bluuebunny/crossref_metadata_2025_split huggingface dataset:
Prognosis impact of ticagrelor vs clopidogrel based DAPT discontinuation after acute coronary syndrome. Insights from the multicenter CREA ARIAM Andalucia registry
Authors: Hernandez Meneses BG , Padilla-Rodriguez G , Carmona-Carmona J , Hidalgo-Urbano R , Almendro-Delia M , Garcia-Rubira JC 
Published: May 2022

Abstract

Funding Acknowledgements
Type of funding sources: Private company. Main funding source(s): The study project was financially supported by a non-conditional grant by Astrazeneca.

Background/Introduction
Premature cessation of dual antiplatelet therapy (DAPT) after acute coronary syndrome (ACS) has been associated with increased risk of major adverse cardiovascular events (MACE)

Purpose
To assess the relationship between premature DAPT discontinuation versus therapy continuation and outcomes in ACS patients discharged on ticagrelor or clopidogrel.

Methods
Prospective, observational, multicentre all-comers registry of ACS patients who were intended to receive 12-month DAPT with ticagrelor or clopidogrel. Adherence was defined by the medication possession ratio metric (MPA, proportion of days of medication supply within a time interval). Categories for DAPT cessation included: physician-recommended discontinuation, brief interruption (invasive procedures), or disruption due to non-compliance or because of bleeding. Fully-adjusted Cox models with time-varying covariates to account for informative censoring, were used to examine the effect of DAPT cessation on MACE (a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, definite stent thrombosis, or target-lesion revascularization). Moderation analysis was also performed to assess for potential exposure-adherence interaction.

Results
Among 2070 patients included (mean age 63 years, 73% men), 150 (7.3%) prematurely discontinued DAPT, median (IQR) 214 (101-236) days. Significantly more clopidogrel than ticagrelor users discontinued medication (9.5% vs 5%, respectively; P = .001), though timing of cessation was similar in both groups. At 1 year, MPR was slightly higher, but not significantly different, in the clopidogrel group than in the ticagrelor group (70±30 vs 64±29; P = .06). Overall, physician-guided discontinuation and bleeding were the main reasons for DAPT cessation. These were observed with a similar rate in both groups, while non-compliant disruption was more common among ticagrelor- than clopidogrel-treated patients (8% vs 2%, respectively; P for trend .04). After adjustments, DAPT cessation was associated with significantly increased risk of MACE (adjusted HR 2.94; 95% CI 1.82 – 4.74; P &lt; .0001), regardless of the P2Y12 inhibitor (P interaction = 0.665). Non-compliance related cessation resulted in higher risk of MACE (HR 6.04, 95%CI 2.15 – 16.95; P = .001).

Conclusion(s)
Overall, approximately 7% of patients discontinued DAPT. Early cessation of either ticagrelor- or clopidogrel-based DAPT portended to a near 3-fold increased risk of MACE. Disruption due to non-compliance resulted in higher risk for ischemic events. These data warrant efforts to focus on patient education in subgroups at high risk of non-compliance.
First-line treatment with oral anticoagulant predicts survival in acute cardiac patients with heparin-induced thrombocytopenia
Authors: Szyda L , Klosinska M , Mrozowska-Peruga E , Nowakowska M , Poninska N , Wiklo K , Kasprzak JD 
Published: May 2022

Abstract

Funding Acknowledgements
Type of funding sources: None.

Introduction
Heparin-induced thrombocytopenia (HIT) is a rare immune-mediated disorder related to the use of unfractionated heparin and low-molecular-weight heparin. Although thrombocytopenic, HIT is a paradoxical prothrombotic state associated with increased risk of vascular thrombosis and death. Non-heparin anticoagulants, parenteral and oral, are recommended for the treatment of HIT. As heparin is commonly used and thrombocytopenia is frequent in critically ill cardiac patients, HIT constitute a relevant clinical issue in the intensive cardiac care unit. Despite this, the incidence of HIT as well as factors influencing clinical outcomes in acute cardiac patients with HIT are unknown and have not been investigated so far.

Purpose
The purpose of our study was to evaluate the incidence of HIT in the population of cardiac patients and to determine if any predictor of survival for acute cardiac patients with HIT can be found.

Methods
We retrospectively collected data of all patients with HIT who were hospitalized in our intensive cardiac care unit in 2016 - 2021. We had used functionalized latex immunoassay to confirm the diagnosis of HIT in all patients. The choice of the non-heparin anticoagulant, oral or parenteral, for the first-line treatment of HIT had been left to clinical judgment of the physician. We performed statistical analysis including clinical and laboratory variables to find the predictors of survival in critically ill cardiac patients with HIT.

Results
Among 22 483 patients hospitalized in 2016 - 2021 in our department of cardiology 12 were diagnosed with HIT (incidence 1 : 1874). 5 of them were treated with parenteral non-heparin whereas 7 with oral anticoagulant as first-line treatment. 4 patients with HIT died during the index hospitalization. All of them were treated with parenteral non-heparin anticoagulant. 7 of 8 survivors were treated with oral anticoagulant as primary drug. First-line treatment with oral anticoagulant was the predictor of survival (p=0,0152) in our study group. There was no other neither clinical nor laboratory factor influencing outcomes in critically ill cardiac patients with HIT (Table 1).

Conclusion
First-line treatment with oral anticoagulant was the only one predictor of survival in acute cardiac patients with HIT. Oral anticoagulants may be preferred for the treatment of HIT in this population.
Acute hemodynamic effect of ketone bodies in patients with decompensated heart failure
Authors: Sramko M , Melenovsky V , Kleissner M , Benak A , Holek M , Pazdernik M , Kautzner J 
Published: May 2022

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
Chronically failing heart increases utilization of ketone bodies as an energy substrate.

Purpose
This study investigated feasibility, safety and acute hemodynamic effect of exogenous ketosis induced by administration of beta-hydroxybutyrate (OHB) in patients with decompensated heart failure and low cardiac output syndrome.

Methods
Patients with acutely decompensated heart failure with reduced ejection fraction (HFrEF), who were on inotropic support for at least 24 hours (milrinone 0.5±0.1 ug/kg/min), were given oral solution of OHB (25g of OHB monoester in 65 ml of solution; H.V.M.N Ketone Ester, H.V.M.N, USA) in 3-hour intervals up to a total dose of 75g. Serum concentration of OHB and invasive hemodynamics (Swan-Ganz catheter with continuous thermodilution) were measured repeatedly before and during 24 hours after administration of OHB. The primary endpoint was the maximum change in cardiac index (CI).

Results
The study included 8 patients with decompensated HFrEF (male/female gender: 6/2; age: 58 ± 6 years; left ventricular ejection fraction: 19 ± 5%; non-ischemic/ischemic cardiomyopathy: 7/1). The baseline OHB concentration was 0.4 ± 0.2 mmol/L (normal range: 0 - 0.6 mmol/L). Mild ketosis (1.8 ± 0.6 mmol/L) was induced in all patients within one hour after administration of OHB. The maximum OHB concentration (2.5 ± 0.8 mmol/L) was reached after a median of 5 hours (IQR, 2 to 7 hours). No complications occurred except of temporary dyspepsia in one patient. Within 3 hours after administration of OHB, the CI increased from the baseline by 39 ± 25% (CI 3.4 ± 0.8 vs. 2.5 ± 0.5 L/min/m2; absolute increase of 1.0 ± 0.6 L/min/m2, p = 0.003). The maximum increase of CI reached 52 ± 20% (1.2 ± 0.4 L/min/m2 from the baseline, p &lt;0.001) and it was observed after a median of 5 hours (IQR 3 to 8 hours). After 24 hours, CI returned to the baseline values (p = 0.4). The increase of CI was nor related to changes in the heart rate (at baseline vs. at the maximum CI: 101 ± 5 vs. 103 ± 6 beats/min, p = 0.5).

Conclusion
Induction of mild ketosis by administration of OHB on top of established inotropic therapy caused a significant temporary increase in myocardial contractility. This novel therapeutic concept might be a promising adjunction to the inotropic support in patients with decompensated HFrEF.
Ten years of experience in pre-transplant patients from an advanced heart failure center - when is the best time to step in?
Authors: Martinho A , Alves T , Rodrigues C , Girao A , Pais J , Fernandes L , Franco F , Costa S , Lourenco C , Prieto D , Goncalves L 
Published: May 2022

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) profiles provide important prognostic information for patients with advanced heart failure (AHF) hospitalized for clinical worsening.

Purpose
Assess the prognosis and fate of patients with Advanced HF (AHF), in INTERMACS I-IV, admitted to an Advanced Heart Failure Unit during 10-years.

Methods
Retrospective, single-center study with AHF’ patients admitted for acute HF during January 2010 and December 2020 in an Advanced Heart Failure Care Unit (AHFCU), who required inotropic therapy (INTERMACS I-IV) and were candidates for heart transplant (&lt;65 years). We assessed the baseline characteristics at the time of admission and the long-term outcomes: death, alive with optimized medical therapy (OMT) and device or transplantation, according to INTERMACS profiles.

Results
For 10 years, 175 patients who met the inclusion criteria were admitted to the AHFC, mostly men (66.2%) and ischemic (30%), with a mean age of 52±10 years. At admission the patients had a mean Left Ventricle Ejection Fraction (LVEF) of 27±10% and a median NT-proBNP of 7230 pg/ml (IQR 3801 to 19882). During the 10-years on focus, 42% patients were transplanted (n=73), 38% (n=66) remained alive with optimized MT and device and 20% (n= 36) died. In-hospital mortality was significant different between profiles (p=0.001), 55% in INTERMACS I patients, 25% in II, and 17% in III-IV. Most transplanted patients (63%) were in INTERMACS IV, 16.4% in III, 12.3% in II and only 11% (n=8) in INTERMACS I (p=0.043).

Conclusion
Our results reinforce the importance of early action in these patients, using INTERMACS profile to prognostic stratification, who is important to identify the ideal time for referral to an appropriate centre, to properly convey expectations to patients and families, and to plan treatment and follow-up strategies (transplant, circulatory mechanical support, or palliative care).
Artificial intelligence model for prediction of cardiogenic shock in patients with acute coronary syndrome
Authors: Bohm A , Jajcay N , Jankova J , Petrikova K , Bezak B 
Published: May 2022

Abstract

Funding Acknowledgements
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Ministry of Education, Science, Research and Sport of the Slovak Republic VEGA

Background
Cardiogenic shock (CS) is a serious life-threatening condition affecting almost 10% of patients suffering from acute coronary syndrome (ACS). Despite recent treatment improvements such as mechanical circulatory support devices (MCS), mortality remains 50%. It is hypothesized that early implantation of MCS before hemodynamic deterioration could prevent CS. Therefore, knowing which ACS patient will progress into CS would be of paramount importance.

Purpose
We aimed to develop a model based on machine learning algorithms for CS prediction in patients with ACS.

Method
Over 40 000 patients from critical care units of the Beth Israel Deaconess Medical Center database were extensively analyzed and sorted. Patients suffering from acute coronary syndrome undergoing cardiac catheterizations were selected and divided into two groups based on the development of CS. Patients in CS at the time of admission were excluded. The study population consisted of 3056 patients who didn’t develop CS and of 176 patients who did develop CS. Important information was also extracted manually from textual summaries of hospital stays. Potentially relevant clinical variables for shock prediction were selected using supervised feature selection, and missing values were supplemented using imputation methods. Seven well-known and established machine learning algorithms were used. Based on preliminary evaluation of classifier performance (AUC on random train-test split with 30% test data), we selected two best-performing algorithms: Logistic Regression and Gaussian Process classifier with Radial Basis Function (RBF) kernel. Both models were subsequently validated using Repeated Stratified K-Fold cross-validation with 5 folds and 20 repeats each.

Results
Age, heart rate, mean arterial pressure, respiratory rate, oxygen flow (liters per minute), peripheral oxygen saturation, blood glucose, pain type, heart rhythm and ectopy frequency were chosen as input variables. Both models showed good discrimination. The Logistic Regression model scored AUC of 0.76 ± 0.04. The Gaussian Process classifier with Radial Basis Function (RBF) kernel scored AUC of 0.77 ± 0.03.

Conclusion
According to our knowledge this is the first study that uses machine learning algorithms to predict CS in patients with ACS based on easily obtainable clinical variables. Further explorations and refinement of used imputation, feature selection, machine learning techniques and validation on an external cohort might result in even better performance of the proposed prediction models. Furthermore, these prediction models could be transformed into a simple predictive scoring system available in clinical practice.
Patient delay in patients with st-elevation myocardial infarction
Authors: Hendin KS , Egholm G , Lassen JF 
Published: May 2022

Abstract

Funding Acknowledgements
Type of funding sources: Foundation. Main funding source(s): Snedkermester Sophus Jacobsen og hustru Astrid Jacobsens fond

Background/Introduction
Rapid revascularisation therapy (primary percutaneous intervention (PCI)) is widely established as the most important factor in preventing myocardial damage after ST-Elevation Myocardial Infarction (STEMI)(1,2). Current ESC (European Society of Cardiology) guidelines recommends fast revascularisation therapy within 120 minutes of symptom onset(3). Despite this, previous studies have shown patient delay times above 120 minutes in more than 50% of patients(2,4). Reducing patient delay is therefore an important factor in the endeavour of decreasing myocardial damage and for prediction of outcome following STEMI. However, most knowledge on this field originates from registry-based studies(4). Previous studies conducted in Denmark, rely on data from danish quality databases containing data such as delay times, cardiac risk factors and procedure specific information. The few studies on this field using patient reported data, have focused on subpopulations or sex differences(5).

Purpose
The purpose of this study was to investigate the patient reported delay in STEMI patients and to compare the registered delay times to the physician reported delay in databases.

Methods
This single center study includes interviews of 129 patients hospitalized for STEMI between April and October 2021. The patients participated in semi-structured patient interviews conducted within 30 days of hospitalization. The main focus of the interviews was time of symptom onset and time of first medical contact, but other factors such as symptom presentation and perception, lifestyle choices and care seeking behaviour were also investigated. The patient reported delay times were then compared with the delay time registered in danish quality databases, using descriptive analysis and double-sided T-test.

Results
148 patients were included to the study. Upon contact, 19 were lost to follow up. 16 patients had missing delay times in the database. The final study cohort consisted of 113 patients (93 men and 20 women) aged 30-94 years (mean: 62,7 years).
We observed that on average patient reported delay times were 5 hours longer than the physician reported delay times in the databases, P=0.0080. The disagreement in delay times ranged from -25 hours to 159 hours.

Conclusions
We found a substantially longer delay time when comparing patient reported delay times with physician reported delay times. This is of high clinical importance in relation to proper prediction of outcomes, and to ensure the aiming of future information campaigns to populations most at need. As quality measures in this field relies on database registrations, it is imperative to address this discrepancy in order to improve patient delay times.
Allopurinol pretreatment effects on coronary blood flow and revascularization outcomes in acute STEMI patients underwent emergency percutaneous coronary intervention
Authors: Kermani-Alghoraishi M , Sanei H , Heshmat-Ghahdarijani K , Sadeghi M , Shirvani E 
Published: May 2022

Abstract

Funding Acknowledgements
Type of funding sources: Foundation. Main funding source(s): Isfahan University of Medical Sciences, Isfahan, Iran.

Introduction
Todays, acute ST-segment elevation myocardial infarction (STEMI) is considered as a most important component of acute coronary syndrome. In this regards, reperfusion therapy with percutaneous coronary intervention (PCI) is the most effective treatment for establishing coronary blood flow; which despite reperfusion of ischemic myocardium, it can also induce secondary injury as myocardial ischemia-reperfusion injury. The generation of reactive oxygen species by activation of xanthine oxidase (XO) enzymatic system is one of the major causes of ischemia-reperfusion injury in the ischemic myocardium and allopurinol, a XO inhibitor, has an inhibitory role on free radical productions in STEMI patients.

Purpose
In this study, we aimed to assess impact of allopurinol pre-treatment on revascularization outcomes, according to Thrombolysis in Myocardial Infarction (TIMI) flow and ST segment elevation recovery as well as clinical finding and major cardiac events incidence in STEMI patients underwent emergency PCI.

Methods
In this randomized double blind clinical trial, we enrolled 90 patients with acute STEMI in two equal groups. Allopurinol group received 600 mg allopurinol loading dose before the emergency PCI and the control group received the same shape medication as a placebo. Both groups also received the standard pretreatment protocol for PCI in acute STEMI setting. TIMI flow, ECG changes, Troponin level and major cardiac events (MACE) occurrence including death, myocardial infarction and ischemic stroke after 1 month follow up were assessed. In case group, allopurinol 100 mg daily and matched placebo pill for control group was continued for one month in addition to standard medications.

Results
Finally, 81 patients with acute STEMI has completed the study. The mean age of study population was 59.52 (11.31) and 61.3 (9.25) in case and control groups respectively (p = 0.49). Troponin level 48 hour after the PCI had not significant difference between the groups (p = 0.25). ECG ST-elevation regression also had not significant difference between the groups [75.0%1 vs 67.10% in case and control groups, respectively (p = 0.21)]. TIMI flow had improved in allopurinol group rather than placebo (p = 0.02). PCI success rate was 78.6% and 61.5% in allopurinol and control group respectively (p = 0.09). MACE and other clinically outcomes in follow up period were similar between groups (p &gt; 0.05).

Conclusions
This study indicated that allopurinol pre-treatment loading dose could improve minimally revascularization outcomes based on TIMI flow in the patients undergoing primary or rescue PCI in acute STEMI setting.
Creation and validation of a biochemical scoring system and smartphone application to predict 30 day mortality in patients requiring left-sided Impella monotherapy
Authors: Tindale A , Cretu I , Tan S-T , Monteagudo Vela M , Panoulas V 
Published: May 2022

Abstract

Funding Acknowledgements
Type of funding sources: None.

Objectives
To create and validate a simple biochemical scoring system and smartphone application that can estimate 30-day mortality in patients requiring left-sided Impella implantation as standalone mechanical circulatory support (MCS).

Methods
Initially, we retrospectively analysed 79 consecutive patients who required left-sided Impella MCS monotherapy. Regression analysis was used to elucidate significant associations between biochemical markers before Impella implantation and all-cause mortality at 30 days. Using these factors, a simple additive scoring system was create. The scoring system was then validated using prospectively collected data from our sister institution. This validated scoring system was then used to create a smartphone application that was formally evaluated by cardiologists.

Results
The BALLAR scoring system was created. Patients are assigned points based upon biochemical markers. These are summed and the final points tally provides an estimate of 30-day mortality. The points are assigned as follows:
Lactate (mmol/litre): &lt;2: 0 points, 2 – 4.9: 1 Point, &gt;4.9: 4 Points
Creatinine Clearance (ml/min): &lt;30: 6 points, 30 - 59.9: 4 points, 60 - 89.9: 1 point, &gt;89.9: 0 points
Serum Albumin (mmol/litre): &lt;25: 6 points, 25 - 34.9: 3 points, &gt;34.9: 0 points
Base Excess (mmol/L): &lt; -2: 2 points, &gt;= -2: 0 points
The total score can be used to estimate the probability of death at 30 days. A score less than 6 predicts a 30-day mortality of under 5%, whereas a score over 11 predicts a greater than 95% chance of death within 30 days.
This scoring system was initially validated using prospectively collected data from 10 patients our sister institution, where it predicted 30-day mortality in all of these patients. A smartphone application was then created which received universally positive feedback for ease of use by cardiologists and trainees at our institution.

Conclusion
The simple heuristic predicted 89% of 30-day deaths in our cohort. All the misclassifications were in the intermediate probability range (scores 5-11). Applied to a small external validation cohort, the predictive accuracy was 100%. This simple scoring system gives an effective estimate of the probability of death at 30 days in our cohort of patients and is now the basis for a novel smartphone application.