bluuebunny/crossref_metadata_2025_split huggingface dataset:
Time to coronary catheterization in patients with NST-ACS and high GRACE score
Authors: Bar O , Elias A , Halhal B , Marcusohn E 
Published: November 2023

Abstract

Introduction
Current European guidelines recommend early (&lt;24 hours) invasive coronary angiography (ICA) strategy in certain high-risk non-ST segment elevation acute coronary syndrome (NSTE-ACS) patients, including those with GRACE score over 140. The evidence for this recommendation is based on older trials using pre high-sensitive troponin (HsTn) biomarkers and non-contemporary therapy.

Purpose
To assess the association between GRACE score over 140, timing of ICA and their interaction on clinical outcomes in patients with ACS with no ST elevation, using (HsTn) as part of the calculated GRACE risk score.

Methods and results
Between February 1st 2016 and July 31th 2021, 1767 patients with a primary diagnosis of NSTE-ACS without indication for urgent ICA, underwent ICA during index hospitalization. 655 (37%) patients underwent early-invasive ICA (within 24 hours) and 1112 (63%) underwent late ICA (between 24 hours and 1 week). 107 patients had a GRACE risk score of 140 or above and 1660 had a GRACE risk score under 140. The primary composite outcome was all-cause mortality, stroke, and recurrent MI. The median time from admission to ICA was 13.3 hours (IQR 6.0,20.6) for the early group and 59.9 hours for the late group (IQR 23.5,96.3). The vast majority of patients had re-vascularization (75.1%) performed, mostly by PCI (69.4%). There was no difference between the early and late ICA groups in the primary composite outcome (late Catheterization &gt;24h HR 1.196, 95% CI 0.969-1.475, P-value 0.096). Using a multivariable cox regression model for the composite outcome revealed no difference between the early and late ICA groups (late Catheterization &gt;24h HR 1.0735, 95% CI 0.862-1.327, P-value 0.512) with no effect for performing early ICA in patients with GRACE score over 140 (HR 1.291 95% CI 0.910-1.831, p-0.151).

Conclusion
Early ICA strategy in patients with NSTE-ACS patients and GRACE risk score over 140, compared with late ICA, was not associated with improved composite outcome of death, myocardial infarction, and stroke at 1 year.
Pretreatment with P2Y12 inhibitors and relationship with clinical outcomes in NSTEMI: Analysis of 2 Argentinian registries
Authors: Sigal A , Rivero M , Mezza M , Kersten S , Boissonnet C , Filippa G , Procopio G , Abud C M , Ahuad Calvelo S A , Nani S , Perez G E , Odone M , Guardiani F , Duronto E , Costabel J P 
Published: November 2023

Abstract

Introduction
Pretreatment with P2Y12 inhibitors has been widely studied in the context of NSTEMI patients, with varying results. General consensus is that this strategy should be avoided, unless a long wait time is expected before angiography can be performed. However, it is unclear whether this strategy is associated with a reduction in clinical outcomes, or an increase in bleeding events.

Purpose
To analyze frequency of pretreatment in NSTEMI in our medium, and association with clinical outcomes.

Methods
We analyzed the results of two Argentinian acute coronary syndrome registries from 2017 and 2022. We explored incidence of pretreatment, and drug used. We evaluated first through univariate analysis the relationship between pretreatment use and a clinical composite outcome of in hospital events: Myocardial infarction + Mortality + In stent thrombosis + post MI angina + Stroke/TIA. We also explored the relationship of pretreatment with bleeding events (BARC 2 or higher). We later conducted a logistic regression with other clinical variables: Age, gender, diabetes, previous bleeding events, previous MI, aspirin use, anticoagulation, killip-kimball scale and ejection fraction.

Results
1297 patients were included in the analysis, after excluding STEMI patients, patients with current use of P2Y12 inhibitors at time of event, and patients who did not undergo angiography. 75.6% were men, 25.6% diabetic, 27,1% smokers, 70.3% hypertensive, and 23.1% had a previous acute coronary syndrome. Mean age was 55.3 years old. Mean GRACE score was 113,5 and CRUSADE 23,8. 44% of patients recieved pretreatment, mostly with clopidogrel (93.5%). Patients that recieved pretreatment were more frequently hypertensive (73.8% vs 67%, p=0.01) and had a higher incidence of previous MI (27% vs 19%, p=0.002). GRACE score was significantly lower in patients that were pretreated (111,5 vs 115, p=0.04). Pretreatment use was significantly associated with a higher incidence of the composite clinical outcome, occuring in 10.1% of patients pretreated and in 6.9% of patients not pretreated (OR 1.56 (1.06-2.3) p=0.02. Bleeding events were numerically more frequent with pretreatment (8.7% vs 5.9%), though did not reach statistical significance (OR 1.51 (0.99-2.3) p=0.054).
In multivariate analysis, after adjusting for multiple clinical variables, pretreatment was no longer associated with a higher incidence of clinical outcomes, though also not with a lower incidence (OR 1.4 (0.89-2.3) p=0.13).

Discussion
Pretreatment, mostly with clopidogrel, did not show a relationship with either benefit or harm with regard to ischemic and bleeding outcomes in NSTEMI patients.
Poor prognosis of total culprit artery occlusion in patients presenting with NSTEMI
Authors: Herman R , Smith S W , Meyers H P , Bertolone D T , Leone A , Bermpeis K , Viscusi M , Martonak M , Bahyl J , Demolder A , Perl L , Wojakowski W , Bartunek J , Barbato E 
Published: November 2023

Abstract

Background
The prognosis of STEMI and NSTEMI patients stratified according to invasive angiographic findings of an occluded culprit coronary, i.e., occlusion myocardial infarction (OMI), remains unclear.

Purpose
This retrospective single-center study aimed to compare the clinical presentation, management, and all-cause mortality of STEMI, NSTEMI-OMI, and NSTEMI-Non-OMI (NSTEMI-NOMI).

Methods
Demographics, clinical and procedural data were pooled for all patients with an index ACS event between January 2011 and May 2021. Patients were classified according to the presence of OMI determined by angiography and troponin. All-cause mortality was compared by Kaplan Meier analysis at 1-year and landmark analysis up to 5 years after the ACS event.

Results
A total of 9,943 patients [64.1 ± 14.2 years, 62.2% males] were included and classified into STEMI (n=507), NSTEMI-OMI (n=685), NSTEMI-NOMI (n=1,535) and MI ruled-out (n=7,216). Median time to coronary angiography (CAG) was 1.4 hours for STEMI compared to 16.3 and 45.8 hours for NSTEMI-OMI and NSTEMI-NOMI, respectively (p&lt;0.001) [Figure 1]. At one year, all-cause mortality occurred in 9.9% of STEMI patients vs. 18.1% of NSTEMI-OMI patients (hazard ratio, 1.84; 95% CI, 1.32 to 2.55; p&lt;0.001) and 7.9% of NSTEMI-NOMI patients (hazard ratio, 0.79; 95% CI, 0.56 to 1.09; p=0.150) [Figure 2]. An unfavorable mortality outcome for NSTEMI-OMI compared to STEMI was maintained in the age and gender-adjusted analyses and landmark analysis beyond 1-year (hazard ratio, 2.59; 95% CI, 1.75 to 3.82; p&lt;0.001).

Conclusions
Despite similar baseline demographics and angiographic findings, patients with NSTEMI-OMI have increased delays to reperfusion and unfavorable short and long-term all-cause mortality compared to STEMI. These findings support the need for more accurate and timely identification of NSTEMI-OMI.Time to Coronary Angiography (CAG)All-cause 1-year Mortality
Machine learning versus guideline recommended pathways for the diagnosis of myocardial infarction
Authors: Boeddinghaus J , Duodesis D , Lopez-Ayala P , Lee K K , Koechlin L , Nestelberger T , Rubini Gimenez M , Wildi K , Mills N L , Mueller C 
Published: November 2023

Abstract

Background
CoDE-ACS (Collaboration for the Diagnosis and Evaluation of Acute Coronary Syndrome) is a validated clinical decision-support tool that uses machine learning to calculate the probability of myocardial infarction (MI) for an individual patient. Current European guidelines recommend the use of 0/1h- and 0/2h-algorithms optimised to rule-out or rule-in MI and the High-STEACS pathway, which enables rapid discharge or admission in patients with suspected MI. However, it is unknown how CoDE-ACS performs against these guideline recommended pathways.

Methods
We enrolled adult patients presenting with suspected acute coronary syndromes at 12 sites in 5 European countries. Patients with ST-elevation MI and those with missing high-sensitivity (hs)-cTnI concentrations at 0h, 1h or 2h were excluded. Final diagnoses were adjudicated by two independent cardiologists according to current guidelines and the 4th universal definition of MI using all information including serial hs-cTnI measurements and imaging. We compare the diagnostic performance and effectiveness of CoDE-ACS with the 0/1h- and 0/2h-algorithms and the High-STEACS pathway.

Results
In 4,105 patients (median age 61 [IQR 50-74], 32% women), the prevalence of type 1 MI was 14%. At presentation, CoDE-ACS identified 56% (2,280/4,105) of patients as low-probability, with a 99.7% (99.5-99.9%) negative predictive value (NPV) and 99.0% (98.6-99.2%) sensitivity, which ruled out twice as many patients as other pathways. CoDE-ACS incorporating 1h hs-cTnI measurements identified 65% (2,671/4,105) patients as low-probability with a 99.7% (99.5-99.8%) NPV and 98.6% (98.2-98.9%) sensitivity and 19% (770/4,105) patients as high-probability with a 64.9% (63.5-66.4%) PPV and 92.4% (91.5-93.1%) specificity, with 16% classified as intermediate probability. In comparison, the 0/1h-algorithm identified 49% (2,014/4,105) patients as low-risk with a 100% (99.9-100%) NPV and 100% (99.9-100%) sensitivity and 20% (829/4,105) patients as high-risk with a 61.5% (60.0-63.0%) PPV and 91.0% (90.0-91.8%) specificity, with 31% triaged to the observe zone. Findings for CoDE-ACS incorporating hs-cTnI measurements at 2h, the 0/2h-algorithm and the High-STEACS pathway were comparable (Table).

Conclusion
All guideline recommended clinical pathways provide excellent performance for the diagnosis of MI. CoDE-ACS provides comparable diagnostic performance, but identifies twice as many patients as low-probability at presentation and fewer patients require further observation following serial hs-cTnI measurements. Implementation studies are warranted to determine whether CoDE-ACS can further improve the early diagnosis of MI.
Temporal trends in intra-aortic balloon pump use
Authors: Cohen B , Kalmanovich E K , Perl L P , Greenberg G G , Samara A S , Beigel R B , Ovdat T O , Kornowski R K , Orvin K O 
Published: November 2023

Abstract

Background
Intra-aortic balloon pump (IABP) is still the most accessible and available mechanical support solution in acute myocardial infarction patients, especially in cardiogenic shock. Although studies from the last decade failed to prove benefit for routine IABP use in this indication, the benefit of IABP utilization in selected cases is still unknown.

Purpose
To follow temporal trends in IABP use in a large-scale, real-world cohort of ACS patients.

Methods
We evaluated IABP utilization and patient’s outcome form the ACS Israel Survey (ACSIS) between 2000-2021. Temporal trends and compared rates of mortality and MACE (comprising death, myocardial infarction, stroke, target vessel revascularization and/or coronary bypass surgery) with IABP at 2 time periods were set: early (2000-2010) and late (2013-2021). Subgroup analysis for cardiogenic shock patients was performed as well.

Results
Out of 18,662 admitted ACS patients, 692 (3.7%) patients were treated with IABP. The rate of IABP use stood at about 4.5% (511 patients) in the early period and decreased to ∼2.5% (181 patients) in the late period. Patients treated with IABP in the early period had more frequently moderately and severely reduced ejection fraction on admission (64.5% vs 53.2%, p&lt;0.01) and were mostly STEMI patients (71.0% vs 62.4%, p=0.04). On admission and in hospital cardiogenic shock (Killip 4) were presented equally in both periods (14.6% vs. 17.1%, p= 0.66 and 42.8% vs. 41.9%, p=0.90, respectively). 30-day mortality and MACE were comparable between time periods (28% vs 30.7%, p=0.547 and 43.6%vs. 44.1%, p=0.978, respectively) however major bleeding complication was significantly higher in the later period (4.8% vs 11.2%, p=0.04). These observations were consistent also in patients with baseline Killip class 3/4.

Conclusions
Our real-world data based prospective study demonstrated poor prognosis with IABP during all time periods, suggesting poor outcome in routine as well as selective use.
Association of myocardial infarction with nonobstructive coronary arteries with long-term outcomes
Authors: Miller A , Tao M , Price J , Dhaliwal S , Masson R , Henriques M D , Kim P M , Rahman T , Bench T J , Pyo R 
Published: November 2023

Abstract

Background
Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA) is a disease classification that is not uncommonly encountered yet poorly characterized. The association of MINOCA with long-term cardiovascular (CV) outcomes has been inconsistently assessed with studies reporting conflicting results. The purpose of this meta-analysis is to evaluate the association of MINOCA with long-term cardiovascular outcomes.

Methods
A literature search was conducted for studies reporting on the association of MINOCA with clinical endpoints as compared to obstructive coronary artery disease (OCAD). The primary end-point was all-cause mortality. Secondary endpoints included CV mortality, need for revascularization, recurrence of acute coronary syndrome (ACS), CV rehospitalization, persistent angina after discharge, and major adverse cardiac events (MACE). Databases searched included Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar. The search was not restricted to time or publication status.

Results
A total of 29 studies with 893134 patients with acute myocardial infarction (AMI) (48425 with MINOCA, 844709 with OCAD) met inclusion criteria. Mean follow-up was 39 months, mean age was 62, 66% were male. MINOCA was associated with significantly lower risk of all-cause mortality compared to OCAD (OR 0.69, 95% CI 0.60-0.78; p&lt;0.01). The overall effect size was large (z=5.72). MINOCA was associated with significantly lower risk of CV mortality, need for revascularization, recurrent ACS, and persistent angina after discharge (OR 0.49, 95% CI 0.36-0.67; p&lt;0.01; OR 0.09, 95% CI 0.03-0.31; p&lt;0.01; OR 0.57, 95% CI 0.37-0.89; p=0.01; OR 0.23, 95% CI 0.11-0.51; p&lt;0.01). MINOCA was not associated with a significant difference in risk of CV rehospitalization (OR 0.74, 95% 0.46-1.19; p=0.21).

Conclusions
In patients with AMI, MINOCA is associated with lower risk of all-cause mortality, CV mortality, need for revascularization, recurrent ACS, and persistent angina on long-term follow-up compared to OCAD. However, MINOCA is associated with similar risk of rehospitalization for CV events. Further studies are needed to determine the association between different medical therapies and clinical outcomes in patients with MINOCA.
Coronary microvascular dysfunction in takotsubo syndrome: an analysis using angiography-derived index of microcirculatory resistance
Authors: Schweiger V , Gilhofer T , Fang R , Wuerdinger M , Candreva A , Di Vece D , Koleva I , Rajman K , Ghadri J R , Cammann V L , Templin C 
Published: November 2023

Abstract

Background
Coronary microvascular dysfunction (CMD) has been proposed to be a major contributing factor in the pathophysiology of Takotsubo syndrome (TTS). To asses CMD, the angiography-derived index of microcirculatory resistance (caIMR) has been developed as a wire-free alternative to the conventional hyperemic wire-based index (IMR). This study aimed at evaluating the extent and transience of CMD and its implications on in-hospital outcome in TTS using caIMR.

Methods
Microcirculatory function of the three main coronary arteries of 96 TTS patients (48 with apical- and 48 with midventricular type) was assessed using caIMR. Measurements were compared with those of non-culprit vessels of 96 matched patients with ST-elevation myocardial infarction, as non-culprit vessels have previously been demonstrated to have an intact microcirculatory function [1]. In ten patients, follow-up caIMR was determined from angiographies without any cardiac event and was compared with event-caIMR. The prognostic role of caIMR on the in-hospital combined endpoint of death, cardiac arrest, ventricular arrhythmia, and vasopressor dependency was assessed via a binomial logistic regression analysis.

Results
CMD was present in all patients with TTS in at least one coronary vessel (caIMR&gt;25), most frequently observed in the LCX (86 of 88 measurable LCXs [98%]). CaIMR in all three coronary arteries was significantly higher compared to the respective vessels of the control group. No significant difference in caIMR was observed comparing the apical and midventricular type of TTS. We could demonstrate normalization of caIMR in patients with follow-up angiographies performed at a median of 22 months (median [IQR] caIMR during event vs. follow-up: LCX 39.5 [33.9-52.0] vs. 25.1 [20.5-31.3]; LAD 34.2 [29.4-38.3] vs. 17.2 [15.9-23.9]; RCA: 31.7 [25.0-39.1] vs. 19.6 [17.1-24.0], Figure 1). The in-hospital combined endpoint correlated with the extent of CMD (p=0.036, Figure 2).

Conclusion
CMD was present during the acute TTS event and normalized during follow-up, suggesting that CMD is only a phenomenon of the acute phase of TTS and IMR values recover to normal dimensions. In addition, LAD caIMR was associated with the in-hospital end point of death, cardiac arrest, ventricular arrhythmia, and vasopressor dependence, however prospective validation will be necessary to further substantiate these findings.
Veno-arterial extracorporeal membrane oxygenation for cardiogenic shock: one-year outcomes from a cardiac intensive care unit led shock team program
Authors: Bello A , Presume J , Gomes D , Albuquerque F , Lopes P , Brizido C , Strong C , Ferreira J , Tralhao A , Neves J P , Brandao H 
Published: November 2023

Abstract

Background
Mechanical circulatory support (MCS) with peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used for severe cardiogenic shock (CS).

Purpose
To describe the initial experience with peripheral VA-ECMO within a cardiac intensivist team led program.

Methods
Retrospective analysis of a short-term MCS prospective registry, from 1 September 2021 to 1 December 2022. Clinical and device related variables were reviewed and reported. We assessed both patient outcomes as well as ECMO-related complications.

Results
A total of 21 patients were included in this analysis (50 ± 13 years-old, 80% male), ranging from SCAI-C (n = 8) to E (n = 5) and with a median predicted mortality by SAVE score of -4 points [IQ -6 - 0] (corresponding to 30% in-hospital survival). All cannulations were done percutaneously, mostly by trained cardiac intensivists and while at the CICU (n = 12). A femoro-femoral configuration was used for all patients. One patient was cannulated at the referring hospital and retrieved to our unit for further care. Three patients were cannulated during intra-hospital cardiac arrest and one patient was cannulated while breathing spontaneously (awake-ECMO). Mean venous and arterial cannula sizes were 22 ± 1.9 Fr and 17 ± 1.6 Fr, respectively. A 7 French (Fr) arterial limb reperfusion cannula was used in 85% of cases. The most frequent etiology was acute decompensation of chronic heart failure (n = 7), followed by acute myocardial infarction related CS (n = 5), fulminant myocarditis (n = 2) and massive pulmonary thromboembolism (n = 2). A left ventricle venting device was used in 70% of patients [intra-aortic balloon pump (n = 10); percutaneous microaxial pump ( n = 2)] and upgrade to a veno-arterio-venous configuration was necessary in one patient due to differential hypoxemia. Mean ECMO-run duration was 8.4 ± 4.8 days while mean CICU length of stay was 22 ± 17.9 In-hospital mortality was 40%. In survivors, decannulation was surgical in all but one patient. The most frequent strategy was bridge to recovery (n = 14). One patient was bridged directly to heart transplant, one to a temporary centrifugal left ventricular assist device (LVAD) and one to a durable magnetically levitated LVAD. Complications were common and included bleeding from cannula insertion sites (n = 19), renal replacement therapy requirement (n= 10), Harlequin syndrome (n = 2), cardiac tamponade (n = 2), intestinal ischemia (n = 3) and limb ischemia (n = 2).

Conclusion
VA-ECMO performed by cardiac intensivists is a feasible MCS strategy for severe cardiogenic shock patients in whom mortality, while high, was similar to large international published series. Further experience will allow for improvement in patient selection and minimization of device related complications.ECMO VA 1 year single-center experience
Validation of SAVE score and the value of serum lactate in patients admitted for cardiogenic shock treated with VA-ECMO
Authors: Presume J , Gomes D A , Albuquerque F , Lopes P , Bello A R , Brizido C , Strong C , Ferreira J , Mendes M , Neves J P , Tralhao A 
Published: November 2023

Abstract

Introduction
Veno-Arterial extracorporeal membrane oxygenation (VA-ECMO) is a treatment option to provide circulatory and pulmonary support to patients with cardiogenic shock. However, a risk profile assessment is essential for an adequate selection of patients for this type of therapy.
The aim of this study was to 1) validate the SAVE score in a Portuguese cohort of patients treated with VA-ECMO due to cardiogenic shock; 2) evaluate the prognostic impact of the maximum serum lactate level pre-VA-ECMO implantation; 3) assess the ability of lactate to improve risk stratification by the SAVE score.

Methods
We conducted a single-center retrospective analysis of patients treated with VA-ECMO due to cardiogenic shock from 2017 until 2022. Variable assessments were considered before VA-ECMO implantation. The primary outcome analyzed was in-hospital mortality.

Results
A total of 61 patients were included (52±12 years, 74% male, 40% with acute myocardial infarction, 54% with an ejection fraction &lt;20%, and 74% in SCAI stage D pre-implantation). Overall, 38 (62%) died during hospitalization. The mean SAVE score was -1.7±7.2 points, and the median maximum serum lactate before ECMO implantation was 5.8 [2.7; 11.8] mmol/L.
SAVE score showed a statistically significant association (1±5 vs. -4±7; OR 0.872 [0.789; 0.964] per each point increase; p=0.008) and good discriminative power (AUC 0.710; p=0.006) to predict in-hospital mortality. When grouping patients according to this score, 25 (41%) were classified as SAVE risk class I or II, and 36 (59%) as SAVE class III, IV, or V.
Maximum serum lactate before VA-ECMO implantation also showed a significant association (4.5±3.1 vs. 9.6±6.6; OR 1.264 [1.066;1.498] per each 1mmol/l increase; p=0.007) and good discriminative power (AUC 0.771; p=0.001) to predict the primary outcome. The best lactate cut-off to identify high mortality risk was 5 mmol/l with a sensitivity of 74% and a specificity of 76%. Additionally, taking into account this threshold, lactate significantly enhanced the SAVE score group stratification, with a net reclassification improvement of 36.7% (p=0.021).

Conclusion
In this cohort of patients, the SAVE score was significantly associated with in-hospital mortality. Maximum serum lactate before VA-ECMO implantation was a strong predictor of in-hospital mortality and significantly improved SAVE score risk stratification.