Journal: Eur Heart J Acute Cardiovasc Care

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Abstract

Acute Heart Failure in the 2021 ESC Heart Failure Guidelines: a scientific statement from the Association for Acute CardioVascular Care (ACVC) of the European Society of Cardiology.

Masip J, Frank Peacok W, Arrigo M, Rossello X, ... Mueller C, Miró Ò
The current European Society of Cardiology (ESC) Heart Failure Guidelines are the most comprehensive ESC document covering heart failure to date; however, the section focused on acute heart failure remains relatively concise. Although several topics are more extensively covered than in previous versions, including some specific therapies, monitoring and disposition in the hospital, and the management of cardiogenic shock, the lack of high-quality evidence in acute, emergency, and critical care scenarios, poses a challenge for providing evidence-based recommendations, in particular when by comparison the data for chronic heart failure is so extensive. The paucity of evidence and specific recommendations for the general approach and management of acute heart failure in the emergency department is particularly relevant, because this is the setting where most acute heart failure patients are initially diagnosed and stabilized. The clinical phenotypes proposed are comprehensive, clinically relevant and with minimal overlap, whilst providing additional opportunity for discussion around respiratory failure and hypoperfusion.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 17 Jan 2022; epub ahead of print
Masip J, Frank Peacok W, Arrigo M, Rossello X, ... Mueller C, Miró Ò
Eur Heart J Acute Cardiovasc Care: 17 Jan 2022; epub ahead of print | PMID: 35040931
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Impact:
Abstract

Adding stress biomarkers to high-sensitivity cardiac troponin for rapid non-ST-elevation myocardial infarction rule-out protocols.

Restan IZ, Sanchez AY, Steiro OT, Lopez-Ayala P, ... Mueller C, Aakre KM
Aims
This study tested the hypothesis that combining stress-induced biomarkers (copeptin or glucose) with high-sensitivity cardiac troponin (hs-cTn) increases diagnostic accuracy for non-ST-elevation myocardial infarction (NSTEMI) in patients presenting to the emergency department.
Methods and results
The ability to rule-out NSTEMI for combinations of baseline hs-cTnT or hs-cTnI with copeptin or glucose was compared with the European Society of Cardiology (ESC) hs-cTnT/I-only rule-out algorithms in two independent (one Norwegian and one international multicentre) diagnostic studies. Among 959 patients (median age 64 years, 60.5% male) with suspected NSTEMI in the Norwegian cohort, 13% had NSTEMI. Adding copeptin or glucose to hs-cTnT/I as a continuous variable did not improve discrimination as quantified by the area under the curve {e.g. hs-cTnT/copeptin 0.91 [95% confidence interval (CI) 0.89-0.93] vs. hs-cTnT alone 0.91 (95% CI 0.89-0.93); hs-cTnI/copeptin 0.85 (95% CI 0.82-0.87) vs. hs-cTnI alone 0.93 (95% CI 0.91-0.95)}, nor did adding copeptin <9 mmol/L or glucose <5.6 mmol/L increase the sensitivity of the rule-out provided by hs-cTnT <5 ng/L or hs-cTnI <4 ng/L in patients presenting more than 3 h after chest pain onset (target population in the ESC-0 h-algorithm). The combination decreased rule-out efficacy significantly (both P < 0.01). These findings were confirmed among 1272 patients (median age 62 years, 69.3% male) with suspected NSTEMI in the international validation cohort, of which 20.7% had NSTEMI. A trend towards increased sensitivity for the hs-cTnT/I/copeptin combinations (97-100% vs. 91-97% for the ESC-0 h-rule-out cut-offs) was observed in the Norwegian cohort.
Conclusion
Adding copeptin or glucose to hs-cTnT/I did not increase diagnostic performance when compared with current ESC guideline hs-cTnT/I-only 0 h-algorithms.

© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur Heart J Acute Cardiovasc Care: 12 Jan 2022; epub ahead of print
Restan IZ, Sanchez AY, Steiro OT, Lopez-Ayala P, ... Mueller C, Aakre KM
Eur Heart J Acute Cardiovasc Care: 12 Jan 2022; epub ahead of print | PMID: 35024819
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Abstract

Association between age and neurological outcomes in out-of-hospital cardiac arrest patients resuscitated with extracorporeal cardiopulmonary resuscitation: a nationwide multicentre observational study.

Miyamoto Y, Matsuyama T, Goto T, Ohbe H, ... Yasunaga H, Ohta B
Aims
Little is known about the difference in outcomes between young and old patients who received extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest (OHCA). Therefore, we aimed to investigate the differences in outcomes between those aged ≥75 years and <75 years who experienced OHCA and were resuscitated with ECPR.
Methods and results
We performed a secondary analysis of a nationwide prospective cohort study using the Japanese Association for Acute Medicine OHCA registry. We identified patients aged ≥18 years with OHCA who received ECPR. The patients were classified into three age groups (18-59 years, 60-74 years, and ≥75 years). The primary outcome was a 1-month neurological outcome. To examine the association between age and 1-month neurological outcome, we performed logistic regression analyses fitted with generalized estimating equations. From 2014 to 2017, we identified 875 OHCA patients aged ≥18 years who received ECPR. The proportion of patients who survived with favourable neurological outcome in the patients aged 18-59 years, 60-74 years, and ≥75 years were 15% (64/434), 8.9% (29/326), and 1.7% (2/115), respectively. In the multivariable analysis, compared with the age of 18-59 years, the proportions of favourable neurological outcomes were significantly lower in patients aged 60-74 years [adjusted odds ratio (OR), 0.44; 95% confidence interval (CI), 0.32-0.61] and those aged ≥75 years (adjusted OR, 0.26; 95% CI, 0.11-0.59).
Conclusion
Advanced age (age ≥75 years in particular) was significantly associated with poor neurological outcomes in patients with OHCA who received ECPR.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 11 Jan 2022; 11:35-42
Miyamoto Y, Matsuyama T, Goto T, Ohbe H, ... Yasunaga H, Ohta B
Eur Heart J Acute Cardiovasc Care: 11 Jan 2022; 11:35-42 | PMID: 33880567
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Impact:
Abstract

Direct comparison of high-sensitivity cardiac troponin T and I in the early differentiation of type 1 vs. type 2 myocardial infarction.

Nestelberger T, Boeddinghaus J, Giménez MR, Lopez-Ayala P, ... Müller C, APACE investigators
Aims
To directly compare the diagnostic accuracy of high-sensitivity cardiac troponin (hs-cTn) T vs. hs-cTnI in the early non-invasive differentiation of Type 1 myocardial infarction (T1MI) due to plaque rupture and atherothrombosis from Type 2 myocardial infarction (T2MI) due to supply-demand mismatch.
Methods and results
In a prospective multicentre diagnostic study, two independent cardiologists centrally adjudicated the final diagnosis of T1MI vs. T2MI according to the fourth universal definition of myocardial infarction (MI), using all available clinical information including cardiac imaging in patients presenting with acute chest pain. Diagnostic accuracy was quantified by the area under the receiver operating characteristics curve (AUC). The most extensively validated hs-cTnT-Elecsys and hs-cTnI-Architect assays were measured at presentation, 1 h, and 2 h. Among 5887 patients, 1106 (19%) had a final diagnosis of MI, including 860 (78%) T1MI and 246 (22%) T2MI. The AUC of hs-cTnT-Elecsys to differentiate T1MI from T2MI was moderate and comparable to that provided by hs-cTnI-Architect: hs-cTnT-Elecsys AUC-presentation 0.67 [95% confidence interval (CI) 0.64-0.71], AUC-1 h 0.70 (95% CI 0.66-0.74), and AUC-2 h 0.71 (95% CI 0.66-0.75) vs. hs-cTnI-Architect AUC-presentation 0.71 (95% CI 0.67-0.74), AUC-1 h 0.72 (95% CI 0.68-0.76), and AUC-2 h 0.74 (95% CI 0.69-0.78), all P = not significant (NS). Similarly, the AUC of absolute changes was moderate and comparable for hs-cTnT-Elecsys and hs-cTnI-Architect (all P = NS). Cut-off concentrations achieving at least 90% specificity for the differentiation of T1MI vs. T2MI were >114 ng/L for hs-cTnT-Elecsys [odds ratio (OR) 4.2, 95% CI 2.7-6.6] and >371 ng/L for hs-cTnI-Architect (OR 4.0, 95% CI 2.6-6.2).
Conclusion
hs-cTnT-Elecsys and hs-cTnI-Architect provided comparable, albeit only moderate, diagnostic accuracy for the early differentiation of T1MI vs. T2MI.
Clinical trial registration
ClinicalTrials.gov number, NCT00470587, https://clinicaltrials.gov/ct2/show/NCT00470587.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 11 Jan 2022; 11:62-74
Nestelberger T, Boeddinghaus J, Giménez MR, Lopez-Ayala P, ... Müller C, APACE investigators
Eur Heart J Acute Cardiovasc Care: 11 Jan 2022; 11:62-74 | PMID: 34195803
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Abstract

Diuretic vs. placebo in intermediate-risk acute pulmonary embolism: a randomized clinical trial.

Lim P, Delmas C, Sanchez O, Meneveau N, ... Layese R, Bastuji-Garin S
Aims
The role of diuretics in patients with intermediate-risk pulmonary embolism (PE) is controversial. In this multicentre, double-blind trial, we randomly assigned normotensive patients with intermediate-risk PE to receive either a single 80 mg bolus of furosemide or a placebo.
Methods and results
Eligible patients had at least a simplified PE Severity Index (sPESI) ≥1 with right ventricular dysfunction. The primary efficacy endpoint assessed 24 h after randomization included (i) absence of oligo-anuria and (ii) normalization of all sPESI items. Safety outcomes were worsening renal function and major adverse outcomes at 48 hours defined by death, cardiac arrest, mechanical ventilation, or need of catecholamine. A total of 276 patients underwent randomization; 135 were assigned to receive the diuretic, and 141 to receive the placebo. The primary outcome occurred in 68/132 patients (51.5%) in the diuretic and in 49/132 (37.1%) in the placebo group (relative risk = 1.30, 95% confidence interval 1.04-1.61; P = 0.021). Major adverse outcome at 48 h occurred in 1 (0.8%) patients in the diuretic group and 4 patients (2.9%) in the placebo group (P = 0.19). Increase in serum creatinine level was greater in diuretic than placebo group [+4 µM/L (-2; 14) vs. -1 µM/L (-11; 6), P < 0.001].
Conclusion
In normotensive patients with intermediate-risk PE, a single bolus of furosemide improved the primary efficacy outcome at 24 h and maintained stable renal function. In the furosemide group, urine output increased, without a demonstrable improvement in heart rate, systolic blood pressure, or arterial oxygenation.ClinicalTrials.gov identifier NCT02268903.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 11 Jan 2022; 11:2-9
Lim P, Delmas C, Sanchez O, Meneveau N, ... Layese R, Bastuji-Garin S
Eur Heart J Acute Cardiovasc Care: 11 Jan 2022; 11:2-9 | PMID: 34632490
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Abstract

Machine learning with D-dimer in the risk stratification for pulmonary embolism: a derivation and internal validation study.

Villacorta H, Pickering JW, Horiuchi Y, Olim M, ... Maisel AS, Than MP
Aim
To develop a machine learning model to predict the diagnosis of pulmonary embolism (PE).
Methods and results
We undertook a derivation and internal validation study to develop a risk prediction model for use in patients being investigated for possible PE. The machine learning technique, generalized logistic regression using elastic net, was chosen following an assessment of seven machine learning techniques and on the basis that it optimized the area under the receiver operator characteristic curve (AUC) and Brier score. Models were developed both with and without the addition of D-dimer. A total of 3347 patients were included in the study of whom, 219 (6.5%) had PE. Four clinical variables (O2 saturation, previous deep venous thrombosis or PE, immobilization or surgery, and alternative diagnosis equal or more likely than PE) plus D-dimer contributed to the machine learning models. The addition of D-dimer improved the AUC by 0.16 (95% confidence interval 0.13-0.19), from 0.73 to 0.89 (0.87-0.91) and decreased the Brier score by 14% (10-18%). More could be ruled out with a higher positive likelihood ratio than by the Wells score combined with D-dimer, revised Geneva score combined with D-dimer, or the Pulmonary Embolism Rule-out Criteria score. Machine learning with D-dimer maintained a low-false-negative rate at a true-negative rate of nearly 53%, which was better performance than any of the other alternatives.
Conclusion
A machine learning model outperformed traditional risk scores for the risk stratification of PE in the emergency department. However, external validation is needed.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 11 Jan 2022; 11:13-19
Villacorta H, Pickering JW, Horiuchi Y, Olim M, ... Maisel AS, Than MP
Eur Heart J Acute Cardiovasc Care: 11 Jan 2022; 11:13-19 | PMID: 34697635
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Abstract

Prognostic value of depressed cardiac index after STEMI: a phase-contrast magnetic resonance study.

Schwaiger JP, Reinstadler SJ, Holzknecht M, Tiller C, ... Metzler B, Klug G
Aims 
An invasively measured cardiac index (CI) of ≤2.2 L/min/m2 is one of the strongest prognostic indicators after ST-elevation myocardial infarction (STEMI), however, knowledge is mainly based on invasive evaluations performed in the pre-stent era. Velocity-encoded phase-contrast cardiac magnetic resonance (PC-CMR) allows non-invasive determination of CI.
Methods and results 
In this prospective study, CMR was performed in 406 stable and contemporarily revascularized patients a median of 3 days after STEMI. Forward stroke volume was assessed at the level of the ascending aorta by PC-CMR. Left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) were determined by cine CMR. Major adverse cardiac events (MACE) were defined as the composite of death, myocardial infarction, or hospitalization for heart failure. Median CI was 2.52 L/min/m2 and 27% of patients had ≤2.2 L/min/m2. Median LVEF was 53% and median GLS was -12.2%. During a median follow-up of 14.2 [95% confidence interval (95% CI) 13.6-14.7] months, 41 patients (10.1%) experienced a MACE. A depressed CI was significantly associated with MACE after adjustment for LVEF, GLS, Thrombolysis in Myocardial Infarction (TIMI) risk score, and infarct size [hazard ratio = 3.15 (95% CI 1.53-6.47); P = 0.002] and led to significant discrimination improvement [net reclassification improvement 0.61 (95% CI 0.25-0.97); P < 0.001].
Conclusions 
A CI of 2.2 L/min/m2 or less as measured by PC-CMR was present in 27% of clinically stable patients after STEMI and strongly and independently predicted medium-term MACE. The prognostic value of a depressed CI was superior and incremental to LVEF, GLS, TIMI risk score, and infarct size.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 11 Jan 2022; 11:53-61
Schwaiger JP, Reinstadler SJ, Holzknecht M, Tiller C, ... Metzler B, Klug G
Eur Heart J Acute Cardiovasc Care: 11 Jan 2022; 11:53-61 | PMID: 34750623
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Abstract

Hypochloraemia following admission to hospital with heart failure is common and associated with an increased risk of readmission or death: a report from OPERA-HF.

Cuthbert JJ, Brown OI, Urbinati A, Pan D, ... Cleland JGF, Clark AL
Aims
Hypochloraemia is common in patients hospitalized with heart failure (HF) and associated with a high risk of adverse outcomes during admission and following discharge. We assessed the significance of changes in serum chloride concentrations in relation to serum sodium and bicarbonate concentrations during admission in a cohort of 1002 consecutive patients admitted with HF and enrolled into an observational study based at a single tertiary centre in the UK.
Methods and results
Hypochloraemia (<96 mmol/L), hyponatraemia (<135 mmol/L), and metabolic alkalosis (bicarbonate >32 mmol/L) were defined by local laboratory reference ranges. Outcomes assessed were all-cause mortality, all-cause mortality or all-cause readmission, and all-cause mortality or HF readmission. Cox regression and Kaplan-Meier curves were used to investigate associations with outcome. During a median follow-up of 856 days (interquartile range 272-1416), discharge hypochloraemia, regardless of serum sodium, or bicarbonate levels was associated with greater all-cause mortality [hazard ratio (HR) 1.44, 95% confidence interval (CI) 1.15-1.79; P = 0.001], all-cause mortality or all-cause readmission (HR 1.26, 95% CI 1.04-1.53; P = 0.02), and all-cause mortality or HF readmission (HR 1.41, 95% CI 1.14-1.74; P = 0.002) after multivariable adjustment. Patients with concurrent hypochloraemia and natraemia had lower haemoglobin and haematocrit, suggesting congestion; those with hypochloraemia and normal sodium levels had more metabolic alkalosis, suggesting decongestion.
Conclusion
Hypochloraemia is common at discharge after a hospitalization for HF and is associated with worse outcome subsequently. It is an easily measured clinical variables that is associated with morbidity or mortality of any cause.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 11 Jan 2022; 11:43-52
Cuthbert JJ, Brown OI, Urbinati A, Pan D, ... Cleland JGF, Clark AL
Eur Heart J Acute Cardiovasc Care: 11 Jan 2022; 11:43-52 | PMID: 34897402
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Abstract

Critical care management of the patient with pulmonary hypertension.

Barnett CF, O\'Brien C, De Marco T
Pulmonary hypertension (PH) is a common diagnosis in patients admitted to the cardiac intensive care unit with a wide range of underlying causes. A detailed evaluation to identify all factors contributing to the elevated pulmonary artery pressure and provide an assessment of right ventricular haemodynamics and function is needed to guide treatment and identify patients at highest risk for poor outcomes. While in many patients management of underlying and triggering medical problems with careful monitoring is appropriate, a subset of patients may benefit from specialized treatments targeting the pulmonary circulation and support of the right ventricle. In such cases, collaboration with or transfer to a centre with special expertise in the management of PH may be warranted.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 11 Jan 2022; 11:77-83
Barnett CF, O'Brien C, De Marco T
Eur Heart J Acute Cardiovasc Care: 11 Jan 2022; 11:77-83 | PMID: 34966914
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Abstract

The effect of the GoodSAM volunteer first-responder app on survival to hospital discharge following out-of-hospital cardiac arrest.

Smith CM, Lall R, Fothergill RT, Spaight R, Perkins GD
Aims
Bystander cardiopulmonary resuscitation and defibrillation can double survival to hospital discharge in out-of-hospital cardiac arrest. Mobile phone applications, such as GoodSAM, alerting nearby volunteer first-responders about out-of-hospital cardiac arrest could potentially improve bystander cardiopulmonary resuscitation and defibrillation, leading to better patient outcomes. The aim of this study was to determine GoodSAM\'s effect on survival to hospital discharge following out-of-hospital cardiac arrest.
Methods and results
We collected data from the Out-of-Hospital Cardiac Arrest Outcomes Registry (University of Warwick, UK) submitted by the London Ambulance Service (1 April 2016 to 31 March 2017) and East Midlands Ambulance Service (1 January 2018 to 17 June 2018) and matched out-of-hospital cardiac arrests to GoodSAM alerts. We constructed logistic regression models to determine if there was an association between a GoodSAM first-responder accepting an alert and survival to hospital discharge, adjusting for location type, presenting rhythm, age, gender, ambulance service response time, cardiac arrest witnessed status, and bystander actions. Survival to hospital discharge was 9.6% (393/4196) in London and 7.2% (72/1001) in East Midlands. A GoodSAM first-responder accepted an alert for out-of-hospital cardiac arrest in 1.3% (53/4196) cases in London and 5.4% (51/1001) cases in East Midlands. When a responder accepted an alert, the adjusted odds ratio for survival to hospital discharge was 3.15 (95% CI: 1.19-8.36, P = 0.021) in London and 3.19 (95% CI: 1.17-8.73, P = 0.024) in East Midlands.
Conclusion
Alert acceptance was associated with improved survival in both ambulance services. Alert acceptance rates were low, and challenges remain to maximize the potential benefit of GoodSAM.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur Heart J Acute Cardiovasc Care: 11 Jan 2022; 11:20-31
Smith CM, Lall R, Fothergill RT, Spaight R, Perkins GD
Eur Heart J Acute Cardiovasc Care: 11 Jan 2022; 11:20-31 | PMID: 35024801
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Abstract

Prognostic relevance of magnesium alterations in patients with a myocardial infarction and left ventricular dysfunction: insights from the EPHESUS trial.

Martens P, Ferreira JP, Vincent J, Abreu P, ... Zannad F, Rossignol P
Aims
Magnesium changes are common in myocardial infarction (MI) complicated with left ventricular systolic dysfunction (LVSD) and/or heart failure (HF). The relation between serum magnesium and clinical outcomes is insufficiently elucidated in this population.
Methods and results
The EPHESUS trial randomized 6632 patients to either eplerenone or placebo. Hypomagnesemia and hypermagnesemia were defined as a serum magnesium <0.66 and >1.10 mmol/L, respectively. Linear mixed models and time-dependent Cox regression analysis were used to determine the effect of eplerenone on magnesium changes and the prognostic importance of magnesium. The co-primary outcomes were all-cause mortality and a composite of cardiovascular (CV) mortality and CV hospitalization. A total of 5371 patients had a post-baseline magnesium measurement. At baseline, 231 (4.3%) patients had hypomagnesemia and 271 (5.0%) patients had hypermagnesemia. During a median follow-up of 16 months, 682 (13%) developed hypomagnesemia and 512 (9.5%) hypermagnesemia. Eplerenone treatment did not result in a different magnesium level during follow-up (P = 0.14). After covariate adjustment hypo- and hypermagnesemia were not associated with a higher risk of CV events. Magnesium levels did not modulate the effect of a high potassium (>5 mmol/L) or low potassium (<4 mmol/L) on the clinical outcome. Baseline magnesium levels did not influence the treatment effect of eplerenone (P-interaction > 0.1 for all primary and secondary endpoints).
Conclusion
In patients with MI complicated by LVSD or HF, magnesium alterations were not associated with clinical outcomes nor did they influence the effect of eplerenone. Serum magnesium did not modulate the effect of potassium changes on clinical outcome or the treatment effect of eplerenone.
Clinicaltrials.gov identifier
NCT00232180.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 10 Jan 2022; epub ahead of print
Martens P, Ferreira JP, Vincent J, Abreu P, ... Zannad F, Rossignol P
Eur Heart J Acute Cardiovasc Care: 10 Jan 2022; epub ahead of print | PMID: 35021200
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Impact:
Abstract

End-of-life care in the cardiac intensive care unit: a contemporary view from the Critical Care Cardiology Trials Network (CCCTN) Registry.

Fagundes A, Berg DD, Bohula EA, Baird-Zars VM, ... Morrow DA, Katz JN
Aims
Increases in life expectancy, comorbidities, and survival with complex cardiovascular conditions have changed the clinical profile of the patients in cardiac intensive care units (CICUs). In this environment, palliative care (PC) services are increasingly important. However, scarce information is available about the delivery of PC in CICUs.
Methods and results
The Critical Care Cardiology Trials Network (CCCTN) Registry is a network of tertiary care CICUs in North America. Between 2017 and 2020, up to 26 centres contributed an annual 2-month snapshot of all consecutive medical CICU admissions. We captured code status at admission and the decision for comfort measures only (CMO) before all deaths in the CICU. Of 13 422 patients, 10% died in the CICU and 2.6% were discharged to palliative hospice. Of patients who died in the CICU, 68% were CMO at death. In the CMO group, only 13% were do not resuscitate/do not intubate at admission. The median time from CICU admission to CMO decision was 3.4 days (25th-75th percentiles: 1.2-7.7) and ≥7 days in 27%. Time from CMO decision to death was <24 h in 88%, with a median of 3.8 h (25th-75th 1.0-10.3). Before a CMO decision, 78% received mechanical ventilation and 26% mechanical circulatory support. A PC provider team participated in the care of 41% of patients who died.
Conclusions
In a contemporary CICU registry, comfort measures preceded death in two-thirds of cases, frequently without PC involvement. The high utilization of advanced intensive care unit therapies and lengthy times to a CMO decision highlight a potential opportunity for early engagement of PC teams in CICU.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2022. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 04 Jan 2022; epub ahead of print
Fagundes A, Berg DD, Bohula EA, Baird-Zars VM, ... Morrow DA, Katz JN
Eur Heart J Acute Cardiovasc Care: 04 Jan 2022; epub ahead of print | PMID: 34986236
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Impact:
Abstract

Adding historical high-sensitivity troponin T results to rule out acute myocardial infarction.

Roos A, Mohammad MA, Ekelund U, Mokhtari A, Holzmann MJ
Aims 
The clinical usefulness of historical concentrations of high-sensitivity cardiac troponin T (hs-cTnT) is unknown. This study investigated the ability to rule out myocardial infarction (MI) with the use of historical hs-cTnT concentrations among patients with chest pain in the emergency department (ED).
Methods and results 
The derivation cohort consisted of patients presenting with chest pain to nine different EDs (n = 60 071), where we included those with ≥1 hs-cTnT analysed at the index visit and ≥1 hs-cTnT results prior to the visit. We developed an algorithm to rule out MI within 30 days with a pre-specified target negative predictive value (NPV) of ≥99.5%. The performance was then validated in a separate cohort of ED chest pain patients (n = 10 994). A historical hs-cTnT < 12 ng/L and a < 3 ng/L absolute change between the historical and the index visit hs-cTnT had the best performance and ruled out 24 862 (41%) patients in the derivation cohort. In the validation cohort, these criteria identified 4764 (43%) low-risk patients in whom 18 (0.4%) MIs within 30 days occurred, and had an NPV for MI of 99.6% (99.4-99.8), a sensitivity of 96.9% (95.2-.2), and an LR- of 0.11 (0.07-0.14).
Conclusion 
Combining a historical hs-cTnT with a single new hs-cTnT may safely rule out MI and thereby reduce the need for serial hs-cTnT measurements in ED patients with chest pain.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2022. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 02 Jan 2022; epub ahead of print
Roos A, Mohammad MA, Ekelund U, Mokhtari A, Holzmann MJ
Eur Heart J Acute Cardiovasc Care: 02 Jan 2022; epub ahead of print | PMID: 34977928
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Impact:
Abstract

Impact of myocardial infarction symptom presentation on emergency response and survival.

Møller AL, Mills EHA, Gnesin F, Jensen B, ... Gerds TA, Torp-Pedersen C
Aims
We examined associations between symptom presentation and chance of receiving an emergency dispatch and 30-day mortality among patients with acute myocardial infarction (MI).
Methods and results
Copenhagen, Denmark has a 24-h non-emergency medical helpline and an emergency number 1-1-2 (equivalent to 9-1-1). Both services register symptoms/purpose of calls. Among patients with MI as either hospital diagnosis or cause of death within 72 h after a call, the primary symptom was categorized as chest pain, atypical symptoms (breathing problems, unclear problem, central nervous system symptoms, abdominal/back/urinary, other cardiac symptoms, and other atypical symptoms), unconsciousness, non-informative symptoms, and no recorded symptoms. We identified 4880 emergency and 3456 non-emergency calls from patients with MI. The most common symptom was chest pain (N = 5219) followed by breathing problems (N = 556). Among patients with chest pain, 95% (3337/3508) of emergency calls and 76% (1306/1711) of non-emergency calls received emergency dispatch. Mortality was 5% (163/3508) and 3% (49/1711) for emergency/non-emergency calls, respectively. For atypical symptoms 62% (554/900) and 17% (137/813) of emergency/non-emergency calls received emergency dispatch and mortality was 23% (206/900) and 15% (125/813). Among unconscious, patients 99%/100% received emergency dispatch and mortality was 71%/75% for emergency/non-emergency calls. Standardized 30-day mortality was 4.3% for chest pain and 15.6% for atypical symptoms, and associations between symptoms and emergency dispatch remained in subgroups of age and sex.
Conclusion
Myocardial infarction patients presenting with atypical symptoms when calling for help have a reduced chance of receiving an emergency dispatch and increased 30-day mortality compared to MI patients with chest pain.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 17 Dec 2021; 10:1150-1159
Møller AL, Mills EHA, Gnesin F, Jensen B, ... Gerds TA, Torp-Pedersen C
Eur Heart J Acute Cardiovasc Care: 17 Dec 2021; 10:1150-1159 | PMID: 33951728
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Abstract

Pre-hospital heparin use for ST-elevation myocardial infarction is safe and improves angiographic outcomes.

Bloom JE, Andrew E, Nehme Z, Dinh DT, ... Smith K, Stub D
Aims
This study aims to evaluate if pre-hospital heparin administration by paramedics is safe and improves clinical outcomes.
Methods and results
Using the multicentre Victorian Cardiac Outcomes Registry, linked with state-wide ambulance records, we identified consecutive patients undergoing primary percutaneous coronary intervention for STEMI between January 2014 and December 2018. Information on thrombolysis in myocardial infarction (TIMI) flow at angiography was available in a subset of cases. Patients receiving pre-hospital heparin were compared to those who did not receive heparin. Findings at coronary angiography and 30-day clinical outcomes were compared between groups. Propensity-score matching was performed for risk adjustment. We identified a total of 4720 patients. Of these, 1967 patients had TIMI flow data available. Propensity-score matching in the entire cohort yielded 1373 matched pairs. In the matched cohort, there was no observed difference in 30-day mortality (no-heparin 3.5% vs. heparin 3.0%, P = 0.25), MACCE (no-heparin 7% vs. heparin 6.2%, P = 0.44), and major bleeding (no-heparin 1.9% vs. heparin 1.4%, P = 0.64) between groups. Propensity-score analysis amongst those with TIMI data produced 552 matched pairs. The proportion of cases with TIMI 0 or 1 flow in the infarct-related artery (IRA) was lower among those receiving pre-hospital heparin (66% vs. 76%, P < 0.001) compared to those who did not.
Conclusion 
In this multicentre, propensity-score matched study, the use of pre-hospital heparin by paramedics was safe and is associated with fewer occluded IRAs in patients presenting with STEMI.

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Eur Heart J Acute Cardiovasc Care: 17 Dec 2021; 10:1140-1147
Bloom JE, Andrew E, Nehme Z, Dinh DT, ... Smith K, Stub D
Eur Heart J Acute Cardiovasc Care: 17 Dec 2021; 10:1140-1147 | PMID: 34189566
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Abstract

The association of anaemia and high-sensitivity cardiac troponin and its effect on diagnosing myocardial infarction.

Haller PM, Neumann JT, Sörensen NA, Hartikainen TS, ... Blankenberg S, Westermann D
Aims
Anaemia is common in patients with acute myocardial infarction (MI). We investigated the association of high-sensitivity cardiac troponin (hs-cTn) and haemoglobin (Hb) and the influence of anaemia on the performance of diagnostic protocols for suspected MI.
Methods and results
Patients with suspected MI were consecutively enrolled at a tertiary centre. Final diagnoses were independently adjudicated by two cardiologists. Performance measures of hs-cTn-based algorithms were compared for anaemic and non-anaemic patients (Hb <12 g/dL in women and <13 g/dL in men). The influence of anaemia on survival (median follow-up 1.7 years) was investigated using multivariable cox-regression analysis and the association of Hb and hs-cTn by multivariable linear regression analysis. Overall, 2223 patients were included, of whom 415 (18.7%) had anaemia. In anaemic patients, the incidence of MI was similar; however, chronic myocardial injury was significantly more prevalent (20.1% vs. 48.2%). The negative predictive value to rule-out MI was similar for both algorithms and all assays in patients with anaemia, although the positive predictive value to rule-in MI was partly reduced for the 0/3-h algorithm. Fewer anaemic patients were triaged after 1 h. Anaemia was an independent predictor of death. Adjusted for patient characteristics, Hb was significantly associated with hs-cTn. By providing a point-based tool, the Hb-associated hs-cTn concentration and thus chronic myocardial injury may be predicted.
Conclusion 
Anaemia partly affects the rule-in, but not the rule-out of MI in hs-cTn-based diagnostic protocols. Hs-cTn concentrations and thus chronic myocardial injury may be predicted by clinical variables and Hb.
Trial registration
clinicaltrials.gov (NCT02355457 and NCT03227159).

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Eur Heart J Acute Cardiovasc Care: 17 Dec 2021; 10:1187-1196
Haller PM, Neumann JT, Sörensen NA, Hartikainen TS, ... Blankenberg S, Westermann D
Eur Heart J Acute Cardiovasc Care: 17 Dec 2021; 10:1187-1196 | PMID: 34350455
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Impact:
Abstract

Renal function and outcome of patients with non-valvular atrial fibrillation.

Barashi R, Hornik-Lurie T, Gabay H, Haskiah F, ... Assali A, Pereg D
Aims
Atrial fibrillation and renal dysfunction are associated with increased cardiovascular risk. We examined the association between renal function and incident ischaemic stroke or myocardial infarction in patients with atrial fibrillation treated with direct oral anticoagulants (DOACs).
Methods and results
This study was conducted using a large health record database. Included were 19 713 patients with first time diagnosis of non-valvular atrial fibrillation treated with DOACs between 2010 and 2018. Patients were categorized into four groups according to the estimated glomerular filtration rate (eGFR) (<30, 30-59, 60-89, and ≥90 mL/min/1.73 m2). Ischaemic stroke and acute myocardial infarction rates were compared between the groups. During 55 086 person-years of follow-up, there were 2295 (11.6%) cases of ischaemic stroke and 1158 (5.9%) cases of acute myocardial infarction. There was a significant inverse association between eGFR and the risk of myocardial infarction. A multivariate analysis using the group with eGFR ≥90 mL/min/1.73 m2 as a reference demonstrated an increased risk of myocardial infarction with lower eGFR [hazard ratio (HR) = 1.2 95% confidence interval (CI) 0.9-1.4, HR = 1.4, 95% CI 1.2-1.7, and HR = 2.5, 95% CI 1.8-3.4 for patients with eGFR 60-89, 30-59, and <30 mL/min/1.73 m2, respectively, P < 0.001]. Each 10 mL decrease in eGFR was associated with an 8% increase in the risk of myocardial infarction. There was no association between eGFR and the risk of ischaemic stroke (HR = 0.9 95% CI 0.8-1.1, HR = 0.93, 95% CI 0.8-1.1, and HR = 1.1, 95% CI 0.8-1.4 for patients with eGFR 60-89, 30-59, and <30 mL/min/1.73 m2, respectively, P = 0.325).
Conclusions
Renal dysfunction is associated with an increased risk of myocardial infarction but not of ischaemic stroke among patients with atrial fibrillation treated with DOACs.

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Eur Heart J Acute Cardiovasc Care: 17 Dec 2021; 10:1180-1186
Barashi R, Hornik-Lurie T, Gabay H, Haskiah F, ... Assali A, Pereg D
Eur Heart J Acute Cardiovasc Care: 17 Dec 2021; 10:1180-1186 | PMID: 34458895
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Impact:
Abstract

Twelve-month clinical outcomes in patients with acute coronary syndrome undergoing complex percutaneous coronary intervention: insights from the ISAR-REACT 5 trial.

Coughlan JJ, Aytekin A, Ndrepepa G, Schüpke S, ... Kastrati A, Cassese S
Aims
Complex percutaneous coronary intervention (PCI) is associated with a higher risk of ischaemic events. However, no study has analysed the effect of PCI complexity on outcomes in a contemporary cohort of acute coronary syndrome (ACS) patients treated with a dual anti-platelet therapy regimen based on potent P2Y12-inhibitors. Therefore, we performed the current analysis.
Methods and results
This analysis included all ACS patients treated with PCI in the Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment (ISAR-REACT) 5 trial. Complex PCI was defined as at least one of: multi-vessel PCI, ≥3 stents implanted, ≥3 lesions treated, and total stented length >60 mm. The primary endpoint was the composite of all-cause death, myocardial infarction (MI), or stroke at 12 months; the safety endpoint was Bleeding Academic Research Consortium types 3-5 bleeding at 12 months. Overall, 3377 patients were included in this analysis (complex PCI, n = 1429; non-complex PCI, n = 1948). The primary endpoint occurred more frequently in the complex PCI group than the non-complex PCI group [10.1% vs. 7.2%, hazard ratio (HR): 1.44, 95% confidence interval (CI) (1.14-1.82), P = 0.002], driven primarily by a higher risk of MI [HR: 1.62, (1.17-2.26), P = 0.004]. The safety endpoint was not statistically different between patients undergoing complex vs. non-complex PCI, although it was numerically higher in the complex PCI group [6.7% vs. 5.3%, HR: 1.28, (0.97-1.70), P = 0.08].
Conclusions
Acute coronary syndrome patients undergoing complex PCI have an increased incidence of ischaemic events compared with ACS patients undergoing non-complex PCI.
Clinical trial registration
NCT01944800, Prospective, Randomized Trial of Ticagrelor Vs. Prasugrel in Patients With Acute Coronary Syndrome-Full-Text View-ClinicalTrials.gov https://clinicaltrials.gov/ct2/show/NCT01944800.

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Eur Heart J Acute Cardiovasc Care: 17 Dec 2021; 10:1117-1124
Coughlan JJ, Aytekin A, Ndrepepa G, Schüpke S, ... Kastrati A, Cassese S
Eur Heart J Acute Cardiovasc Care: 17 Dec 2021; 10:1117-1124 | PMID: 34468709
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Impact:
Abstract

Acute kidney injury in patients with acute coronary syndrome undergoing invasive management treated with bivalirudin vs. unfractionated heparin: insights from the MATRIX trial.

Landi A, Branca M, Andò G, Russo F, ... Valgimigli M, MATRIX Investigators
Aims
Acute kidney injury (AKI) is a critical complication among patients with acute coronary syndrome (ACS) undergoing invasive management. The value of adjunctive antithrombotic strategies, such as bivalirudin or unfractionated heparin (UFH) on the risk of AKI is unclear.
Methods and results
Among 7213 patients enrolled in the MATRIX-Antithrombin and Treatment Duration study, 128 subjects were excluded due to incomplete information on serum creatinine (sCr) or end-stage renal disease on dialysis treatment. The primary endpoint was AKI defined as an absolute (>0.5 mg/dL) or a relative (>25%) increase in sCr. AKI occurred in 601 patients (16.9%) treated with bivalirudin and 616 patients (17.4%) treated with UFH [odds ratio (OR): 0.97; 95% confidence interval (CI): 0.85-1.09; P = 0.58]. A >25% sCr increase was observed in 597 patients (16.8%) with bivalirudin and 616 patients (17.4%) with UFH (OR: 0.96; 95% CI: 0.85-1.08; P = 0.50), whereas a >0.5 mg/dL absolute sCr increase occurred in 176 patients (5.0%) with bivalirudin vs. 189 patients (5.4%) with UFH (OR: 0.92; 95% CI: 0.75-1.14; P = 0.46). By implementing the Kidney Disease Improving Global Outcomes (KDIGO) criteria, the risk of AKI was not significantly different between bivalirudin and UFH groups (OR: 0.88; 95% CI: 0.72-1.07; P = 0.21). Subgroup analyses of the primary endpoint suggested a benefit with bivalirudin in patients randomized to femoral access.
Conclusion
Among ACS patients undergoing invasive management, the risk of AKI was not significantly lower with bivalirudin compared with UFH.
Trial registration
clinicaltrials.gov NCT01433627.

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Eur Heart J Acute Cardiovasc Care: 17 Dec 2021; 10:1170-1179
Landi A, Branca M, Andò G, Russo F, ... Valgimigli M, MATRIX Investigators
Eur Heart J Acute Cardiovasc Care: 17 Dec 2021; 10:1170-1179 | PMID: 34491323
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Impact:
Abstract

Helmet continuous positive airway pressure vs. high flow nasal cannula oxygen in acute cardiogenic pulmonary oedema: a randomized controlled trial.

Osman A, Via G, Sallehuddin RM, Ahmad AH, ... Fong CP, Tavazzi G
Aims 
Non-invasive ventilation represents an established treatment for acute cardiogenic pulmonary oedema (ACPO) although no data regarding the best ventilatory strategy are available. We aimed to compare the effectiveness of helmet CPAP (hCPAP) and high flow nasal cannula (HFNC) in the early treatment of ACPO.
Methods and results 
Single-centre randomized controlled trial of patients admitted to the emergency department due to ACPO with hypoxemia and dyspnoea on face mask oxygen therapy. Patients were randomly assigned with a 1:1 ratio to receive hCPAP or HFNC and FiO2 set to achieve an arterial oxygen saturation >94%. The primary outcome was a reduction in respiratory rate; secondary outcomes included changes in heart rate, PaO2/FiO2 ratio, Heart rate, Acidosis, Consciousness, Oxygenation, and Respiratory rate (HACOR) score, Dyspnoea Scale, and intubation rate. Data were collected before hCPAP/HFNC placement and after 1 h of treatment. Amongst 188 patients randomized, hCPAP was more effective than HFNC in reducing respiratory rate [-12 (95% CI; 11-13) vs. -9 (95% CI; 8-10), P < 0.001] and was associated with greater heart rate reduction [-20 (95% CI; 17-23) vs. -15 (95% CI; 12-18), P = 0.042], P/F ratio improvement [+149 (95% CI; 135-163) vs. +120 (95% CI; 107-132), P = 0.003] as well as in HACOR scores [6 (0-12) vs. 4 (2-9), P < 0.001] and Dyspnoea Scale [4 (1-7) vs. 3.5 (1-6), P = 0.003]. No differences in intubation rate were noted (P = 0.321).
Conclusion 
Amongst patients with ACPO, hCPAP resulted in a greater short-term improvement in respiratory and hemodynamic parameters as compared with HFNC.
Trial registration 
Clinical trial submission: NMRR-17-1839-36966 (IIR). Registry name: Medical Research and Ethics Committee of Malaysia Ministry of Health. Clinicaltrials.gov identifier: NCT04005092. URL registry: https://clinicaltrials.gov/ct2/show/NCT04005092.

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Eur Heart J Acute Cardiovasc Care: 17 Dec 2021; 10:1103-1111
Osman A, Via G, Sallehuddin RM, Ahmad AH, ... Fong CP, Tavazzi G
Eur Heart J Acute Cardiovasc Care: 17 Dec 2021; 10:1103-1111 | PMID: 34632507
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Impact:
Abstract

De novo and pre-existing atrial fibrillation in acute coronary syndromes: impact on prognosis and cardiovascular events in long-term follow-up.

Buchta P, Kalarus Z, Mizia-Stec K, Myrda K, Skrzypek M, Ga Sior M
Aims
The aim of the study was to compare in-hospital and long-term prognosis in patients with acute coronary syndromes (ACS) and de novo vs. pre-existing atrial fibrillation (AF). Atrial fibrillation increases the risk of serious adverse events including death in patients with ACS. However, it is unclear whether de novo and pre-existing AF portend a different risk.
Methods and results
We analysed the incidence, clinical characteristics, and in-hospital and long-term outcomes in patients with AF and ACS based on combined data from Polish Registry of Acute Coronary Syndrome (PL-ACS) (n = 581 843) and SILICARD (n = 852 063) databases. Atrial fibrillation at admission was diagnosed in of 6.16% patients [de novo: 1129 (2.46%); pre-existing: 1691 (3.7%)]. Groups were compared (N = 1023 vs. 1023) after matching for relevant clinical factors. De novo and pre-existing AF differed in in-hospital diuretic (52% vs. 58%; P = 0.008) and aldosterone inhibitor (27.5% vs. 32.5%; P = 0.02) use, Thrombolysis In Myocardial Infarction (TIMI) flow before percutaneous coronary intervention (P = 0.016), and diuretic (52.1% vs. 58%; P = 0.008) and oral anticoagulant (27.5% vs. 32.5%; P = 0.018) use at discharge. In-hospital mortality in the de novo AF group was significantly higher (13.1% vs. 8.31%; P = 0.0005). Post-discharge 12-month survival was similar between groups (14.5% vs. 15.3%, P = 0.63). Long-term re-hospitalization due to heart failure (22.7% vs. 17.2%; P < 0.005) and medical contact due to AF (48.4% vs. 26.1%, P < 0.0001) rates were higher in the group with pre-existing AF, without the difference of stroke or myocardial infarction occurrence.
Conclusion
De novo AF accounts for 40% of all AF cases in ACS patients and is an unfavourable in-hospital prognostic factor. The occurrence of de novo AF during ACS should require special attention and caution in the treatment of these patients.

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Eur Heart J Acute Cardiovasc Care: 17 Dec 2021; 10:1129-1139
Buchta P, Kalarus Z, Mizia-Stec K, Myrda K, Skrzypek M, Ga Sior M
Eur Heart J Acute Cardiovasc Care: 17 Dec 2021; 10:1129-1139 | PMID: 34718473
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Impact:
Abstract

Acute aortic syndromes: a review of what we know and future considerations.

King RW, Bonaca MP
Acute aortic syndromes represent a spectrum of life-threatening aortic pathologies. Prompt diagnosis and proper management of these syndromes are important in reducing overall mortality and morbidity, which remains high. Acute aortic dissections represent most of these aortic wall pathologies, but intramural haematomas and penetrating atherosclerotic ulcers have been increasingly diagnosed. Type A dissections require prompt surgical treatment, with endovascular options on the horizon. Type B dissections can be complicated or uncomplicated, and treatment is determined based on this designation. Complicated Type B dissections require prompt repair with thoracic endovascular aortic repair (TEVAR) becoming the preferred method. Uncomplicated Type B dissections require medical management, but early TEVAR in the subacute setting is becoming more prominent. Proper surveillance for an uncomplicated Type B dissection is crucial in detecting aortic degeneration and need for intervention. Intramural haematomas and penetrating atherosclerotic ulcers are managed similarly to aortic dissections, but more research is needed to determine the proper management algorithms. Multi-disciplinary aortic programmes have been shown to improve patient outcomes and are necessary in optimizing long-term follow-up.

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Eur Heart J Acute Cardiovasc Care: 17 Dec 2021; 10:1197-1203
King RW, Bonaca MP
Eur Heart J Acute Cardiovasc Care: 17 Dec 2021; 10:1197-1203 | PMID: 34849689
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Impact:
Abstract

A new fastening system for temporary pacing with active-fixation leads: effectiveness and safety.

Vicente-Miralles R, Martín-Langerwerf DA, Núñez-Martínez JM, Marco-Juan A, ... Gil-Guillén VF, Bertomeu-Gonzalez V
Aims
Temporary cardiac pacing with active-fixation leads (TPAFL) using a reusable permanent pacemaker generator has been shown to be safer than lead systems without fixation. However, TPAFL requires the off-label use of pacemaker leads and generators. We designed a fastening system to ensure the safety and efficacy of the procedure: the KronoSafe System®. To demonstrate the safety and effectiveness of the KronoSafe System® for temporary pacing in a series of patients receiving TPAFL.
Methods and results
A prospective cohort of 20 patients undergoing TPAFL between August 2019 and June 2020 was recruited in a Spanish region. The temporary pacemaker was implanted through jugular access and secured with the KronoSafe System®. R-wave detection, lead impedance, and capture threshold were assessed every 48 h. Complications associated with the procedure or occurring during TPAFL were recorded. There were no complications associated with temporary pacing, and the therapy was effective in all cases. TPAFL was used for a mean of 7.6 days (maximum 25 days), and 84.56% of the time in a cardiology ward.
Conclusion
TPAFL secured using the KronoSafe system® provides safe and stable cardiac stimulation for patients requiring temporary cardiac pacing.

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Eur Heart J Acute Cardiovasc Care: 16 Dec 2021; epub ahead of print
Vicente-Miralles R, Martín-Langerwerf DA, Núñez-Martínez JM, Marco-Juan A, ... Gil-Guillén VF, Bertomeu-Gonzalez V
Eur Heart J Acute Cardiovasc Care: 16 Dec 2021; epub ahead of print | PMID: 34918044
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Impact:
Abstract

Clinical Frailty Scale classes are independently associated with 6-month mortality for patients after acute myocardial infarction.

Ekerstad N, Javadzadeh D, Alexander KP, Bergström O, ... Yndigegn T, Alfredsson J
Aims
Data on the prognostic value of frailty to guide clinical decision-making for patients with myocardial infarction (MI) are scarce. To analyse the association between frailty classification, treatment patterns, in-hospital outcomes, and 6-month mortality in a large population of patients with MI.
Methods and results
An observational, multicentre study with a retrospective analysis of prospectively collected data using the SWEDEHEART registry. In total, 3381 MI patients with a level of frailty assessed using the Clinical Frailty Scale (CFS-9) were included. Of these patients, 2509 (74.2%) were classified as non-vulnerable non-frail (CFS 1-3), 446 (13.2%) were vulnerable non-frail (CFS 4), and 426 (12.6%) were frail (CFS 5-9). Frailty and non-frail vulnerability were associated with worse in-hospital outcomes compared with non-frailty, i.e. higher rates of mortality (13.4% vs. 4.0% vs. 1.8%), cardiogenic shock (4.7% vs. 2.5% vs. 1.9%), and major bleeding (4.5% vs. 2.7% vs. 1.1%) (all P < 0.001), and less frequent use of evidence-based therapies. In Cox regression analyses, frailty was strongly and independently associated with 6-month mortality compared with non-frailty, after adjustment for age, sex, the GRACE risk score components, and other potential risk factors [hazard ratio (HR) 3.32, 95% confidence interval (CI) 2.30-4.79]. A similar pattern was seen for vulnerable non-frail patients (fully adjusted HR 2.07, 95% CI 1.41-3.02).
Conclusion
Frailty assessed with the CFS was independently and strongly associated with all-cause 6-month mortality, also after comprehensive adjustment for baseline differences in other risk factors. Similarly, non-frail vulnerability was independently associated with higher mortality compared with those with preserved functional ability.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur Heart J Acute Cardiovasc Care: 13 Dec 2021; epub ahead of print
Ekerstad N, Javadzadeh D, Alexander KP, Bergström O, ... Yndigegn T, Alfredsson J
Eur Heart J Acute Cardiovasc Care: 13 Dec 2021; epub ahead of print | PMID: 34905049
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Impact:
Abstract

Prognostic impact of non-culprit chronic total occlusion over time in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention.

Milasinovic D, Mladenovic D, Zaharijev S, Mehmedbegovic Z, ... Vukcevic V, Stankovic G
Aims
Previous studies indicated that a chronic total occlusion (CTO) in a non-infarct-related artery is linked to higher mortality mainly in the acute setting in patients with ST-elevation myocardial infarction (STEMI). Our aim was to assess the temporal distribution of mortality risk associated with non-culprit CTO over years after STEMI.
Methods and results
The study included 8679 STEMI patients treated with primary percutaneous coronary intervention (PCI). Kaplan-Meier cumulative mortality curves for non-culprit CTO vs. no CTO were compared with log-rank test, with landmarks set at 30 days and 1 year. Adjusted Cox regression models were constructed to assess the impact of non-culprit CTO on mortality over different time intervals. Tests for interaction were pre-specified between non-culprit CTO and acute heart failure and left ventricular ejection fraction. The primary outcome variable was all-cause mortality, and the median follow-up was 5 years. Non-culprit CTO was present in 11.6% of patients (n = 1010). Presence of a CTO was associated with increased early [30-day adjusted hazard ratio (HR) 1.91, 95% confidence interval (CI) 1.54-2.36; P < 0.001] and late mortality (5-year adjusted HR 1.66, 95% CI 1.42-1.95; P < 0.001). Landmark analyses revealed an annual two-fold increase in mortality in patients with vs. without a CTO after the first year of follow-up. The observed pattern of mortality increase over time was independent of acute or chronic LV impairment.
Conclusions
Non-culprit CTO is independently associated with mortality over 5 years after primary PCI for STEMI, with a constant annual two-fold increase in the risk of death beyond the first year of follow-up.

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Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:990-998
Milasinovic D, Mladenovic D, Zaharijev S, Mehmedbegovic Z, ... Vukcevic V, Stankovic G
Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:990-998 | PMID: 34151365
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Impact:
Abstract

Classification performance of clinical risk scoring in suspected acute coronary syndrome beyond a rule-out troponin profile.

Khan E, Lambrakis K, Blyth A, Seshadri A, ... Nelson AJ, Chew DP
Aims
High-sensitivity cardiac troponin strategies can provide risk stratification in patients with suspected acute coronary syndrome (ACS) in the emergency department (ED). This study evaluated whether clinical risk scoring improves the classification performance of a rule-out profile in suspected ACS.
Methods and results
Patients presenting to ED with suspected ACS as part of the RAPID-TnT trial randomized to the intervention arm were included. Results ≥5 ng/L were available for all participants in this analysis. We evaluated the Thrombolysis In Myocardial Infarction (TIMI) risk score, History ECG Age Risk factors Troponin (HEART) score, and Emergency Department Assessment of Chest pain Score (EDACS) in addition to a rule-out profile based on the 0/1-h high-sensitivity cardiac troponin T protocol (<5 ng/L or ≤12 ng/L and a change of <3 ng/L at 1-h) using test performance parameters focusing on low-risk groups to identify the primary endpoint (TIMI ≤ 1, HEART ≤ 3, EDACS < 16). Primary endpoint was a composite of type 1/2 myocardial infarction (MI) at index presentation and all-cause mortality or type 1/2 MI at 30 days. A total of 3378 participants were enrolled between August 2015 and April 2019 of which 108 were ineligible/withdrew consent (intervention arm: n = 1638). Sensitivity, specificity, negative predictive value (NPV), and area under the curve (AUC) of the rule-out profile was 94.4%, 76.8%, 99.6%, and 0.86, respectively with 72.9% identified as \'low-risk\'. Adding the clinical risk scores did not improve the sensitivity, NPV, or AUC with significantly lower specificity and \'low-risk\' classified participants.
Conclusions
Addition of clinical risk scores to rule-out profile did not demonstrate improved classification performance for identifying the composite of type 1/2 MI at index presentation and all-cause mortality or type 1/2 MI at 30 days.
Clinical trials registration
URL: https://www.anzctr.org.au. Reg. No. ACTRN12615001379505.

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Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:1038-1047
Khan E, Lambrakis K, Blyth A, Seshadri A, ... Nelson AJ, Chew DP
Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:1038-1047 | PMID: 34195809
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Impact:
Abstract

Revisiting the lipid paradox in ST-elevation myocardial infarction in the Chinese population: findings from the CCC-ACS project.

Sun H, Li Z, Song X, Liu H, ... Yang Q, CCC-ACS Investigators
Aims
Previous observations revealed a negative association between low-density lipoprotein cholesterol (LDL-C) and clinical outcomes following myocardial infarction, i.e., the lower level the higher mortality, which was referred to as lipid paradox. We sought to re-evaluate this association in ST-elevation myocardial infarction (STEMI) in contemporary practice.
Methods and results
We examined the association between admission LDL-C and in-hospital mortality among 44 563 STEMI patients enrolled from 2014 to 2019 in a nationwide registry in China. A total of 43 covariates, which were temporally classified into the following three domains were used for adjustment: (i) pre-admission characteristics; (ii) percutaneous coronary intervention (PCI)-related variables; and (iii) other in-hospital medications. In-hospital mortality was 2.01% (897/44 563). When no covariate adjustment was performed, an inversely \'J-shaped\' curve was observed between admission LDL-C levels and in-hospital mortality by restricted cubic spline in logistic regression, with a threshold value of <75 mg/dL that associated with increased risk for in-hospital mortality. However, a gradual attenuation for this association was noted when step-wise adjustments were performed, with the threshold values for LDL-C decreasing from 75 mg/dL to 70 mg/dL after accounting for pre-admission characteristics, further to 65 mg/dL after accounting for PCI-related variables, and finally to no statistical association after further adjustment for other in-hospital medications.
Conclusions
In a nationwide registry in China, our findings do not support the lipid paradox in terms of in-hospital mortality in STEMI patients in contemporary practice. Previous findings in this scenario are possibly due to inadequate control for confounders.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:978-987
Sun H, Li Z, Song X, Liu H, ... Yang Q, CCC-ACS Investigators
Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:978-987 | PMID: 34263300
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Impact:
Abstract

Long-term 5-year outcome of the randomized IMPRESS in severe shock trial: percutaneous mechanical circulatory support vs. intra-aortic balloon pump in cardiogenic shock after acute myocardial infarction.

Karami M, Eriksen E, Ouweneel DM, Claessen BE, ... Lagrand WK, Henriques JPS
Aims
To assess differences in long-term outcome and functional status of patients with cardiogenic shock (CS) treated by percutaneous mechanical circulatory support (pMCS) and intra-aortic balloon pump (IABP).
Methods and results
Long-term follow-up of the multicentre, randomized IMPRESS in Severe Shock trial (NTR3450) was performed 5-year after initial randomization. Between 2012 and 2015, a total of 48 patients with severe CS from acute myocardial infarction (AMI) with ST-segment elevation undergoing immediate revascularization were randomized to pMCS by Impella CP (n = 24) or IABP (n = 24). For the 5-year assessment, all-cause mortality, functional status, and occurrence of major adverse cardiac and cerebrovascular event (MACCE) were assessed. MACCE consisted of death, myocardial re-infarction, repeat percutaneous coronary intervention, coronary artery bypass grafting, and stroke. Five-year mortality was 50% (n = 12/24) in pMCS patients and 63% (n = 15/24) in IABP patients (relative risk 0.87, 95% confidence interval 0.47-1.59, P = 0.65). MACCE occurred in 12/24 (50%) of the pMCS patients vs. 19/24 (79%) of the IABP patients (P = 0.07). All survivors except for one were in New York Heart Association Class I/II [pMCS n = 10 (91%) and IABP n = 7 (100%), P = 1.00] and none of the patients had residual angina. There were no differences in left ventricular ejection fraction between the groups (pMCS 52 ± 11% vs. IABP 48 ± 10%, P = 0.53).
Conclusions
In this explorative randomized trial of patients with severe CS after AMI, there was no difference in long-term 5-year mortality between pMCS and IABP-treated patients, supporting previously published short-term data and in accordance with other long-term CS trials.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:1009-1015
Karami M, Eriksen E, Ouweneel DM, Claessen BE, ... Lagrand WK, Henriques JPS
Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:1009-1015 | PMID: 34327527
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Impact:
Abstract

Device-related complications after Impella mechanical circulatory support implantation: an IMP-IT observational multicentre registry substudy.

Ancona MB, Montorfano M, Masiero G, Burzotta F, ... Tarantini G, Chieffo A
Aims
To report the incidence, the predictors and clinical impact of device-related complications (DRCs) in the IMP-IT (IMPella Mechanical Circulatory Support Device in Italy) registry. Impella is percutaneous left ventricular assist devices, which provides mechanical circulatory support both in cardiogenic shock (CS) and high-risk percutaneous coronary intervention (HR-PCI). The IMP-IT registry is a multicentre registry evaluating the trends in use and clinical outcomes of Impella in Italy.
Methods and results
A total of 406 patients have been included in this registry: 56.4% in the setting of CS, while 43.6% patients in the setting of HR-PCI. DRCs were defined as a composite endpoint of access-site bleeding, limb ischaemia, vascular complication requiring treatment, haemolysis, aortic injury, and left ventricular perforation. DRC incidence in the overall population was 25.6%, with significantly higher rate in the CS (37.1%) than in the HR-PCI (10.7%) group. The most frequent complication was haemolysis (11.8%), which occurred almost exclusively in CS population. Access-site bleeding was observed in 9.6% of the overall population, with no significant difference between the two groups. Limb ischaemia was observed in 8.3% of the overall population, with significantly higher rate in the CS group. CS and right ventricular dysfunction appear as the strongest independent predictors of DRC. One-year mortality in patients with DRC appears higher than in patients with no DRC. However, DRC was not confirmed as an independent predictor of 1-year mortality at multivariate analysis.
Conclusion
In the IMP-IT registry, the rate of DRC was 25.6%, with CS being the strongest independent predictor. DRC was not found as an independent predictor of 1-year mortality.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:999-1006
Ancona MB, Montorfano M, Masiero G, Burzotta F, ... Tarantini G, Chieffo A
Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:999-1006 | PMID: 34389852
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Impact:
Abstract

Predicting mortality in cardiac care unit patients: external validation of the Mayo cardiac intensive care unit admission risk score.

Chichareon P, Nilmoje T, Suriyaamorn W, Preechawettayakul I, Suwanugsorn S
Aims
The Mayo Cardiac Intensive Care Unit Admission Risk Score (M-CARS) had excellent performance in predicting in-hospital mortality in the US population. We sought to validate the M-CARS for in-hospital and post-discharge mortality in Asian patients admitted to the cardiac care unit (CCU).
Methods and results
Patients admitted to the CCU of a tertiary care centre between July 2015 and December 2019 were included into the study. Patients with intra-hospital transfer to the CCU due to intensive care unit overflow, postoperative cardiac surgery, or for monitoring after elective procedures were excluded. Cardiac arrest, cardiogenic shock, respiratory failure, Braden skin score, blood urea nitrogen, anion gap, and red cell distribution width, were used to calculate the M-CARS. Patients were stratified into three groups, according to the M-CARS (<2, 2-6, >6). Of 1988 patients in the study, 30.1% were female with a median age of 65 years. Prevalence of cardiogenic shock and respiratory failure at admission were 2.8% and 4.5%, respectively. One hundred and seventeen patients died during the admission (mortality rate of 5.9%). The in-hospital mortality rate in patients with M-CARS of <2, 2-6, and >6 was 1.1%, 9.8%, and 35.5%, respectively. C-statistic of M-CARS for in-hospital mortality was 0.840 (95% CI 0.805-0.873); whereas, it was 0.727 (95% CI 0.690-0.761) for 1-year post-discharge mortality. Calibration plot showed good agreement between predicted and observed in-hospital mortality in the majority of patients.
Conclusions
The M-CARS was useful in our study, in terms of discrimination and calibration. M-CARS identified high-risk patients in CCU, who had unacceptably high mortality rate during hospital stay and thereafter.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:1065-1073
Chichareon P, Nilmoje T, Suriyaamorn W, Preechawettayakul I, Suwanugsorn S
Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:1065-1073 | PMID: 34448824
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Impact:
Abstract

External validation of a high-sensitive troponin I algorithm for rapid evaluation of acute myocardial infarction in a Danish cohort.

Andersen CF, Bang C, Lauridsen KG, Frederiksen CA, ... Hornung N, Løfgren B
Aims
An accelerated diagnostic algorithm for ruling-in or ruling-out myocardial infarction (MI) after 1 hour (1 h) has recently been derived and internally validated for the Siemens ADVIA Centaur TNIH assay. We aimed to validate the diagnostic performance of the TNIH 0 h/1 h algorithm ad modum Boeddinghaus in a Danish cohort.
Methods and results
Patients with chest pain suggestive of MI were prospectively enrolled. High-sensitive troponin I (TNIH) was measured at admission (0 h) and after 30 minutes (30 m), 1 h, and 3 hours (3 h). We externally validated the TNIH 0 h/1 h algorithm ad modum Boeddinghaus in Danish patients. Moreover, we applied the algorithm using the second TNIH measurement at 30 m instead of 1 h. We enrolled 1003 patients: median (Q1-Q3) age 64 (52-74) years, 42% female, and 23% with previous MI. Myocardial infarction was the final diagnosis in 9% of patients. Median (Q1-Q3) times from admission to 30 m and 1 h blood draw were 35 min (30-37 min) and 67 min (62-75 min), respectively. Using the 0 h and 1 h results, 468 (47%) patients were assigned to rule-out, 104 (10%) to rule-in, and 431 (43%) to the observational zone. This resulted in a negative predictive value of 100% (95% confidence interval: 99.2-100%), sensitivity of 100% (95.9-100%), positive predictive value of 79.8 (70.8-87.0%), and specificity of 97.7% (96.5-98.6%). The diagnostic performance after 30 m was similar.
Conclusions
The TNIH 0 h/1 h algorithm ad modum Boeddinghaus performed excellently for rule-out of MI in a Danish cohort. The Boeddinghaus algorithm also performed excellently after only 30 m.
Trial registration number
NCT03634384.
Trial registry name and url
Rapid Use of High-Sensitive Cardiac Troponin I for Ruling-in and Ruling-out Acute Myocardial Infarction (RACING-MI), https://clinicaltrials.gov/ct2/show/NCT03634384.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:1056-1064
Andersen CF, Bang C, Lauridsen KG, Frederiksen CA, ... Hornung N, Løfgren B
Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:1056-1064 | PMID: 34423355
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Impact:
Abstract

Clinical significance of the N-terminal pro-brain natriuretic peptide and B-type natriuretic peptide ratio in the acute phase of acute heart failure.

Sawatani T, Shirakabe A, Okazaki H, Matsushita M, ... Shimizu W, Asai K
Aims
Serum N-terminal pro-brain natriuretic peptide (NT-proBNP) and B-type natriuretic peptide (BNP) levels are rarely evaluated simultaneously in the acute phase of acute heart failure (AHF).
Method and results
A total of 1207 AHF patients were enrolled, and 1002 patients were analysed. Blood samples were collected within 15 min of admission. Patients were divided into two groups according to the median value of the NT-proBNP/BNP ratio [low-NT-proBNP/BNP group (Group L) vs. high-NT-proBNP/BNP group (Group H)]. A multivariate logistic regression model showed that the C-reactive protein level (per 1-mg/dL increase), Controlling Nutrition Status score (per 1-point increase), and estimated glomerular filtration rate (eGFR, per 10-mL/min/1.73 m2 increase) were independently associated with Group H [odds ratio (OR) 1.049, 95% confidence interval (CI) 1.009-1.090, OR 1.219, 95% CI 1.140-1.304, and OR 1.543, 95% CI 1.401-1.698, respectively]. A Kaplan-Meier curve analysis showed that the prognosis was significantly poorer in Group H than in Group L, and a multivariate Cox regression model revealed Group H to be an independent predictor of 180-day mortality [hazard ratio (HR) 3.084, 95% CI 1.838-5.175] and HF events (HR 1.963, 95% CI 1.340-2.876). The same trend in the prognostic impact was significantly observed in the low-BNP (<810 pg/mL, n = 501), high-BNP (≥810 pg/mL, n = 501), and low-eGFR (<60 mL/min/1.73 m2, n = 765) cohorts, and tended to be observed in normal-eGFR (≥60 mL/min/1.73 m2, n = 237) cohort.
Conclusion
A high NT-proBNP/BNP ratio was associated with a non-cardiac condition (e.g. inflammatory reaction, nutritional status, and renal dysfunction) and is independently associated with adverse outcomes in AHF.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:1016-1026
Sawatani T, Shirakabe A, Okazaki H, Matsushita M, ... Shimizu W, Asai K
Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:1016-1026 | PMID: 34432003
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Impact:
Abstract

Outcomes in patients with acute myocardial infarction and history of illicit drug use: a French nationwide analysis.

Ma I, Genet T, Clementy N, Bisson A, ... Ivanes F, Fauchier L
Aims 
Several reports suggest that illicit drug use may be a major cause of acute myocardial infarction (AMI) independently of smoking habits and associated with a poorer prognosis. The aim of our study was to evaluate the impact of illicit drug use on (i) the risk of AMI and (ii) its prognosis.
Methods and results 
This French longitudinal cohort study was based on the administrative hospital-discharge database from the entire population. First, we collected data for all patients admitted in hospital in 2013 with at least 5 years of follow-up to identify potential predictors of AMI. In a second phase, we collected data for all patients admitted with AMI from January 2010 to December 2018. We identified patients with a history of illicit drug use (cannabis, cocaine, or opioid). These patients were matched with patients without illicit drug use to assess their prognosis. In 2013, 3 381 472 patients were hospitalized with a mean follow-up of 4.7 ± 1.8 years. In multivariable analysis, among all drugs under evaluation, only cannabis use was significantly associated with a higher risk of AMI [HR 1.32 (95% CI 1.09-1.59), P = 0.004]. Between January 2010 and December 2018, we then identified 738 899 AMI patients. Among these patients, 3827 (0.5%) had a known history of illicit drug use. These patients were younger, most often male and had less comorbidities. After 1:1 propensity score matching, during a mean follow-up of 1.9 ± 2.3 years, there was no significant difference between patients without illicit drug use and patients with illicit drug use regarding all-cause death, cardiovascular death, stroke, or heart failure.
Conclusion 
In a large and systematic nationwide analysis, cannabis use was an independent risk factor for the incidence of AMI. However, the prognosis of illicit drug users presenting with AMI was similar to patients without illicit drug use.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:1027-1037
Ma I, Genet T, Clementy N, Bisson A, ... Ivanes F, Fauchier L
Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:1027-1037 | PMID: 34453835
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Impact:
Abstract

Potential of unenhanced computed tomography as a screening tool for acute aortic syndromes.

Otani T, Ichiba T, Kashiwa K, Naito H
Aims
Contrast-enhanced computed tomography (CE-CT) is the gold standard for diagnosing acute aortic syndromes (AAS). Unenhanced computed tomography (unenhanced-CT) also provides specific findings for AAS; however, its diagnostic ability is not well discussed. This study aims to evaluate the potential of unenhanced-CT as an AAS screening tool.
Methods and results
We retrospectively examined AAS patients who visited our hospital between 2011 and 2021 to validate the diagnostic value of unenhanced-CT alone and along with the aortic dissection detection risk score (ADD-RS) plus D-dimer. Acute aortic syndrome was assessed as detectable using unenhanced-CT with any of the following findings: pericardial haemorrhage, high-attenuation haematoma, and displacement of intimal calcification or a flap. Of the 316 AAS cases, 292 (92%) were detectable with unenhanced-CT. Twenty-four (8%) cases undetectable with unenhanced-CT involved younger patients [median (interquartile range), 45 (42-51) years vs. 72 (63-80) years, P < 0.001] and patients more frequently complicated with a patent false lumen (79% vs. 42%, P < 0.001). Acute aortic syndrome-detection rate with unenhanced-CT increased with age, reaching 98% (276/282) in those ≥50 years of age and 100% (121/121) in those ≥75 years of age. With the ADD-RS plus D-dimer, there was only one AAS case undetectable with unenhanced-CT among patients ≥50 years of age, except for cases with the ADD-RS ≥1 plus D-dimer levels of ≥0.5 μg/mL.
Conclusion
Acute aortic syndromes in younger patients and patients with a patent false lumen could be misdiagnosed with unenhanced-CT alone. The combination of the ADD-RS plus D-dimer and unenhanced-CT could minimize AAS misdiagnosis while avoiding over-testing with CE-CT.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:967-975
Otani T, Ichiba T, Kashiwa K, Naito H
Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:967-975 | PMID: 34458899
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Impact:
Abstract

Temporal trends in patient characteristics, presumed causes, and outcomes following cardiogenic shock between 2005 and 2017: a Danish registry-based cohort study.

Petersen LT, Riddersholm S, Andersen DC, Polcwiartek C, ... Rasmussen BS, Kragholm KH
Aims
Most cardiogenic shock (CS) studies focus on acute coronary syndrome (ACS). Contemporary data on temporal trends in patient characteristics, presumed causes, treatments, and outcomes of ACS- and in particular non-ACS-related CS patients are sparse.
Methods and results
Using nationwide medical registries, we identified patients with first-time CS between 2005 and 2017. Cochrane-Armitage trend tests were used to examine temporal changes in presumed causes of CS, treatments, and outcomes. Among 14 363 CS patients, characteristics remained largely stable over time. As presumed causes of CS, ACS (37.1% in 2005 to 21.4% in 2017), heart failure (16.3% in 2005 to 12.0% in 2017), and arrhythmias (13.0% in 2005 to 10.9% in 2017) decreased significantly over time; cardiac arrest increased significantly (11.3% in 2005 to 24.5% in 2017); and changes in valvular heart disease were insignificant (11.5% in 2005 and 11.6% in 2017). Temporary left ventricular assist device, non-invasive ventilation, and extracorporeal membrane oxygenation use increased significantly over time; intra-aortic balloon pump and mechanical ventilation use decreased significantly. Over time, 30-day and 1-year mortality were relatively stable. Significant decreases in 30-day and 1-year mortality for patients presenting with ACS and arrhythmias and a significant increase in 1-year mortality in patients presenting with heart failure were seen.
Conclusion
Between 2005 and 2017, we observed significant temporal decreases in ACS, heart failure, and arrhythmias as presumed causes of first-time CS, whereas cardiac arrest significantly increased. Although overall 30-day and 1-year mortality were stable, significant decreases in mortality for ACS and arrhythmias as presumed causes of CS were seen.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:1074-1083
Petersen LT, Riddersholm S, Andersen DC, Polcwiartek C, ... Rasmussen BS, Kragholm KH
Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:1074-1083 | PMID: 34648620
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Impact:
Abstract

Cardiac device troubleshooting in the intensive care unit: an educational review.

Dauw J, Dupont M, Martens P, Nijst P, Mullens W
Numerous patients with a cardiac implantable electronic device are admitted to the cardiac intensive care unit (ICU). When taking care of these patients, it is essential to have basic knowledge of potential device problems and how they could be tackled. This review summarizes common issues with pacemakers, implantable cardioverter-defibrillators, and cardiac resynchronization devices and provides a framework for troubleshooting in the ICU. In addition, specific aspects of intensive care that might interfere with cardiac devices are discussed.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:1086-1098
Dauw J, Dupont M, Martens P, Nijst P, Mullens W
Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; 10:1086-1098 | PMID: 34697640
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Impact:
Abstract

Impact of hospital volume of valve operations on the utilization and outcomes of surgery for patients with infective endocarditis.

Bansal A, Jaber WA, Cremer P, Wassif H, Mentias A, Menon V
Aims
Valve surgery is indicated and can be life-saving in patients with infective endocarditis (IE). We evaluated the impact of hospital valvular surgery volume on utilization and outcomes of surgery for IE.
Methods and results
National Inpatient Sample (NIS) database was used for IE hospitalizations from 2008 to 2015. Hospitals were divided into quartiles based on valve surgery volume with quartile 1 (Q1) indicating lowest volume and quartile 4 (Q4) highest volume. Primary outcome was utilization of valve surgery in patients hospitalized with IE and secondary outcomes were in-hospital mortality and length of stay for IE patients undergoing valve surgery. Volume-outcome relationship was analysed both as categorical (quartiles) and continuous variable (restricted cubic splines). A total of 36 471 hospitalizations for IE were identified using the NIS database from 2008 to 2015 of which 17.33% underwent any valve surgery. Utilization rates of valve surgery for IE were significantly higher in Q4 hospitals (Q1: 6.73%; Q2: 10.39%; Q3: 14.91%; Q4: 2321%). Amongst the admissions for IE endocarditis undergoing valve surgery, there was no significant difference in in-hospital mortality when analysed as a categorical variable (as quartiles). However, when analysed as a continuous variable we note significant variation in outcomes across the Q4 hospitals, with highest volume centres having reduced mortality rates and length of stay.
Conclusion
Hospital valvular surgery volume has direct impact on utilization and outcomes of surgery for IE. Given rising rates of IE and ongoing intravenous drug pandemic, there is need for regionalization of care for IE patients and development of \'endocarditis centres of excellence\' for improved patient outcomes.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; epub ahead of print
Bansal A, Jaber WA, Cremer P, Wassif H, Mentias A, Menon V
Eur Heart J Acute Cardiovasc Care: 05 Dec 2021; epub ahead of print | PMID: 34871384
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Impact:
Abstract

Incidence, clinical presentation, management, and outcome of acute pericarditis and myopericarditis.

Prepoudis A, Koechlin L, Nestelberger T, Boeddinghaus J, ... Miro O, Mueller C
Aims
Little is known about the epidemiology, clinical presentation, management, and outcome of acute pericarditis and myopericarditis.
Methods and results
The final diagnoses of acute pericarditis, myopericarditis, and non-ST-segment elevation myocardial infarction (NSTEMI) of patients presenting to seven emergency departments in Switzerland with acute chest pain were centrally adjudicated by two independent cardiologists using all information including serial measurements of high-sensitivity cardiac troponin T. The overall incidence of pericarditis and myopericarditis was estimated relative to the established incidence of NSTEMI. Current management and long-term outcome of both conditions were also assessed. Among 2533 chest pain patients, the incidence of pericarditis, myopericarditis, and NSTEMI were 1.9% (n = 48), 1.1% (n = 29), and 21.6% (n = 548), respectively. Accordingly, the estimated incidence of pericarditis and myopericarditis in Switzerland was 10.1 [95% confidence interval (95% CI) 9.3-10.9] and 6.1 (95% CI 5.6-6.7) cases per 100 000 population per year, respectively, vs. 115.0 (95% CI 112.3-117.6) cases per 100 000 population per year for NSTEMI. Pericarditis (85% male, median age 46 years) and myopericarditis (62% male, median age 56 years) had male predominance, and commonly (50% and 97%, respectively) resulted in hospitalization. No patient with pericarditis or myopericarditis died or had life-threatening arrhythmias within 30 days [incidence 0% (95% CI 0.0-4.8%)]. Compared with NSTEMI, the 2-year all-cause mortality adjusted hazard ratio of pericarditis and myopericarditis was 0.40 (95% CI 0.05-2.96), being 0.59 (95% CI 0.40-0.88) for non-cardiac causes of chest pain.
Conclusion
Pericarditis and myopericarditis are substantially less common than NSTEMI and have an excellent short- and long-term outcome.
Clinical trial registration
ClinicalTrial.gov, number NCT00470587, https://clinicaltrials.gov/ct2/show/NCT00470587.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 27 Nov 2021; epub ahead of print
Prepoudis A, Koechlin L, Nestelberger T, Boeddinghaus J, ... Miro O, Mueller C
Eur Heart J Acute Cardiovasc Care: 27 Nov 2021; epub ahead of print | PMID: 34849666
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Impact:
Abstract

Association of plasma interleukin-6 with infarct size, reperfusion injury, and adverse remodelling after ST-elevation myocardial infarction.

Tiller C, Reindl M, Holzknecht M, Lechner I, ... Metzler B, Reinstadler SJ
Aims 
Little is known about the clinical relevance of interleukin (IL)-6 in patients with acute ST-elevation myocardial infarction (STEMI). This study examined the possible associations of plasma IL-6 concentrations with infarct size (IS), reperfusion injury and adverse left ventricular remodelling (LVR), in STEMI patients treated with primary percutaneous coronary intervention (PCI).
Methods and results
We prospectively included 170 consecutive STEMI patients (median age 57 years, 14% women) treated with primary PCI between 2017 and 2019. Blood samples for biomarker analyses including IL-6 were collected on Day 2. Left ventricular ejection fraction (LVEF), IS, and reperfusion injury [microvascular obstruction (MVO) and intramyocardial haemorrhage (IMH)] were determined using cardiac magnetic resonance (CMR) imaging on Day 4. Left ventricular remodelling was defined as ≥10% increase in left ventricular end-diastolic volume from baseline to 4 months CMR follow-up. Patients with IL-6 concentrations ≥median (17 ng/L) showed a significantly lower LVEF (43% vs. 52%, P < 0.001), larger IS (22% vs. 13%, P < 0.001), larger MVO (1.9% vs. 0.0%, P < 0.001), and more frequent IMH (52% vs. 18%, P < 0.001). Left ventricular remodelling was more common in patients with IL-6 ≥ median (24% vs. 9%, P = 0.005). In both linear and binary multivariable regression analyses, IL-6 remained independently associated with lower LVEF [odds ratio (OR): 0.10, 95% confidence interval (CI) 0.02-0.42, P = 0.002], larger IS (OR: 5.29, 95% CI 1.52-18.40, P = 0.009), larger MVO (OR: 5.20, 95% CI 1.30-20.85, P = 0.020), with presence of IMH (OR: 3.73, 95% CI 1.27-10.99, P = 0.017), and adverse LVR (OR: 2.72, 95% 1.06-6.98, P = 0.038).
Conclusions 
High concentrations of circulating plasma IL-6 on Day 2 after STEMI were independently associated with worse myocardial function, larger infarct extent, more severe reperfusion injury, and a higher likelihood for LVR, suggesting IL-6 as a useful biomarker of more serious outcome and potential therapeutic target.
Clinical trial registration
https://clinicaltrials.gov/ct2/show/NCT04113356;NCT04113356.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 24 Nov 2021; epub ahead of print
Tiller C, Reindl M, Holzknecht M, Lechner I, ... Metzler B, Reinstadler SJ
Eur Heart J Acute Cardiovasc Care: 24 Nov 2021; epub ahead of print | PMID: 34849677
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Impact:
Abstract

Referral decisions based on a pre-hospital HEART score in suspected non-ST-elevation acute coronary syndrome: final results of the FamouS Triage study.

Tolsma RT, Fokkert MJ, van Dongen DN, Badings EA, ... Ottervanger JP, van \'t Hof AWJ
Aims
Although pre-hospital risk stratification of patients with suspected non-ST-elevation acute coronary syndrome (NSTE-ACS) by ambulance paramedics is feasible, it has not been investigated in daily practice whether referral decisions based on this risk stratification is safe and does not increase major adverse cardiac events (MACE). In Phase III of the FamouS Triage study, it was investigated whether referral decisions by ambulance paramedics based on a pre-hospital HEART score, is non-inferior to routine management.
Methods and results
FamouS Triage Phase III is a non-inferiority study, comparing the occurrence of MACE before (Phase II) and after (Phase III) implementation of referral decisions based on a pre-hospital HEART score. In Phase II, all patients were risk-stratified and referred to the hospital; in Phase III, low-risk patients (HEART score ≤ 3) were not referred. Primary endpoint was MACE (acute coronary syndrome, revascularization, or death) within 45 days. A total of 1236 patients were included. Mean age was 63 years, 43% were female, 700 patients were included in the second phase and 536 in the third phase in which 149 low-risk patients (28%) were not transferred to the hospital. Occurrence of 45 days MACE was 16.6% in Phase II and 15.7% in Phase III (P = 0.67). Percentage MACE in low-risk patients was 2.9% in Phase II and 1.3% in Phase III. After adjustments for differences in baseline variables, the hazard ratio of 45 days MACE in Phase III was 0.88 (95% confidence interval 0.63-1.25) as compared to Phase II.
Conclusion
Pre-hospital risk stratification of patients with suspected NSTE-ACS, avoiding hospitalization of a substantial number of low-risk patients, seems feasible and non-inferior to transferring all patients to the hospital.

© The Author(s) 2021. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur Heart J Acute Cardiovasc Care: 24 Nov 2021; epub ahead of print
Tolsma RT, Fokkert MJ, van Dongen DN, Badings EA, ... Ottervanger JP, van 't Hof AWJ
Eur Heart J Acute Cardiovasc Care: 24 Nov 2021; epub ahead of print | PMID: 34849660
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Abstract

Recognition of acute myocardial infarction caused by spontaneous coronary artery dissection of first septal perforator.

Sharkey SW, Alfadhel M, Thaler C, Lin D, ... Henry TD, Saw J
Aims 
Spontaneous coronary artery dissection (SCAD) diagnosis is challenging as angiographic findings are often subtle and differ from coronary atherosclerosis. Herein, we describe characteristics of patients with acute myocardial infarction (MI) caused by first septal perforator (S1) SCAD.
Methods and results 
Patients were gathered from SCAD registries at Minneapolis Heart Institute and Vancouver General Hospital. First septal perforator SCAD prevalence was 11 of 1490 (0.7%). Among 11 patients, age range was 38-64 years, 9 (82%) were female. Each presented with acute chest pain, troponin elevation, and non-ST-elevation MI diagnosis. Initial electrocardiogram demonstrated ischaemia in 5 (45%); septal wall motion abnormality was present in 4 (36%). Angiographic type 2 SCAD was present in 7 (64%) patients with S1 TIMI 3 flow in 7 (64%) and TIMI 0 flow in 2 (18%). Initial angiographic interpretation failed to recognize S1-SCAD in 6 (55%) patients (no culprit, n = 5, septal embolism, n = 1). First septal perforator SCAD diagnosis was established by review of initial coronary angiogram consequent to cardiovascular magnetic resonance (CMR) demonstrating focal septal late gadolinium enhancement with corresponding oedema (n = 3), occurrence of subsequent SCAD event (n = 2), or second angiogram showing healed S1-SCAD (n = 1). Patients were treated conservatively, each with ejection fraction >50%.
Conclusion 
First septal perforator SCAD events may be overlooked at initial angiography and mis-diagnosed as \'no culprit\' MI. First septal perforator SCAD prevalence is likely greater than reported herein and dependent on local expertise and availability of CMR imaging. Spontaneous coronary artery dissection events may occur in intra-myocardial coronary arteries, approaching the resolution limits of invasive coronary angiography.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:933-939
Sharkey SW, Alfadhel M, Thaler C, Lin D, ... Henry TD, Saw J
Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:933-939 | PMID: 33580787
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Abstract

Effect of primary percutaneous coronary intervention on in-hospital outcomes among active cancer patients presenting with ST-elevation myocardial infarction: a propensity score matching analysis.

Mohamed MO, Van Spall HGC, Kontopantelis E, Alkhouli M, ... Bhatt DL, Mamas MA
Aims
Primary percutaneous coronary intervention (pPCI) is the gold standard, guideline-recommended revascularization strategy in patients presenting with ST-elevation myocardial infarction (STEMI). However, there are limited data on its use and effectiveness among patients with active cancer presenting with STEMI.
Methods and results
All STEMI hospitalizations between 2004 and 2015 from the National Inpatient Sample were retrospectively analysed, stratified by cancer type. Propensity score matching was performed to estimate the average treatment effect of pPCI in each cancer on in-hospital adverse events, including major adverse cardiovascular and cerebrovascular events (MACCE) and its individual components, and compare treatment effect between cancer and non-cancer patients. Out of 1 870 815 patients with STEMI, 38 932 (2.1%) had a current cancer diagnosis [haematological: 11 251 (28.9% of all cancers); breast: 4675 (12.0%); lung: 9538 (24.5%); colon: 3749 (9.6%); prostate: 9719 (25.0%)]. Patients with cancer received pPCI less commonly than those without cancer (from 54.2% for lung cancer to 70.6% for haematological vs. 82.3% in no cancer). Performance of pPCI was strongly associated with lower adjusted probabilities of MACCE and all-cause mortality in the cancer groups compared with the no cancer group. There was no significant difference in estimated average pPCI treatment effect between the cancer groups and non-cancer group.
Conclusion
Primary percutaneous coronary intervention is underutilized in STEMI patients with current cancer despite its significantly lower associated rates of in-hospital all-cause mortality and MACCE that is comparable to patients without cancer. Further work is required to assess the long-term benefit and safety of pPCI in this high-risk group.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:829-839
Mohamed MO, Van Spall HGC, Kontopantelis E, Alkhouli M, ... Bhatt DL, Mamas MA
Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:829-839 | PMID: 33587752
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Abstract

Spontaneous coronary artery dissection in old patients: clinical features, angiographic findings, management and outcome.

Díez-Villanueva P, García-Guimaraes M, Sanz-Ruiz R, Roura G, ... Salamanca J, Alfonso F
Aims
Spontaneous coronary artery dissection (SCAD) is a relatively rare but well-known cause of acute coronary syndrome. Clinical features, angiographic findings, management and outcomes of SCAD in old patients (>65 years of age) remain unknown.
Methods and results
The Spanish multicentre prospective SCAD registry (NCT03607981), included 318 consecutive patients with SCAD. Data were collected between June 2015 and April 2019. All angiograms were analysed in a centralized corelab. For the purposes of this study, patients were classified according to age in two groups <65 and ≥65 years old and in-hospital outcomes were analysed. Fifty-five patients (17%) were ≥65 years old (95% women). Older patients had more often hypertension (76% vs. 29%, P < 0.01) and dyslipidaemia (56% vs. 30%, P < 0.01), and less previous (4% vs. 18%, P < 0.001) or current smoking habit (4% vs. 33%, P < 0.001). An identifiable trigger was less often present in old patients (27% vs. 43%, P = 0.028). They also had more often severe coronary tortuosity (36% vs. 11%, P = 0.036) and showed more frequently coronary ectasia (24% vs. 9%, P < 0.01). Older patients were more often managed conservatively (89% vs. 75%, P = 0.025), with no significant differences in major adverse cardiac events during index admission (7% vs. 8%, P = 0.858). There were no differences between groups in terms of in-hospital stay, new acute myocardial infarction, unplanned coronary angiography or heart failure.
Conclusion
Older patients with SCAD show different clinical and angiographic characteristics compared with younger patients. Initial treatment strategy was different between groups, though in-hospital outcomes do not significantly differ (NCT03607981).

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:926-932
Díez-Villanueva P, García-Guimaraes M, Sanz-Ruiz R, Roura G, ... Salamanca J, Alfonso F
Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:926-932 | PMID: 33620451
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Abstract

Association between new-onset right bundle branch block and primary or secondary ventricular fibrillation in ST-segment elevation myocardial infarction.

Galcerá-Jornet E, Consuegra-Sánchez L, Galcerá-Tomás J, Melgarejo-Moreno A, ... Vicente-Gilabert M, Padilla-Serrano A
Aims
New-onset right bundle branch block (RBBB) in myocardial infarction (MI) is often associated with ventricular fibrillation (VF) but the nature of this relationship has not been determined.
Methods and results
Between 1998 and 2014, among other data, incidence and duration of RBBB and VF occurrence were prospectively collected in 5301 patients with ST-segment elevation MI (STEMI) admitted to two University Hospitals in Murcia (Spain). Multinomial adjusted logistic regression analyses were used to examine the association between RBBB, attending to its duration, and VF according to its primary VF (PVF) or secondary VF (SVF) character. Among 284 (5.4%) patients with new-onset RBBB, 158 were transient and 126 permanent. VF occurred in 339 (6.4%) patients, 201 PVF and 138 SVF, documented within the first 2 h of symptoms-onset in 78% and 60%, respectively. New-onset RBBB was more frequent in PVF (11.4%) and SVF (20.3%), than in non-VF (4.7%). Transient RBBB incidence was higher in PVF (9.0%) and SVF (9.4) than in non-VF (2.6%), whereas permanent RBBB was higher in SVF (10.9%) than PVF (2.5%) and non-VF (2.1%). New-onset RBBB 1.83 [95% confidence interval (CI): 1.07-3.11] and new-onset transient RBBB 2.39 (95% CI: 1.32-4.32) were independently associated with PVF. New-onset 3.03 (95% CI: 1.83-5.02), transient 2.40 (95% CI: 1.27-4.55), and permanent 2.99 (95% CI: 1.52-5.86) RBBB were independently associated with SVF.
Conclusion
New-onset RBBB and VF in STEMI are independently associated and show particularities based on the duration of the conduction disturbance and/or the primary or secondary character of the arrhythmia.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:918-925
Galcerá-Jornet E, Consuegra-Sánchez L, Galcerá-Tomás J, Melgarejo-Moreno A, ... Vicente-Gilabert M, Padilla-Serrano A
Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:918-925 | PMID: 33993235
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Abstract

Improving 1-year mortality prediction in ACS patients using machine learning.

Weichwald S, Candreva A, Burkholz R, Klingenberg R, ... Buhmann JM, Matter CM
Background
The Global Registry of Acute Coronary Events (GRACE) score is an established clinical risk stratification tool for patients with acute coronary syndromes (ACS). We developed and internally validated a model for 1-year all-cause mortality prediction in ACS patients.
Methods
Between 2009 and 2012, 2\'168 ACS patients were enrolled into the Swiss SPUM-ACS Cohort. Biomarkers were determined in 1\'892 patients and follow-up was achieved in 95.8% of patients. 1-year all-cause mortality was 4.3% (n = 80). In our analysis we consider all linear models using combinations of 8 out of 56 variables to predict 1-year all-cause mortality and to derive a variable ranking.
Results
1.3% of 1\'420\'494\'075 models outperformed the GRACE 2.0 Score. The SPUM-ACS Score includes age, plasma glucose, NT-proBNP, left ventricular ejection fraction (LVEF), Killip class, history of peripheral artery disease (PAD), malignancy, and cardio-pulmonary resuscitation. For predicting 1-year mortality after ACS, the SPUM-ACS Score outperformed the GRACE 2.0 Score which achieves a 5-fold cross-validated AUC of 0.81 (95% CI 0.78-0.84). Ranking individual features according to their importance across all multivariate models revealed age, trimethylamine N-oxide, creatinine, history of PAD or malignancy, LVEF, and haemoglobin as the most relevant variables for predicting 1-year mortality.
Conclusions
The variable ranking and the selection for the SPUM-ACS Score highlight the relevance of age, markers of heart failure, and comorbidities for prediction of all-cause death. Before application, this score needs to be externally validated and refined in larger cohorts.
Clinical trial registration
NCT01000701.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:855-865
Weichwald S, Candreva A, Burkholz R, Klingenberg R, ... Buhmann JM, Matter CM
Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:855-865 | PMID: 34015112
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Impact:
Abstract

Assessment of the ESC quality indicators in patients with acute myocardial infarction: a systematic review.

Rossello X, Massó-van Roessel A, Perelló-Bordoy A, Mas-Lladó C, ... Pons J, Peral V
Aims
To help improving quality of care in patients with acute myocardial infarction (AMI), the European Society of Cardiology (ESC) set 20 quality indicators (QIs). There is a need to compile and summarize QI availability, feasibility, and global compliance in real-world registries.
Methods and results
A systematic review of PubMed and Web of Science was conducted including all original articles reporting the use of the ESC QIs in AMI patients. Methods and reporting follow the guidelines of the PRISMA Statement and the protocol was registered in PROSPERO (CRD42020190541). Among the 220 screened citations, 9 studies met the inclusion criteria after full-text review. Among these 9 studies, there were 11 different cohorts. Patients were recruited from three different continents (31 countries). The number of QIs assessed ranged from 6 to 20, with 5 studies (56%) reporting data for at least 75% of the 20 QIs. There were room for improvement in terms of data availability (i.e. domain 6 measuring patient\'s satisfaction), feasibility (i.e. difficulties to find all data for composite QIs in domain 7), and attainment (i.e. high levels of compliance with the percentage of reperfused ST-segment elevation myocardial infarction patients, but low levels for a timely reperfusion).
Conclusions
Our systematic review has shown that it is possible to measure most QIs in existing registries, and that there is room for improvement in terms of data availability, feasibility, and levels of attainment to QIs. Our findings may influence the design of future registries to capture this information and help in QIs definition updates.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:878-889
Rossello X, Massó-van Roessel A, Perelló-Bordoy A, Mas-Lladó C, ... Pons J, Peral V
Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:878-889 | PMID: 34151368
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Abstract

A-lines and B-lines in patients with acute heart failure.

Johannessen Ø, Claggett B, Lewis EF, Groarke JD, ... Solomon SD, Platz E
Aims
Lung ultrasound (LUS) relies on detecting artefacts, including A-lines and B-lines, when assessing dyspnoeic patients. A-lines are horizontal artefacts and characterize normal lung, whereas multiple vertical B-lines are associated with increased lung density. We sought to assess the prevalence of A-lines and B-lines in patients with acute heart failure (AHF) and examine their clinical correlates and their relationship with outcomes.
Methods and results
In a prospective cohort study of adults with AHF, eight-zone LUS and echocardiography were performed early during the hospitalization and pre-discharge at an imaging depth of 18 cm. A- and B-lines were analysed separately off-line, blinded to clinical and outcome data. Of 164 patients [median age 71 years, 61% men, mean ejection fraction (EF) 40%], the sum of A-lines at baseline ranged from 0 to 19 and B-line number from 0 to 36. One hundred and fifty-six patients (95%) had co-existing A-lines and B-lines at baseline. Lower body mass index and lower chest wall thickness were associated with a higher number of A-lines (P trend < 0.001 for both). In contrast to B-lines, there was no significant change in the number of A-lines from baseline to discharge (median 6 vs. 5, P = 0.80). While B-lines were associated with 90-day HF readmission or death, A-lines were not [HR 1.67, 95% confidence interval (CI) 1.11-2.51 vs. HR 0.97, 95% CI 0.65-1.43].
Conclusions
A-lines and B-lines on LUS co-exist in the vast majority of hospitalized patients with AHF. In contrast to B-lines, A-lines were not associated with adverse outcomes.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:909-917
Johannessen Ø, Claggett B, Lewis EF, Groarke JD, ... Solomon SD, Platz E
Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:909-917 | PMID: 34160009
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Impact:
Abstract

Prognostic value of shock index in patients admitted with non-ST-segment elevation myocardial infarction: the ARIC study community surveillance.

Chunawala ZS, Hall ME, Arora S, Dai X, ... Matsushita K, Caughey MC
Aims
Shock index (SI), defined as the ratio of heart rate (HR) to systolic blood pressure (SBP), is easily obtained and predictive of mortality in patients with ST-segment elevation myocardial infarction. However, large-scale evaluations of SI in patients with non-ST-segment elevation myocardial infarction (NSTEMI) are lacking.
Methods and results
Hospitalizations for acute myocardial infarction were sampled from four US areas by the Atherosclerosis Risk in Communities (ARIC) study and classified by physician review. Shock index was derived from the HR and SBP at first presentation and considered high when ≥0.7. From 2000 to 2014, 18 301 weighted hospitalizations for NSTEMI were sampled and had vitals successfully obtained. Of these, 5753 (31%) had high SI (≥0.7). Patients with high SI were more often female (46% vs. 39%) and had more prevalent chronic kidney disease (40% vs. 32%). TIMI (Thrombolysis in Myocardial Infarction) risk scores were similar between the groups (4.3 vs. 4.2), but GRACE (Global Registry of Acute Coronary Syndrome) score was higher with high SI (140 vs. 118). Angiography, revascularization, and guideline-directed medications were less often administered to patients with high SI, and the 28-day mortality was higher (13% vs. 5%). Prediction of 28-day mortality by SI as a continuous measurement [area under the curve (AUC): 0.68] was intermediate to that of the GRACE score (AUC: 0.87) and the TIMI score (AUC: 0.54). After adjustments, patients with high SI had twice the odds of 28-day mortality (odds ratio = 2.02; 95% confidence interval: 1.46-2.80).
Conclusion
The SI is easily obtainable, performs moderately well as a predictor of short-term mortality in patients hospitalized with NSTEMI, and may be useful for risk stratification in emergency settings.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:869-877
Chunawala ZS, Hall ME, Arora S, Dai X, ... Matsushita K, Caughey MC
Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:869-877 | PMID: 34263294
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Impact:
Abstract

Prognostic impact of left ventricular ejection fraction recovery in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: analysis of an 11-year all-comers registry.

Otero-García O, Cid-Álvarez AB, Juskova M, Álvarez-Álvarez B, ... Trillo-Nouche R, González-Juanatey JR
Aims
Left ventricular ejection fraction (LVEF) recovery after an ST-segment elevation myocardial infarction (STEMI) identifies a group of patients with a better prognosis. However, the association between long-term outcomes and LVEF recovery among patients with STEMI undergoing primary percutaneous coronary intervention (PCI) has not yet been well investigated. Our study aims to detect differences in long-term all-cause and cardiovascular mortality between patients who recover LVEF at 1-year post-PCI and those who do not, and search for predictors of LVEF recovery.
Methods and results
This is a retrospective, single-centre study of 2170 consecutive patients admitted for STEMI in which primary PCI is performed. LVEF was determined at admission and at 1-year follow-up. The primary outcomes were long-term all-cause and cardiovascular mortality. Among the 2168 patients with baseline LVEF data, 822 (38%) had a LVEF < 50% and 1346 (62%) ≥ 50%. Among those with LVEF < 50%, LVEF data at 1-year were available in 554, and 299 (54.0%) presented with complete recovery (LVEF ≥ 50%). LVEF recovery was associated with a reduction in long-term all-cause and cardiovascular mortality (P < 0.0001). Female sex, treatment with ACEIs, lower creatinine levels, infarct-related artery different from the left main or left anterior descendent artery, and absence of prior ischaemic heart disease were independently associated with LVEF recovery.
Conclusions
Nearly 40% of patients with STEMI undergoing primary PCI presented with LVEF depression at hospital admission. Among them, LVEF recovery at 1-year occurred in more than 50% and was independently associated with a significant decrease in long-term all-cause and cardiovascular mortality.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:898-908
Otero-García O, Cid-Álvarez AB, Juskova M, Álvarez-Álvarez B, ... Trillo-Nouche R, González-Juanatey JR
Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:898-908 | PMID: 34327531
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Impact:
Abstract

Mechanical ventilation at the time of heart transplantation and associations with clinical outcomes.

Miller PE, Mullan CW, Chouairi F, Sen S, ... Desai NR, Ahmad T
Aims
The impact of mechanical ventilation (MV) at the time of heart transplantation is not well understood. In addition, MV was recently removed as a criterion from the new US heart transplantation allocation system. We sought to assess for the association between MV at transplantation and 1-year mortality.
Methods and results
We utilized the United Network for Organ Sharing database and included all adult, single organ heart transplantations from 1990 to 2019. We utilized multivariable logistic regression adjusting for demographics, comorbidities, and markers of clinical acuity. We identified 60 980 patients who underwent heart transplantation, 2.4% (n = 1431) of which required MV at transplantation. Ventilated patients were more likely to require temporary mechanical support, previous dialysis, and had a shorter median waitlist time (21 vs. 95 days, P < 0.001). At 1 year, the mortality was 33.7% (n = 484) for ventilated patients and 11.7% (n = 6967) for those not ventilated at the time of transplantation (log-rank P < 0.001). After multivariable adjustment, patients requiring MV continued to have a substantially higher 90-day [odds ratio (OR) 3.20, 95% confidence interval (CI): 2.79-3.66, P < 0.001] and 1-year mortality (OR 2.67, 95% CI: 2.36-3.03, P < 0.001). For those that survived to 90 days, the adjusted mortality at 1 year continued to be higher (OR 1.48, 95% CI: 1.16-1.89, P = 0.002).
Conclusion
We found a strong association between the presence of MV at heart transplantation and 90-day and 1-year mortality. Future studies are needed to identify which patients requiring MV have reasonable outcomes, and which are associated with substantially poorer outcomes.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:843-851
Miller PE, Mullan CW, Chouairi F, Sen S, ... Desai NR, Ahmad T
Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:843-851 | PMID: 34389855
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Impact:
Abstract

Past, present, and future of mortality risk scores in the contemporary cardiac intensive care unit.

Jentzer JC, Rossello X
Risk stratification dates to the dawn of the cardiac intensive care unit (CICU). As the CICU has evolved from a dedicated unit caring for patients with acute myocardial infarction to a complex healthcare environment encompassing a broad array of acute and chronic cardiovascular pathology, an expanding array of risk scores are available that can be applied to CICU patients. Most of these scores were designed for use either in patients with a specific acute cardiovascular diagnosis or unselected critically ill patients, and risk scores developed in other populations often underperform in the CICU. More recently, risk scores have been developed specific to the CICU population, demonstrating improved performance. All existing risk scores have relevant limitations, both in terms of performance and applicability to patient care. Risk scores have been predominantly developed to predict short-term mortality, either by quantifying severity of illness or by incorporating other risk factors for mortality. It is essential to distinguish mortality risk attributable to severity of illness, which may be modifiable through intervention, from mortality risk attributable to non-modifiable risk factors. This review discusses established risk scores applicable to the CICU population, details how risk score performance is characterized, describes how new risk scores can be developed, explains how the information provided by risk scores can be used in clinical practice, and highlights how novel risk stratification approaches can be developed.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:940-946
Jentzer JC, Rossello X
Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:940-946 | PMID: 34453848
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Impact:
Abstract

Evaluation and management of cancer patients presenting with acute cardiovascular disease: a Consensus Document of the Acute CardioVascular Care (ACVC) association and the ESC council of Cardio-Oncology-Part 1: acute coronary syndromes and acute pericardial diseases.

Gevaert SA, Halvorsen S, Sinnaeve PR, Sambola A, ... Okines A, Asteggiano R
Advances in treatment, common cardiovascular (CV) risk factors and the ageing of the population have led to an increasing number of cancer patients presenting with acute CV diseases. These events may be related to the cancer itself or the cancer treatment. Acute cardiac care specialists must be aware of these acute CV complications and be able to manage them. This may require an individualized and multidisciplinary approach. We summarize the most common acute CV complications of cytotoxic, targeted, and immune-based therapies. This is followed by a proposal for a multidisciplinary approach where acute cardiologists work close together with the treating oncologists, haematologists, and radiation specialists, especially in situations where immediate therapeutic decisions are needed. In this first part, we further focus on the management of acute coronary syndromes and acute pericardial diseases in patients with cancer.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:947-959
Gevaert SA, Halvorsen S, Sinnaeve PR, Sambola A, ... Okines A, Asteggiano R
Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:947-959 | PMID: 34453829
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Impact:
Abstract

Comparison of risk prediction models in infarct-related cardiogenic shock.

Freund A, Pöss J, de Waha-Thiele S, Meyer-Saraei R, ... Desch S, Thiele H
Aims
Several prediction models have been developed to allow accurate risk assessment and provide better treatment guidance in patients with infarct-related cardiogenic shock (CS). However, comparative data between these models are still scarce. The objective of the study is to externally validate different risk prediction models in infarct-related CS and compare their predictive value in the early clinical course.
Methods and results
The Simplified Acute Physiology Score (SAPS) II Score, the CardShock score, the IABP-SHOCK II score, and the Society for Cardiovascular Angiography and Intervention (SCAI) classification were each externally validated in a total of 1055 patients with infarct-related CS enrolled into the randomized CULPRIT-SHOCK trial or the corresponding registry. The primary outcome was 30-day all-cause mortality. Discriminative power was assessed by comparing the area under the curves (AUC) in case of continuous scores. In direct comparison of the continuous scores in a total of 161 patients, the IABP-SHOCK II score revealed best discrimination [area under the curve (AUC = 0.74)], followed by the CardShock score (AUC = 0.69) and the SAPS II score, giving only moderate discrimination (AUC = 0.63). All of the three scores revealed acceptable calibration by Hosmer-Lemeshow test. The SCAI classification as a categorical predictive model displayed good prognostic assessment for the highest risk group (Stage E) but showed poor discrimination between Stages C and D with respect to short-term-mortality.
Conclusion
Based on the present findings, the IABP-SHOCK II score appears to be the most suitable of the examined models for immediate risk prediction in infarct-related CS. Prospective evaluation of the models, further modification, or even development of new scores might be necessary to reach higher levels of discrimination.

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Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:890-897
Freund A, Pöss J, de Waha-Thiele S, Meyer-Saraei R, ... Desch S, Thiele H
Eur Heart J Acute Cardiovasc Care: 26 Oct 2021; 10:890-897 | PMID: 34529043
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Impact:

This program is still in alpha version.