bluuebunny/crossref_metadata_2025_split huggingface dataset:
Endomyocardial biopsy in patients with myocarditis - still justified in the CMR era? A single-centre experience
Authors: Seuthe K , Pfister R , Pennig L , Mons U , Klingel K , Ten Freyhaus H 
Published: October 2024

Abstract

Background
Endomyocardial biopsy (EMB) is still considered the diagnostic gold standard for myocarditis. However, in the past decades, cardiac magnetic resonance (CMR) was established as a non-invasive tool supporting the diagnosis of myocarditis. Furthermore, there is often reluctance in performing EMB due to rare but potentially severe complications. We therefore sought to identify patient subgroups that could potentially derive benefits from EMB. This involved a comprehensive analysis of the diagnostic and therapeutic outcomes resulting from the procedure at our centre.

Methods
In this retrospective single-centre study, data of all patients presenting with (peri-) myocarditis between 01/2016 and 06/2023 at our tertiary care centre were included. Frequency of histological confirmation of acute myocarditis and histology leading to immunosuppressive therapy were analysed according to patient risks. Prespecified risk factors were (i) LV-EF ≤30%, (ii) presence of severe arrhythmias (VF, VT, high grade AV-block) or (iii) pre-existing autoimmune disease. Furthermore, the subgroup of recurrent myocarditis cases was analysed separately.

Results
A total of 150 consecutive patients (36.7 ± 15.5 years, 77.3% male) were included in this study. 26/150 patients had a documented EF ≤30%, 13/150 an EF &gt;30% with another risk factor and 111/150 an EF&gt;30% without another risk factor. EMB was performed in 21/26 patients with EF ≤30% (80.7%), in 7/13 patients with EF &gt;30% and another risk factors (53.8%) and in 16/111 (14%) patients without risk factors. EMB led to the initiation of immunosuppressive therapy in 11/28 patients with risk factors (39.3%) and in none of the patients without risk factors (0/16, 0%, p=0.003)(figure 1). With respect to the subgroup of patients presenting with recurrent myocarditis (n=10), no specific therapy was performed.

Conclusion
Due to a high therapeutic yield for initiation of immunosuppressive therapy in non-infectious myocarditis, performing EMB should be considered in all high-risk patients. In patients without clinical risk factors including cases of recurrent or relapsing myocarditis no specific therapy was initiated.
Rationale and study design of the international randomized control trial MYocarditis THerapy with Steroids: the MYTHS trial
Authors: Ammirati E , Conti N , Frea S , Uribarri A , Grosu A , Loffredo F , Corsi D , Tomasoni D , Cappelli F , Marini M , Garascia A , Van De Heyning C M , Crespo-Leiro M , Adler E D , Potena L 
Published: October 2024

Abstract

Background
Immunosuppression is generally suggested in patients with specific subtypes of acute myocarditis, such as eosinophilic myocarditis or giant cell myocarditis or associated with systemic autoimmune disorders. In contrast, no specific treatment for most acute myocarditis complicated by acute heart failure (HF) or cardiogenic shock is recommended beyond the management of acute HF and supportive therapy. Nevertheless, large registries commonly reported using corticosteroids in severe forms without data supporting this strategy.

Purpose
To assess the safety and efficacy of high-dose pulse intravenous (IV) corticosteroid therapy to treat patients with complicated/fulminant acute myocarditis based on clinical suspicion.

Methods
An international pragmatic investigator-initiated single-blinded randomized controlled trial that screens patients between 18 and 70 years admitted to the hospital for suspected acute myocarditis (cardiac symptoms onset within three weeks) complicated by acute HF/cardiogenic shock and left ventricular (LV) ejection fraction&lt;41% without significant LV dilation is ongoing. Patients are randomized in a 1:1 ratio to pulsed IV methylprednisolone (1 g) in saline solution (250 mL) daily for three days or placebo (saline without methylprednisolone) on top of standard therapy and maximal supportive care. A final diagnosis of myocarditis is confirmed by histology or cardiac magnetic resonance imaging. A population of 288 patients has been planned to assess a reduction in the probability of reaching the primary endpoint from 25% in the placebo arm to 12% in the methylprednisolone arm with a power of 0.80 (Figure). The main analysis will be conducted on an intention-to-treat basis.

Results
The primary efficacy endpoint of the trial is defined as the time from randomization to the first event occurring within 6 months, including all-cause death, heart transplantation, or long-term LV assist device implant, or need for an upgrading of the temporary mechanical circulatory support (t-MCS), or ventricular tachycardia (VT)/fibrillation (VF) treated with direct current (DC) shock, or first rehospitalization due to HF or VT/VF, or advanced atrioventricular block. The safety endpoints include a composite of potential complications that can occur, including serious infections, acute gastrointestinal bleeding, and other complications that can be related to corticosteroid therapy or prolonged stay on t-MCS. There are 32 active centers, and 48 patients have been randomized since December 2021. The trial is expected to be completed by the end of 2028.

Conclusion
The results of the MYTHS trial can define the role of IV methylprednisolone in the initial treatment of patients with complicated forms of acute myocarditis that currently have an unacceptably high mortality rate.
Identifying prognostic factors in patients with cardiogenic shock undergoing VA-ECMO treatment: insights from ECLS-SHOCK using machine learning
Authors: Kresoja K P , Zweymer U , Akin I , Rassaf T , Mahabadi A A , Lehmann R , Eitel I , Graf T , Schuster A , Skurk C , Lurz P , Schneider S , Desch S , Freund A , Thiele H 
Published: October 2024

Abstract

Background/Introduction
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has not been shown to reduce short-term mortality in patients with acute myocardial infarction complicated by cardiogenic shock. However, whether some patients might benefit from VA-ECMO remains to be cleared.

Purpose
To identify the impact of VA-ECMO therapy on outcomes by leveraging the potential of machine learning.

Methods
The ECLS-SHOCK trial is a randomized controlled trial where patients with acute myocardial infarction complicated by cardiogenic shock for whom early revascularization was planned were randomly assigned to receive early VA-ECMO plus usual medical treatment or usual medical treatment alone. The primary outcome was death from any cause at 30 days. Extreme gradient boosting (XGBoost) was used to develop a model for the prediction of 30-day all-cause mortality and to assess the influence of VA-ECMO on outcomes.

Results
Overall, 209 patients were randomized to the VA-ECMO and 208 to control. Baseline characteristics between groups were well balanced (median age 63 years, 81% male, 67% presenting with ST-segment elevation myocardial infarction).
At 30-days 100 patients in the VA-ECMO and 102 in the control group were dead. The final XGBoost model contained 27 variables and the 10 most influential variables are shown in Fig. 1. On derivation the model predicted mortality with an AUC of 1.00 and on validation with an AUC of 0.80 (95% CI 0.71 to 0.89), with a sensitivity of 95% (95% CI 88% to 100%) and a specificity of 55% (40% to 69%), resulting in a positive predictive value of 65% and a negative predictive value of 92% at a Youden-derived cut-off. Importantly, neither the VA-ECMO therapy nor its complications were among the most influential factors of the model with a relative importance of 1.1% for VA-ECMO therapy and 0.25% for peripheral vascular complications and bleeding complications even being discarded by the model.

Conclusion
In patients with acute myocardial infarction complicated by cardiogenic shock the influence of VA-ECMO therapy on 30-day mortality, even when investigated with complex machine learning models, is negligibly low.
Levosimendan in patients with cardiogenic shock refractory to dobutamine weaning
Authors: Zeitouni M , Dorvillius E , Sulman D , Procopi N , Beaupre F , Devos P , Barthelemy O , Rouanet S , Ferrante A , Chommeloux J , Hekimian G , Kerneis M , Silvain J , Montalescot G 
Published: October 2024

Abstract

Background
The role of Levosimendan in managing cardiogenic shock remains the subject of debate.

Objective
This study examines the use and effects of Levosimendan when combined with dobutamine in patient’s refractory to dobutamine weaning.

Methods
This retrospective study included patients with cardiogenic shock admitted between January 1st, 2010, and October 31st, 2022. After initial dobutamine weaning failure, we compared patients who were treated with dobutamine alone versus those for whom Levosimendan was added in top of dobutamine. The primary outcome was successful inotrope withdrawal, defined as survival without catecholamine support, transplant, or definitive ventricular assist device at 30 days. Secondary outcomes included all-cause mortality at 30 and 90 days. Data analysis used inverse probability weighting according to propensity score.

Results
Among 349 patients with cardiogenic shock and failure to withdraw dobutamine, Levosimendan was used on top of dobutamine in 114 patients, and another try of dobutamine alone was made in 235 patients. At 30 days, successful inotrope withdrawal occurred in 46 (43.4%) patients with Levosimendan and dobutamine versus 24 (10.5%) patients of the dobutamine only group (weighted OR 4.99 [2.65 - 9.38]; p&lt;0.001), with similar results at 90 days (weighted OR 6.16 [3.22-11.78]; p&lt;0.001). Levosimendan + dobutamine was associated with lower 30-day mortality (weighted OR 0.47 [0.26-0.84]; p=0.01), with no difference at 90 days (weighted OR= 0.67 [0.39-1.14]; p=0.14).

Conclusion
Adding Levosimendan to dobutamine may improve inotrope withdrawal success and reduce 30-day mortality in patients with initial weaning failure, especially in those without project of cardiac assistance or transplant.
Comparing outcomes in cardiogenic shock patients with ischemic versus nonischemic cardiomyopathy: A nationwide retrospective observational study
Authors: Gupta S , Thakkar A , Carter K , Choi J , Saravia S , Mahmood K 
Published: October 2024

Abstract

Introduction
Ischemic and non-ischemic cardiomyopathy are common causes of heart failure. In our study, we compare the in-hospital outcomes between these two groups of patients with cardiogenic shock.

Methods
Data was obtained from the Nationwide Inpatient Sample database between January 2016 to December 2020. The study included all adult patients who were in cardiogenic shock and either ischemic cardiomyopathy (ICM) or non-ischemic cardiomyopathy (NICM). The primary outcome was inpatient mortality. Secondary outcomes were cardiac arrest, arrhythmias, acute respiratory failure, and acute renal failure, as well as the need for ventilators, dialysis, and ECMO.

Results
Among 168,591 adult patients who had cardiogenic shock during their hospitalization, 72,538 patients had either ischemic cardiomyopathy or nonischemic cardiomyopathy. Among them, 31,854 (43.9%) had ischemic cardiomyopathy (ICM) vs 40,684 (56.1%) who had nonischemic cardiomyopathy (NICM). Patients with NICM had higher in-patient mortality (24.6% vs 26.1, aOR: 1.12; 95% CI: 1.08-1.16, p&lt;0.001); when adjusted for age, sex, race, and Charlson comorbidity index. Furthermore, patients with NICM also had a higher risk of respiratory failure (54.1% vs 53.8%, aOR:1.11, 95% CI: 1.07-1.14, p&lt;0.001) and required more life-saving treatments like pressors (1.6% vs 0.7%, aOR: 1.14; 95% CI: 1.10-1.20, p&lt; 0.001) and dialysis (12.7.1% vs 11.3%, aOR:1.20, 95% CI: 1.14-1.26, p&lt;0.001).
However, these patients with NICM had a lower risk of cardiac arrest (7.2% vs 7.8%, aOR: 0.88; 95% CI: 0.84-0.94, p&lt; 0.001) and ventricular arrhythmias (29.5% vs 32.2%, aOR: 0.82; 95% CI: 0.80-0.86, p&lt;0.001) as well as lower ECMO utilization (2.5 vs 2.1, aOR:0.82; 95% CI: 0.73-0.92, p &lt;0.001) and blood transfusions (9.8% vs 11.7%, aOR:0.839; 95% CI: 0.80-0.88, p&lt; 0.001). There was no significant difference in the ventilator use between the 2 groups (40.3% vs 39.7%, aOR:1.01, 95% CI: 0.97-1.04, p=0.714).

Conclusion
The findings of this study underscore the higher in-patient mortality among patients with non-ischemic cardiomyopathy (NICM) presenting with cardiogenic shock. These results emphasize the need for tailored treatment approaches targeting NICM-CS, warranting dedicated diagnostic and therapeutic strategies to improve prognosis in this vulnerable patient subset.Odd's ratios for NICM-CS vs ICM-CS
A practical nomogram and risk stratification system for predicting in-hospital mortality of patients with non-acute myocardial infarction related cardiogenic shock
Authors: Wang X K , Wu Y , Li T , Shi X , Che S P 
Published: October 2024

Abstract

Background
The morbidity and mortality of Cardiogenic Shock(CS) remain high despite the advance in management these years1.As acute myocardial infarction (AMI) is considered to be the most common reason for cardiogenic shock,Non-AMI related CS is excluded from the majority of CS studies and remains largely understudied2. Considering its inherent complexity and hemodynamically multiplicity, it is needed to focusing on these patients to identify specific risk factors, which may be conducive to the promotion of critically CS patients with early decision and timely intervention.

Purpose
In this study,we sought to investigate the variables which are predictive of in hospital mortality in non AMI related CS patients, developed and validated a practical nomogram for risk quantification.

Methods
1298 patients and 548 patients with cardiogenic shock from the MIMIC-IV (version 1.0) and MIMIC-III(version1.4) databaes were included in the study after excluding acute myocardial infarction. We used in-hospital death and 30 day survival as the end points. Lasson and logistic regression analysis were used to identify statistically significant predictors which were finally involved in the nomogram. The predictive performance of the nomogram was evaluated by Harrell’s concordance index (C-index) and calibration after comparing with commonly used ICU scores for in-hospital death.Lastly, we plotted Kaplan-Meier curves of three subgroup classified by the identified cutoff values of the nomogram to further assess the discriminative ability of the prognosis.

Results
The in-hospital mortality of patients with non-AMI related CS is about 36.6%.After the analysis of regression, age, heart rate, wbc, albumin, lactic acid, GCS score, urine volume, using vasopressor were identified as the most critical factors for the in-hospital death. Based on the these results, a nomogram for predicting in-hospital death was established.The calibration plot also shows good consistency between nomogram prediction and actual in-hospital mortality.In addition, compared with other scores, the AUC value of nomogram was 0.806 (95% CI = 0.799-0.831) in the training queue, 0.814 (95% CI = 0.771-0.852) in the internal validation queue and 0.730 (95% CI = 0.690-0.767) in the external validation set, which was significantly higher than other commonly used ICU scoring systems(SAPSII, APSIII and SOFA).Also, three risk subgroups were created using two boundary points (303 and 339) of the nomogram score and the survival curve shows that there were significant differences in the 30 day survival of each subgroup.

Conclusion
A prognostic nomogram and risk stratification system of non-AMI related CS were established and verified, which can provide a practical tool for individualized clinical management of patients.Workflow of the study.Nomogram for non-AMI related CS patients
Dysregulation of sympathoadrenal system activity in patients with microvascular angina
Authors: Nasirdinov N , Uzbekova N R , Usmanov B B , Ruzimatov S H G 
Published: October 2024

Abstract

Introduction
Recent studies have highlighted that a significant proportion of patients (up to 47%) undergoing coronary angiography due to clinical indications do not exhibit significant stenosis in epicardial vessels. Among these patients, up to 50% may suffer from microvascular angina (MVA). Despite the absence of intramural coronary artery lesions typically associated with atherosclerosis, the occurrence of transient myocardial ischemia and cardiac pain syndrome raises interest due to the incomplete understanding of their underlying mechanisms.

Objective
This study aims to comprehensively investigate sympathoadrenal system activity in patients with microvascular angina.

Materials and Methods
A total of 40 patients diagnosed with MVA, aged 35-76 years, including 11 (27.5%) men and 29 (72.5%) women, were enrolled, along with 20 healthy individuals. Assessment of sympathoadrenal system (SAS) activity involved determining daily urinary excretion levels of free and conjugated catecholamine fractions (CA) using solid-phase enzyme immunoassay: adrenaline (A), noradrenaline (NA), dopamine (DA), and DOFA. Additionally, catecholamine deamination enzyme activity—monoamine oxidase (MAO)—was determined using solid-phase EIA.

Results
Patients with MVA exhibited a significant increase in the excretion of all CA fractions. Specifically, adrenaline (A) excretion increased by 56.7%, surpassing the control by 1.7 times (p&lt;0.001). Noradrenaline (NA) levels were elevated by 59.5% in MVA patients, which was 1.6 times higher than the control group (p&lt;0.001). Dopamine (DA) levels in MVA patients increased by 31.0%, surpassing control values by 1.36 times (p&lt;0.001). Moderate elevation in DOFA levels by 19.7% was observed, which was 1.23 times higher than the control (p&lt;0.01). Ratios of CA sulfocatecholamine formation processes indicated pronounced deviations from normal. Gender differences revealed marked changes in sympathoadrenal activity, particularly in women (p&lt;0.001). Studies of MAO activity on the first day identified a moderate decrease in its activity in MVA patients—0.03±0.002 units/ext. (p&lt;0.01), while healthy individuals exhibited an activity level of 0.07±0.001 units/ext.

Conclusion
The findings underscore the crucial pathogenetic role of SAS in the development of MVA. The study demonstrates that the severity of ischemia correlates with disruptions in SAS components. Notably, these disruptions are pronounced in MVA, indicating an overload of the sympathoadrenal system—a critical component of organismal homeostasis. Under conditions of SAS overload, the pivotal enzyme in biogenic amine oxidation, MAO, undergoes significant transformation, leading to reduced activity towards monoamines. These findings were consistent with our clinical investigation.
Prevalence of coronary microvascular disease in myocardial infarction with non-obstructive coronary artery disease
Authors: Carrington J , Moustafa A , Lerman A , Raphael C E 
Published: October 2024

Abstract

Background
Six percent of patients presenting with acute myocardial infarction (MI) have MI with non-obstructed coronary artery disease (MINOCA). Coronary microvascular disease (CMD) is common in angina with non-obstructive coronary artery disease (ANOCA), but its prevalence and severity in MINOCA is undefined.

Purpose
Patients with CMD may have elevated risk of myocardial infarction despite no significant stenosis. We tested the hypothesis that patients with MINOCA have more significant burden of CMD than patients with ANOCA.

Methods
A retrospective case-control study was performed on patients who underwent invasive testing for signs of coronary ischemia and found to have non-obstructive disease (stenoses&lt; 50%). Cases of MI were classified as MINOCA (n=87) and compared to patients with ANOCA (n=552). Patients with spontaneous coronary artery dissection, myocarditis, Takotsubo cardiomyopathy or prior atherothrombotic MI were excluded. Coronary catheterization was performed followed by invasive provocation testing with adenosine and acetylcholine using a Doppler flow wire. CMD was subdivided into endothelium-independent, defined as coronary flow reserve (CFR) &lt; 2.5 with intra-coronary adenosine, and endothelium dependent, defined as &lt; 50% increase in coronary blood flow with acetylcholine. Epicardial vasoconstriction &gt; 90% with typical anginal symptoms was classified as epicardial vasospasm.

Results
There was no difference in age, sex or traditional coronary risk factors between the MINOCA and ANOCA groups (Table 1). Fifty (57%) of patients with MINOCA had type 2 MI secondary to supply-demand mismatch. Both MINOCA and suspected ANOCA patients had a high prevalence of CMD (71% vs 67%) and endothelium-independent CMD is more prevalent in MINOCA (64.5% vs 50.4%). Although odds of endothelium-dependent CMD were similar, the CFR within this group and CMD overall was worse in MINOCA patients (Figure 1). There was no difference in epicardial spasm.

Conclusion
Coronary microvascular disease and vasomotor dysfunction are common in patients with MINOCA, with a higher prevalence of endothelium-independent CMD and more severe CMD overall compared to patients with ANOCA. Treatment of CMD in patients with MINOCA may help reduce recurrence and warrants further investigation.