, while Hypercarbia was defined as PCO2 &gt;35 mmHg during CICU admission. The primary outcome was in-hospital mortality. Multivariable logistic regression was used to assess the association between hyperoxia and in-hospital mortality adjusted for age, female sex, Oxford Acute Severity of Illness Score, creatinine, lactate, pH, PaO2/FiO2 ratio, PCO2, PEEP, and time spent on PEEP.

Results
Among 136 patients, PaO2 = 139±55 mmHg, PCO2 = 39±10 mmHg, and PEEP = 6.4±2.2cmH2O. Unadjusted mortality was higher in the hyperoxic group (51.4%) compared to the non-hyperoxic group (29.0%) (long rank test p=0.0034, figure). In multivariable analysis, hyperoxia was independently associated with higher in-hospital mortality (OR 4.046, 95% CI: 1.501–10.907, p=0.0057). Additionally, there was no association between the presence of hypercarbia and in-hospital mortality (OR 0.896, 95% CI: 0.319 to 2.521, p=0.836) nor when PCO2 was analyzed as a continuous variable (OR 1.063 per 1 mmHg increase in CO2, 95% CI: 0.111–10.145, p=0.957). Similarly, there was no assocation between PEEP and in-hospital mortality (OR 1.012 per 1cmH2O increase, 95% CI: 0.807 to 1.270, p=0.917). Post-hoc analysis with PaO2 as a continuous variable was consistent with the primary analysis (OR 1.214 per 10 mmHg increase in PaO2, 95% CI: 1.059–1.391, p=0.005).

Conclusions
In patients with CA, hyperoxia was associated with increased mortality, while PCO2 and PEEP levels were not. Optimal MV parameters are important in the management of patients with CA. Further research is warranted to confirm this association and explore the mechanisms behind these observations. These studies can help establish the best MV strategies for patients with CA.

Funding Acknowledgement
Type of funding source: None
Impact of resuscitation guidelines updates on global outcomes after cardiac arrest
Authors: Marco Clement I , Rosillo Rodriguez S.O , Merino Argos C , Martin-Polo L , Martinez-Marin L.A , Rodriguez-Sotelo L , Arbas Redondo E , Poveda Pinedo D.I , Tebar Marquez D , Armada Romero E , Garcia-Arribas D , Gonzalez Fernandez O , Caro Codon J , Lopez-Sendon J.L , Lopez-De-Sa E 
Published: November 2020

Abstract

Background
Cardiopulmonary resuscitation (CPR) Guidelines are updated every five years in the light of new evidence. Recent major changes emphasized the importance of quality chest compressions during CPR and simplified recommendations for lay providers, but it is unknown whether these changes improved neurological outcomes.

Purpose
To analyse whether changes in CPR guidelines had an impact on the prognosis of comatose survivors after cardiac arrest (CA).

Methods
Prospective database of consecutive patients (pts) admitted to the acute cardiac care unit of a tertiary hospital after in-hospital and out-of-hospital CA (IHCA and OHCA) treated with targeted temperature management (32–34°) from August 2006 to January 2020. Patients were divided into three groups, each one representing the 5-year time frame of publication/implementation of CPR Guidelines: G1 (2006–2010); G2 (2011–2015); G3 (2016–2020).

Results
A total of 510 pts were included: G1 94 (18.4%), G2 243 (47.6%), G3 173 (33.9%). Mean age was 62.6±14.5 and 413 (81.0%) were men. Demographic characteristics and cardiovascular risk factors did not differ significantly among groups. Changes in CA features among the three analysed periods are shown in Table 1. On regards of prehospital care, CPR provided by lay bystanders (G1 51.6%; G2 63.3%, G3 69.8%) and the use of automated external defibrillators (AED) (G1 11.0%; G2 14.9%; G3 18.9%) progressively increased (p=0.01 and p=0.04, respectively) (Figure 1, A and B). After 2010, there was a higher proportion of CPR-related injuries: G1 12.7%, G2 23.5%, G3 22.7% (p=0.02). Global survival at discharge was 51.6% (263/510). Cerebral Performance Category (CPC) of 1–2 within a 3-month follow-up period significantly increased over time when comparing G1, G2, G3 groups (p=0.04) (Figure 1, D). Among all pts, those with CPR related injuries had a higher proportion of CPC 1–2 (71/109, 65.1% vs 168/389, 43.2%, p&lt;0.01).

Conclusions
We found a progressive increase of lay bystander CPR and use of AED over the three time periods. Moreover, a higher proportion of CPR-related injuries was observed after publication of 2010 CPR Guidelines which recommended greater depth and higher rate of chest compressions. Survival and neurological outcomes improved significantly over time.
Figure 1

Funding Acknowledgement
Type of funding source: None
Combined use of VA-ECMO and IMPELLA (ECPELLA) as a possible strategy to improve outcomes in patients who underwent E-CPR
Authors: Unoki T , Tamura Y , Nakayama T , Kametani M , Minami Y , Konami Y , Suzuyama H , Inoue M , Yuhu T , Kodama K , Yamamuro M , Taguchi E , Sawamura T , Nakao K , Sakamoto T 
Published: November 2020

Abstract

Background
Extracorporeal Cardio-Pulmonary Resuscitation (E-CPR) is an effective tool for patients with refractory cardiac arrest (CA). Since VA-ECMO provides strong afterload, IABP is often used to increase left ventricular load. Recently, in Japan, the effectiveness of VA-ECMO in combination with IMPELLA, a forward flow mechanical circulatory support device (ECPELLA) is gaining attention.

Purpose
We investigated usefulness of ECPELLA in patients with refractory CA.

Method
We reviewed 133 patients that had E-CPR from January 2012 through January 2020 {mean age: 67±15 years, male 65%, Out of hospital Cardiac Arrest (OHCA) 35%, Acute coronary Syndrome (ACS) 54%}. We divided these patients into ECMO with IMPELLA (ECPELLA group), ECMO with IABP (IABP group) and ECMO alone (ECMO alone group). The primary endpoint is 30-day survival and good neurological prognosis defined as CPC (cerebral performance categories) 1 or 2.

Result
During the study period, of the 133 patients, there were 20 in the ECPELLA group, 78 in the IABP group, 35 in the ECMO alone group. There were no significant differences in age in all three groups. There were more males, shockable rhythm, OHCA and ACS in the ECPELLA and IABP groups compared to the ECMO alone group. But there was no significant difference between the ECPELLA and IABP groups. Compared with other groups, ECPELLA had the shortest time from cardiac arrest to ECMO placement. Regarding endpoints, the rate of 30-day survival and favorable neurological prognosis were higher in the ECPELLA group, followed by the IABP group and then the ECMO alone group. (ECPELLA: 55% vs. IABP: 23% vs. ECMO alone: 9%; P=0.0009, ECPELLA: 35% vs. IABP: 13% vs. ECMO alone: 9%; P=0.04) Next, Kaplan Meier analysis was performed to analyze 30-day all-cause mortality. The ECPELLA group had a significantly higher survival rate (P=0.01 by log-rank test). Multivariate cox proportional hazard analysis including the age, OHCA, shockable rhythm, ACS, Collapse-to-ECMO under 60 min revealed that the age (hazard ratio [HR], 1.28 (10 years increase), 95% confidence interval [CI], 1.08–1.53, P=0.004) and Collapse-to-ECMO under 60 min (HR, 0.37, 95% CI, 0.21–0.68, P=0.001) or ECPELLA (HR, 0.46, 95% CI, 0.20–0.694, P=0.03) were significantly associated with mortality.

Conclusion
ECPELLA used with E-CPR is an effective tool to improve mortality and neurologic status.

Funding Acknowledgement
Type of funding source: None