bluuebunny/crossref_metadata_2025_split huggingface dataset:
P207 KOUNIS SYNDROME TYPE 2: A COLD CASE
Authors: Zerillo L , Oppo I , Aveta P , Rotunno R 
Published: May 2022

Abstract

Case Report
A 61–year–old man, smoker and family history of cardiovascular diseases, started oral antibiotic therapy with amoxicillin / clavulanic acid following the appearance of a dental abscess. About 30 minutes after taking the antibiotic, he complained of widespread erythema in the limbs, followed by intense itching and dyspnea. Upon arrival of the medical staff, IV cortisone and antihistamine therapy was performed with gradual and progressive resolution of the symptoms. Despite the doctors’ invitation, the patient refused access to the emergency room for fear of a possible hospital infection with SARS–CoV–2. Almost two months later, due to the onset of exertional dyspnea, he is persuaded to go to the hospital for further tests. The ECG showed signs of diffuse anterolateral necrosis (Figure 1). Echocardiography showed severe left ventricular dysfunction (FE 35%) with extensive akinesia of the mid–distal SIV, apex, and anterior mid–distal wall. Myocardiocytolysis indices were negative and allergy tests positive for beta–lactam antibiotics. Subsequently he underwent coronary angiography which showed proximal occlusion of an intermediate branch (Figure 2) treated with angioplasty and drug stent release. Cardiac MRI was then performed with evidence of a large area of ischemic necrosis (subendocardial / transmural) of the antero–septal, anterior and anterolateral wall with FE 35% (Figure 3).

Comment
Kounis syndrome is a clinical emergency characterized by the appearance of an acute coronary syndrome during an anaphylactic–type reaction. A correct diagnosis is of fundamental importance to limit the extent of myocardial damage as much as possible. In Kounis type 2, the mediators of the allergic reaction can cause not only vasospasm but also the activation of metalloproteases that induce the degradation of collagen with consequent rupture of pre–existing atheromatous plaques, as in our patient. Failure to perform an ECG during first aid leaves doubts about the possible allergic genesis of the episode, which however cannot be excluded with certainty. We have decided to report this clinical case to emphasize the importance of always taking into consideration the possibility of being compared with a case of Kounis when assisting a patient with an anaphylactic type reaction.
P211 LONG–TERM OUTCOME OF PATIENTS WITH STEMI AND CARDIOGENIC SHOCK TREATED BY PPCI
Authors: Frattini S , Maccagni G , Danzi G 
Published: May 2022

Abstract

Background
There is little data on the long–term outcome of patients with cardiogenic shock (CS) treated with primary angioplasty (PPCI) in the setting of acute ST–segment elevation myocardial infarction (STEMI). The aim of this study was to assess long–term mortality among hospital STEMI survivors who received a PPCI procedure, based on the presence of acute–phase CS.

Methods
We analyzed long–term follow–up data in a series of consecutive patients admitted to our institution for STEMI from 2009 to 2019 who were treated with PPCI.

Results
Of the 1288 patients who presented with STEMI, 1137 received a PPCI procedure. CS occurred in 111 (9.8%) of these patients. The in–hospital mortality rate was 5.6%; 2.9% in patients without and 30.6% in those with shock (P &lt; 0.001)). The 1073 patients who survived the acute phase were followed up for 9 + 5 years. Survivors with CS had a more severe clinical profile and more frequent concomitant hospital complications. Long–term survival was 75.6% in patients with shock versus 84.0% in those without shock (P &lt; 0.05). Patients with complete revascularization at the index procedure had similar survival compared to other patients with CS (survival rate 75% vs 75.4%; P = ns).

Conclusions
CS carries an increased risk of death during the hospital phase and at long–term follow–up: complete revascularization at the index procedure does not appear to offer any additional benefit on outcome
P214 PROGNOSTIC IMPACT OF RESIDUAL INFLAMMATORY RISK AFTER ACUTE CORONARY SYNDROME
Authors: Toso A , Leoncini M , Villani S , Tropeano F , Maioli M , Bellandi F 
Published: May 2022

Abstract

Background
Recent randomized clinical trials have shown that an anti–inflammatory treatment may reduce the recurrence of cardiovascular events in association with traditional secondary prevention measures. Aim: The aim of this observational retrospective study based on patients with acute coronary syndrome (ACS), treated with high intensity statins and undergoing an early invasive strategy, was to evaluate the incidence of residual inflammatory risk after 1 month, its possible determinants and its association with the medium–long term prognosis.

Methods
We selected patients with ACS without ST segment elevation (ACS–NSTEMI) admitted to our hospital from June 2015 to June 2018 who had a complete biochemical examination at 1 month after the acute event. All these patients were included in the PRATO–ACS Registry (ClinicalTrials.gov ID: NCT04087200). All–cause mortality was analyzed within 3 years. Residual inflammatory risk (RIR) was defined as 1–month high sensitivity C reactive protein (hs–CRP) value &gt; 2 mg/l. The association between 1–month hs–CRP and 3–year all–cause mortality was expressed by hazard ratio (HR) and 95% confidence interval (CI).

Results
The study group consisted of 739 patients (mean age 68 ± 12 years, male 68.3%, mean hospital stay 5 ± 2 days) all treated with high intensity statins (rosuvastatin 20–40 mg or atorvastatin 40–80 mg) immediately upon admission and scheduled for early invasive strategy (74.5% underwent PCI). At baseline 525 patients (71%) had hs–CRP values ≥ 2 mg/l and 568 (77%) LDL cholesterol levels &gt; 100 mg/dl. The incidence of RIR was 58.7%, with no significant differences between patients with LDL &lt;or&gt; 70 mg/dl. Lipid profile (LDL &gt; 100 mg/dl, HDL &lt; 40mg/dl in man and &lt; 50mg/dl in woman), hs–CRP &gt; 2 mg/l, the left ventricular ejection fraction &lt; 40% and glomerular filtration rate &lt;60 ml/min/m2 were independently associated with RIR. Multivariate analysis showed that RIR was an independent predictor of 3–year all–cause mortality (HR = 2.15 (95% CI 1.06–4.33; p = 0.03)) while LDL cholesterol &gt; 70 mg/dl did not (HR = 0.98 95% (CI 0.50–1.91; p = 0.9)).

Conclusions
In a population of ACS patients treated with high intensity statins and an early invasive therapeutic strategy, the incidence of RIR (hs–CRP ≥ 2 mg/l) at 1 month after ACS is high (58.7%). The RIR is associated with a higher baseline clinical risk profile and was an independent predictor of 3 year all–cause mortality regardless of achieved LDL values.
P215 PROGNOSTIC IMPACT OF EARLY VERSUS DEFERRED CORONARY ANGIOGRAPHY IN MINOCA PATIENTS
Authors: Armillotta M , Sansonetti A , Amicone S , Stefanizzi A , Fabrizio M , Angeli F , Bergamaschi L , Paolisso P , Impellizzeri A , Foà A , Rinaldi A , Casella G , Galiè N , Pizzi C 
Published: May 2022

Abstract

Background
Although an early invasive strategy (coronary angiography performed &lt; 24 hours) is associated with a lower risk of recurrent/refractory ischaemia among patients with acute myocardial infarction (AMI) and obstructive coronary arteries, the optimal timing of invasive examination in patients with non–obstructive coronary arteries and non–ST–segment elevation presentation (NSTE–MINOCA) has not been explored.

Purpose
This study tested the hypothesis that, compared to early (&lt; 24 h) invasive strategy, deferred (≥ 24 h) coronary angiography has an equivalent prognostic impact in patients with NSTE–MINOCA.

Methods
From 2016 to 2020, all consecutive MINOCA patients diagnosed according to the current ESC diagnostic criteria (angiographic conventional cut–off of &lt; 50% coronary stenosis without a clinically apparent alternative diagnosis) and admitted to our Centre with non–ST–segment elevation myocardial infarction (NSTEMI) presentation were enrolled. Very high–risk NSTEMI patients had been excluded from the study. The prognostic value of an early (&lt; 24 h) vs. deferred (≥ 24 h) coronary angiography was assessed. All–cause mortality and a composite endpoint (MACE) of all–cause mortality, stroke, re–hospitalization for heart failure and myocardial re–infarction were evaluated.

Results
198 NSTE–MINOCA patients were enrolled, of which 79 underwent coronary angiography &lt; 24 hours and 119 ≥ 24 hours. MINOCA patients were more frequently females (64%) and the mean age was 66.8±13.2 years. After a median follow–up of 26 [14–40] months, the overall all–cause mortality was 13,6% and the composite endpoint (MACE) was achieved in 27.3% of the entire population. Kaplan–Meier curves showed that there was no statistically significant difference (p = 0.88) between the two study groups depending on the time of invasive strategy adopted. Specifically, rates of death (11.4% vs. 15.1%) and MACE (25.3% vs. 28.6%) were similar in MINOCA patients undergoing early versus deferred coronary angiography.

Conclusions
We demonstrated for the first time that in the MINOCA population the prognosis is not influenced by an early versus deferred coronary angiography, as opposed to AMI patients with obstructive coronary arteries. These results add another piece to the puzzle and pave the way for the initial use of a non–invasive imaging strategy (eg. Coronary–CT), mostly in patients with NSTEMI and high clinical suspicion of non–obstructive coronary arteries.
P218 POTENTIAL ROLE OF NITROGLYCERIN FOR DIURETIC RESISTANCE IN ACUTE DECOMPENSATED HEART FAILURE: A PROOF OF CONCEPT STUDY
Authors: Scollo A , Frea S , Bocchino P , Angelini F , De Ferrari G 
Published: May 2022

Abstract

Background
Congestion is a major determinant of end–organ dysfunction and diuretic resistance in acute decompensated heart failure (ADHF). Vasodilator therapy with nitroglycerin may help treat misdistribution of blood volume, reduce intra–abdominal pressure and improve end–organ function by recruiting capacitance veins. We assessed the role of intravenous nitroglycerin on top of maximal medical therapy to overcome diuretic resistance in ADHF patients.

Methods
This is a monocentric prospective study including patients with ADHF, systolic dysfunction (left ventricular ejection fraction [LVEF]&lt;35%), persistent moderate–to–severe congestion and oliguria (&lt;0.5 ml/Kg/h) despite high dose intravenous furosemide (&gt;250 mg/die) plus a second diuretic (metolazone and/or acetazolamide). Exclusion criteria were systolic blood pressure &lt; 90mmHg and eGFR &lt; 20 ml/min/1.73m2. Intravenous nitroglycerin was added and uptitrated to the maximum tolerated dose while keeping the other treatments unchanged for at least 24 hours. The primary endpoint was change in urine output at 24 hours (T1) and 72 hours (T3) after nitroglycerin initiation compared to baseline (T0). Secondary endpoints were changes in central venous pressure (CVP), creatinine and total bilirubin.

Results
We enrolled 17 consecutive patients between March 2020 and October 2021. Mean age was 63±14 years, mean LVEF 31±15%, mean tricuspid annular plane systolic excursion 14.5±4 mm and mean eGFR 41.7±27.3 ml/min/1.73m2. 13 (76%) patients showed a cold profile; among them, 9 (69%) were on dobutamine, 5 (38%) on adrenaline and 3 (23%) on dopamine. At study enrolment all patients were receiving high dose intravenous furosemide (535±395mg/die), 8 (47%) sodium nitroprusside (0.3±0.5y/Kg/min), 9 (53%) metolazone (5mg/die) and 8 (47%) acetazolamide (250 mg/die). Urine output was significantly higher both at T1 and T3 compared to T0 (192±140ml/h vs 50±34ml/h, p &lt; 0.001, and 153±87ml/h vs 50±34ml/h, p &lt; 0.001, respectively; p for overall comparison&lt;0.001). Also, a significant reduction of CVP was found at T1 and T3 compared to T0 (14±6mmHg vs 19±3mmHg, p = 0.025, and 12±5mmHg vs 19±3mmHg, p = 0.022, respectively; p for overall comparison=0.039). No significant changes of creatinine and total bilirubin were reported.

Conclusions
In this cohort of ADHF patients with diuretic resistance, adding nitroglycerin on top of maximal treatment yielded a potential benefit by significantly increasing hourly urine output whilst reducing CVP.
P236 LONG TERM FOLLOW UP WITH A DRASTIC REDUCTION OF HOSPITALIZATION IN HEART FAILURE PATIENT WITH MULTIPLE AETIOLOGIES TREATED WITH CARDIAC CONTRACTILITY MODULATION THERAPY: A CASE REPORT
Authors: Mattera A , Brignoli M , Coscia V , Fusco A , Diana V , Chianese R , De Michele A , Concilio C , Pariggiano I , Viscusi M , Calabrò P 
Published: May 2022

Abstract

Aims
Cardiac contractility modulation (CCM) shows to be a concrete therapeutic option in patients with symptomatic HF despite optimal medical therapy (OMT), with Left Ventricular Ejection Fraction (LVEF) between 25% and 45%, with narrow QRS complex (&lt;130ms) for reduction of hospitalization and improvement Quality of life (QoL). This case aims to explore the effectiveness of CCM therapy in a patient affected by concomitant ischemic cardiomyopathy and cardiac amyloidosis (CA)

Methods
A 42–year–old man with Chronic HF secondary to both post–ischemic due to spontaneous coronary artery dissection (SCAD) and post alcoholic dilated cardiomyopathy was hospitalized at our department in February 2020 due to worsening HF (3rd HF hospitalization in the same year). The patient was a NYHA class III, with chronic kidney failure, a narrow QRS complex (100 ms) and a LVEF of 27% with familiar history of sudden death, already implanted with ICD. The patient resulted untreatable with Sacubitril/Valsartan, as it elicited strong hypotension. During current hospitalization the BNP value was 942,60 pg/ml, and the Quality of Life (QoL) evaluated from Minnesota Living with Heart Failure Questionnaire (MLHFQ) score was 72 points. Moreover, the patient underwent umbilical biopsy that confirmed the presence of amyloidosis. Thus, the CCM therapy device (Optimizer® Smart, Impulse Dynamics) was implanted to try to reduce HF symptoms and hospitalizations (Fig 1 A/B).

Results
The patient significantly improved as early as the first period after implantation. The 10–month in–office FU performed on December 2020 revealed in addition to the absence of new HF hospitalizations, a significant improvement in QoL and HF–symptoms, with a MLWHFQ score of 42, an enhancement to NHYA class II and even a slight decrease of BNP of 767 pg/ml. The echo exam revealed no significant changes in the EF, with an improvement of global longitudinal strain and no worsening of other hemodynamic parameters. A further FU performed in June 2021 showed continuous improvement of QoL (MLWHFQ = 25) e no HF hospitalizations.

Conclusions
In this patient affected by multiple cardiomyopathies, including CA, CCM therapy proved to improve its QoL with no HF hospital admissions since the implantation. The absence of significant echocardiographic worsening is a positive aspect, considering the patient’s status, the concomitant aetiologies, and the presence of amyloidosis, given its progressive and infiltrative nature.
P242 ADVANCED HEART FAILURE: ENHANCEMENT OF INTEGRATED MANAGEMENT IN THE METROPOLITAN AREA OF FORLÌ
Authors: Delvecchio A , Galvani M , Monti E , Nanni D , Lombardi E , Brighi C , Guidi I , Greppi R , Gardini E 
Published: May 2022

Abstract

The aim of this study is to assess the effectiveness of a multi–professional home care (HC) model – cardiologist, general practitioner, cardiology nurse – which has been active in the metropolitan area of Forlì since 1999. In May 2021, 14 patients were enrolled (mean age=75.43). Inclusion criteria: heart failure (HF) in NYHA class III–IV, recurrent hospitalizations for HF and difficulties to reach the clinic. 4 out of 14 patients had been followed by the cardiologic HC program since 2016, 3 patients since 2018, 1 patient since 2019, 1 patient since 2020, 5 patients since 2021.

Outcome Measures
Rate of hospital admissions for HF 6 and 12 months before and after admission in HC pathway, quality of life (Minnesota Test), functional residual capacity (Palliative Performance Scale, PPS), compliance to the therapeutic program (Morisky Test). Questionnaires were administered when patients were included in HC and repeated at the time of enrollment and after 6 months. 3 patients were excluded from the analysis after enrollment because they died (n = 2) or were admitted in nursing homes (n = 1). It was observed that hospitalizations due to HF decreased from 1.64 during the 6 months preceding the admission in HC to 0.36 in the following 6 months (–78.05%, p = .002); furthermore, patients included in HC for more than 12 months (n = 9) decreased their hospitalizations from 1.78 in the year before their inclusion in the HC pathway to 0.33 in the year after (81.46%, p = .012). Since the cost of an average hospitalization for HF has been evaluated to be € 3,265.90 (DRG 127 Emilia–Romagna Region 2020), it was estimated a reduction in costs per patient of € 4,180.36 in 6 months and € 4,735.55 in 12 months. During the follow–up period, patients experienced a clinically significant improvement in psychophysical and social well–being and in the performance of daily activities. The mean Minnesota Test score improved (p = .001) from 62.86 (at the admission in HC) to 44.21 (at the enrollment) and 40.09 (at 6 months); the PPS score increased (p = .0021) from 56.43% (at the admission in HC) to 61.43% (at the enrollment) and 67.27% (at 6 months). Good therapeutic adherence was maintained, with a Morisky Test score ≥ 10.
In conclusion, these preliminary results are consistent with recent ESC guidelines for the multi–professional care of patients with chronic HF and show the efficacy of this approach in order to prevent hospital admissions and to improve quality of life.
P246 URINARY SODIUM–GUIDED I.V. DIURETIC THERAPY IN ACUTE HEART FAILURE: APPLICATION OF THE YALE DIURETIC PROTOCOL IN A REAL–WORLD ITALIAN SETTING
Authors: Pellegrino M , Gasparini G , Ghianda D , Villaschi A , Oliva A , Loiacono F , Pagliaro B , Natali Testona N , Atuncar M , Pini D 
Published: May 2022

Abstract

Background
Loop diuretics are the cornerstone of acutely decompensated heart failure (ADHF) treatment, but evidences on doses and administration modalities are still lacking. Veena S. et al have recently validated the Natriuretic Response Prediction Equation and applied it with the Yale Diuretic Protocol (YDP) in a clinical implementation cohort demonstrating its safety.

Objectives
Our purpose is to test the applicability and safety of YDP for titration of diuretic therapy in a real–world in–hospital setting, as compared to standard diuretic therapy. METHODS From 15th September 2021 patients hospitalized with ADHF, almost one sign of congestion and need of i.v. diuretics were enrolled. Patients with active bleeding, hematocrit &lt; 21%, or on dialysis were excluded. Patients were treated with i.v. diuretic therapy guided by urinary sodium (YDP–group) or by weight changes and urinary output (control group) based on logistic in–hospital reasons.

Results
Thirty patients were included. Median age was 76.4 [IQR 68.3; 82.7] years old; median EF and glomerular filtration rate were 40% [IQR 30; 55] and 57.2 ml/min/m2 [IQR 44.9; 79.9], respectively. Nineteen (63.3%) patients were on chronic loop diuretic treatment. Ten (33.3%) patients were treated according to YDP. Main results are shown in the Table attached. YDP patients were younger (p = 0.02) and received shorter treatment with i.v. diuretics (YDP 36 [IQR 27; 48] hours, controls 48 [IQRS 38; 88] hours; p = 0.03). No differences in terms of total diuresis, weight loss at the end of i.v. diuretic therapy and length of hospitalization were shown. YDP patients experienced significant lower increase in creatinine during i.v. diuretic therapy (p = 0.02). The incidence of adverse events was comparable between groups, with equal hypotension rate (10%), and similar plasma levels of electrolytes at the end of i.v. diuretic therapy; YDP patients required less potassium supplementation. Reasons for i.v. diuretic therapy suspension were comparable between groups; 7 (70%) YDP patients concluded i.v. diuretic therapy for satisfactory decongestion, while only one patient because of hypotension and none because of worsening of renal function.

Conclusion
In our reality the YDP appeared to be applicable, safe and comparable to the standard i.v. diuretic therapy in terms of in–hospital outcomes. These preliminary results need to be confirmed in a larger cohort and longer term outcomes still need to be explored.
P267 EFFECTIVENESS OF SHOCK INDICES AND ALTERATION OF VITAL PARAMETERS IN THE DIAGNOSTIC SUSPICION OF ORGAN DAMAGE FROM PULMONARY EMBOLISM IN ELDERLY: THE EMERGENCY ROOM AS A WINDOW ON REAL LIFE
Authors: Savioli G , Ceresa I , Mugellini A , Martignoni A , Maggioni P , Fumoso F , Lapia F , Muzzi A , Novelli V , Preda L , Lava M , Manzoni F , Brattoli M , Bressan M 
Published: May 2022

Abstract

Aim
Assess which vital parameters and shock indices correlate with the presence of organ damage from pulmonary embolism to see which ones can help to suspect this condition early.

Methods
Single–center retrospective observational study, on all geriatric patients (&gt; 75 y) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We collected data from medical history, physical examination, laboratory tests, imaging; we calculated the characteristic scores from the diagnostic/therapeutic algorithm, both for the risk of PE (Wells, Geneva and Years), and for the presentation of the risk of mortality at 30 days (sPESI). We then had all chest CTs retested by an experienced radiologist. We went to see the correlation of vital parameters and shock indexes from these derivatives with the presence of organ damage from pulmonary embolism. We considered right ventricular dilation, pulmonary artery dilation and the presence of pulmonary infarction organ damage. We have considered as shock indices: the shock index (SI), the modified shock index (MSI) and the age–shock index (AGE_SI).

Results
We enrolled 247 patients, with a mean age of 83 years and prevalence of female (F = 63%). Of these 79 (32%) have organ damage from pulmonary embolism. There is no correlation between the values of blood pressure, systolic and diastolic, respiratory rate with the presence of organ damage (p &gt; 0.05). However, there is a strong statistical correlation between heart rate values and the presence of organ damage from pulmonary embolism (p &lt; 0.001) The shock index correlates with the presence of organ damage with good statistical strength (p &lt; 0.001 ); also the modified shock index, albeit with a slightly lower statistical strength (P &lt; 0.005). The age–shock index correlates with the presence of pulmonary embolism with excellent statistical strength (p &lt; 0.001).

Conclusions
The alteration of the shock indices, in particular the AGE–shock index, correlate with the condition of organ damage. Taking into consideration these parameters, of very low cost, available from triage and obtainable in a few minutes at the medical examination, which can be easily performed in the various Italian situations, can help to raise the suspicion of organ damage from pulmonary embolism early and address more quickly the patient towards the therapeutic diagnostic process.