Journal: Eur Heart J Acute Cardiovasc Care

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<div><h4>Trajectory and correlates of pulmonary congestion by lung ultrasound in patients with acute myocardial infarction: Insights from PARADISE-MI.</h4><i>Platz E, Claggett B, Jering KS, Kovacs A, ... Pfeffer MA, Shah A</i><br /><b>Background</b><br />PARADISE-MI examined the efficacy of sacubitril/valsartan in acute myocardial infarction (AMI) complicated by reduced left ventricular ejection fraction (LVEF), pulmonary congestion or both. We sought to assess the trajectory of pulmonary congestion using lung ultrasound (LUS) and its association with cardiac structure and function in a prespecified substudy.<br /><b>Methods</b><br />Patients without prior heart failure (HF) underwent 8-zone LUS and echocardiography at baseline (±2 days of randomization) and after 8 months. B-lines were quantified offline, blinded to treatment, clinical findings, timepoint and outcomes.<br /><b>Results</b><br />Among 152 patients (median age 65, 32% women, mean LVEF 41%), B-lines were detectable in 87% at baseline (median B-line count: 4 [IQR 2-8]). Among 115 patients with LUS data at baseline and follow-up, B-lines decreased significantly from baseline (mean ± SD: -1.6 ± 7.3; p=0.018). The proportion of patients without pulmonary congestion at follow-up was significantly higher in those with fewer B-lines at baseline. Adjusted for baseline, B-lines at follow-up were on average 6 (95% CI: 3, 9) higher in patients who experienced an intercurrent HF event vs. those who did not (p=0.001). A greater number of B-lines at baseline was associated with larger left atrial size, higher E/e\' and E/A ratios, greater degree of mitral regurgitation, worse right ventricular systolic function, and higher tricuspid regurgitation velocity (p trend <0.05 for all).<br /><b>Conclusions</b><br />In this AMI cohort, B-lines, indicating pulmonary congestion, were common at baseline and, on average, decreased significantly from baseline to follow-up. Worse pulmonary congestion was associated with prognostically important echocardiographic markers.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 17 Jan 2023; epub ahead of print</small></div>
Platz E, Claggett B, Jering KS, Kovacs A, ... Pfeffer MA, Shah A
Eur Heart J Acute Cardiovasc Care: 17 Jan 2023; epub ahead of print | PMID: 36649251
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<div><h4>Simulation in cardiac critical care.</h4><i>Yuen T, Brindley PG, Senaratne JM</i><br /><AbstractText>Medical simulation is a broad topic but at its core is defined as any effort to realistically reproduce a clinical procedure, team, or situation. Its goal is to allow risk-free practice-until-perfect, and in doing so, augment performance, efficiency, and safety. In medicine, even complex clinical situations can be dissected into reproducible parts that may be repeated and mastered, and these iterative improvements can add up to major gains. With our modern cardiac intensive care units treating a growing number of medically complex patients, the need for well-trained personnel, streamlined care pathways, and quality teamwork is imperative for improved patient outcomes. Simulation is therefore a potentially life-saving tool relevant to anyone working in cardiac intensive care. Accordingly, we believe that simulation is a priority for cardiac intensive care, not just a luxury. We offer the following primer on simulation in the cardiac intensive care environment.</AbstractText><br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 09 Jan 2023; epub ahead of print</small></div>
Yuen T, Brindley PG, Senaratne JM
Eur Heart J Acute Cardiovasc Care: 09 Jan 2023; epub ahead of print | PMID: 36622806
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<div><h4>Mean arterial pressure predicts 48-hour clinical deterioration in intermediate-high risk patients with acute pulmonary embolism.</h4><i>Zuin M, Rigatelli G, Bongarzoni A, Enea I, ... Casazza F, Roncon L</i><br /><b>Aims</b><br />We assess the prognostic role of mean arterial pressure (MAP) for 48-h clinical deterioration in intermediate-high risk pulmonary embolism (PE) patients after admission.<br /><b>Methods and results</b><br />A post-hoc analysis of intermediate-high risk PE patients enrolled in the Italian Pulmonary Embolism Registry (IPER) (Trial registry: ClinicalTrials.gov; No.: NCT01604538) was performed. 48-h clinical deterioration was defined as patient worsening from a stable to an unstable hemodynamic condition, need of catecholamine infusion, endotracheal intubation or cardiopulmonary resuscitation. Of 450 intermediate-high risk PE patients (mean age 71.4 ± 13.8 years, 298 males), 40 (8.8%) experienced clinical deterioration within 48 hours from admission. Receiver operating characteristic analysis established the optimal cut-off value for MAP, as a predictor of 48-hour clinical deterioration,  ≤ 81.5 mmHg (AUC of 0.77 ± 0.3) with sensitivity, specificity, PPV and NPV were 77.5%, 95.0%, 63.2% and 97.7%, respectively. Multivariate Cox regression analysis showed that independent risk factors for 48-h clinical deterioration were age (HR: 1.26, 9% CI: 1.19-1.28, p < 0.0001), history of heart failure (HR: 1.76, 95% CI: 1.72-1.81, p < 0.0001), sPESI (HR: 1.52, 95% CI: 1.49-1.58, p = 0.001), systemic thrombolysis (HR: 0.54, 95% CI: 0.30-0.65, p < 0.0001) and a MAP ≤81.5 mmHg at admission (HR: 3.25, 95% CI: 1.89-5.21, p < 0.0001). The deteriorating group had a significantly higher risk of 30-day mortality (HR: 2.61, 95% CI 2.54-2.66, p < 0.0001) compared to the non-deteriorating group.<br /><b>Conclusions</b><br />MAP appears to be a useful, bed-side and non-invasive prognostic tool potentially able to promptly identify intermediate-high risk PE patients at higher risk of 48-h clinical deterioration.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 29 Dec 2022; epub ahead of print</small></div>
Zuin M, Rigatelli G, Bongarzoni A, Enea I, ... Casazza F, Roncon L
Eur Heart J Acute Cardiovasc Care: 29 Dec 2022; epub ahead of print | PMID: 36580441
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<div><h4>Acute LDL-C reduction post ACS: strike early and strike strong: from evidence to clinical practice. A clinical consensus statement of the Association for Acute CardioVascular Care (ACVC), in collaboration with the European Association of Preventive Cardiology (EAPC) and the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy.</h4><i>Krychtiuk KA, Ahrens I, Drexel H, Halvorsen S, ... Pedretti R, Catapano A</i><br /><AbstractText>After experiencing an acute coronary syndrome (ACS), patients are at a high risk of suffering from recurrent ischaemic cardiovascular events, especially in the very early phase. Low density lipoprotein-cholesterol (LDL-C) is causally involved in atherosclerosis and a clear, monotonic relationship between pharmacologic LDL-C lowering and a reduction in cardiovascular events post-ACS has been shown, a concept termed \'the lower, the better\'. Current ESC guidelines suggest an LDL-C guided, step-wise initiation and escalation of lipid-lowering therapy (LLT). Observational studies consistently show low rates of guideline-recommended LLT adaptions and concomitant low rates of LDL-C target goal achievement, leaving patients at residual risk, especially in the vulnerable post-ACS phase. In addition to the well-established \'the lower, the better\' approach, a \'strike early and strike strong\' approach in the early post-ACS phase with upfront initiation of a combined lipid-lowering approach using high-intensity statins and ezetimibe seems reasonable. We discuss the rationale, clinical trial evidence and experience for such an approach and highlight existing knowledge gaps. In addition, the concept of acute initiation of PCSK9 inhibition in the early phase is reviewed. Ultimately, we focus on hurdles and solutions to provide high-quality, evidence-based follow-up care in post-ACS patients.</AbstractText><br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 27 Dec 2022; 11:939-949</small></div>
Abstract
<div><h4>Management of patients with electrical storm: an educational review.</h4><i>Dinov B, Darma A, Nedios S, Hindricks G</i><br /><AbstractText>Electrical storm (ES) is a medical emergency that is defined as ≥ 3 separate ventricular tachycardia (VT) episodes causing ICD therapy within 24 h. Patients with ES have high risk for hospitalization, heart failure decompensation, in-hospital death. Furthermore, it is associated with significant anxiety and distress for the patients. Frequent triggers of ES are myocardial ischemia, acute decompensation of heart failure, metabolic and electrolyte disorders, drug side effects, increased sympathetic tone. Acute management of ES requires sedation, antiarrhythmic drugs and correction of the precipitating factors; although, in severe refractory cases, intubation, mechanical ventilation and circulatory support might be necessary. Radiofrequency catheter ablation is superior than antiarrhythmic drugs to suppress the ES and is also frequently required to terminate the ES as well as to achieve acute and long-term freedom of VT. Optimization of the ICD programming is crucial to reduce the burden of further appropriate and inappropriate shocks. Use of appropriate discrimination criteria and algorithms, ATPs and extending the detection times are important measures to reduce the burden of ES. In patients with end-stage heart failure, ES can be a sign of failing heart and can be refractory of treatment. In such cases, deactivation of the ICD therapy should be considered and discussed with patients and their care givers.</AbstractText><br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 27 Dec 2022; epub ahead of print</small></div>
Dinov B, Darma A, Nedios S, Hindricks G
Eur Heart J Acute Cardiovasc Care: 27 Dec 2022; epub ahead of print | PMID: 36574428
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<div><h4>Smartphone Activated Volunteer Responders and Bystander Defibrillation for Out-of-Hospital Cardiac Arrest in Private Homes and Public Locations.</h4><i>Andelius L, Hansen CM, Jonsson M, Gerds TA, ... Ringh M, Folke F</i><br /><b>Aim</b><br />To investigate the association between arrival of smartphone activated volunteer responders before the Emergency Medical Services (EMS) and bystander defibrillation in out-of-hospital cardiac arrest (OHCA) at home and public locations.<br /><b>Methods and results</b><br />A retrospective study (September 1, 2017-May 14, 2019) from the Stockholm Region of Sweden and the Capital Region of Denmark. We included 1271 OHCAs, of which 1029 (81.0%) occurred in private homes and 242 (19.0%) in public locations. Main outcome was bystander defibrillation. At least one volunteer responder arrived before EMS in 381 (37.0%) of OHCAs at home and 84 (34.7%) in public. More patients received bystander defibrillation when a volunteer responder arrived before EMS at home (15.5% vs 2.2%, P < 0.001) and in public locations (32.1% vs 19.6%, P = 0.030). Similar results were found among the 361 patients with an initial shockable heart rhythm (52.7% vs 11.5%, P < 0.001 at home and 60.0% vs 37.8%, P = 0.025 in public). The standardized probability of receiving bystander defibrillation increased with longer EMS response times in private homes. 30-day survival was not significantly higher when volunteer responders arrived before EMS (9.2% vs 7.7% in private homes, P = 0.41 and 40.5% vs 35.4% in public locations, P = 0.44).<br /><b>Conclusions</b><br />Bystander defibrillation was significantly more common in private homes and public locations when a volunteer responder arrived before the EMS. The standardized probability of bystander defibrillation increased with longer EMS response times in private homes. Our findings support activation of volunteer responders, and suggest that volunteer responders could increase bystander defibrillation, particularly in private homes.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 27 Dec 2022; epub ahead of print</small></div>
Andelius L, Hansen CM, Jonsson M, Gerds TA, ... Ringh M, Folke F
Eur Heart J Acute Cardiovasc Care: 27 Dec 2022; epub ahead of print | PMID: 36574433
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<div><h4>UpStreAm doxycycline in ST-eLeVation myocArdial infarction - targetinG infarct hEaling and ModulatIon (SALVAGE-MI trial).</h4><i>Noaman S, Neil C, O\'Brien J, Frenneaux M, ... Taylor A, Chan W</i><br /><b>Background:</b><br/>and aims</b><br />Experimental studies demonstrate protective effects of doxycycline on myocardial ischemia-reperfusion injury. The trial investigated whether doxycycline administered prior to reperfusion in patients presenting with ST-elevation myocardial infarction (STEMI) reduces infarct size (IS) and ameliorates adverse left ventricular (LV) remodeling.<br /><b>Methods</b><br />In this randomized, double-blind, placebo-controlled trial, patients presenting with STEMI undergoing primary percutaneous coronary intervention (PPCI) were randomized to either intravenous doxycycline or placebo prior to reperfusion followed by 7-days of oral doxycycline or placebo. The primary outcome was final IS adjusted for area-at-risk (fIS/AAR) measured on two cardiac magnetic resonance scans ∼6 months apart.<br /><b>Results</b><br />Of 103 participants, 50 were randomized to doxycycline and 53 to placebo and were matched for age (59 ± 12 vs. 60 ± 10 years), male sex (92% vs. 79%), diabetes mellitus (26% vs. 11%) and left anterior descending artery occlusion (50% vs. 49%), all p > 0.05. Patients treated with doxycycline had a trend for larger fIS/AAR (0.79 [0.5-0.9] vs. 0.61 [0.47-0.76], p = 0.06), larger fIS at 6 months (18.8% [12-26] vs. 13.6% [11-21], p = 0.08), but similar acute IS (21.7% [17-34] vs. 19.4% [14-27], p = 0.19) and AAR (26% [20-36] vs. 24.7% [16-31], p = 0.22) compared to placebo. Doxycycline did not ameliorate adverse LV remodeling (%Δend-diastolic volume index, 1.1% [-3.8-8.4] vs. -1.34% [-6.1-5.8], p = 0.42) and was independently associated with larger fIS (regression coefficient = 0.175, p = 0.03).<br /><b>Conclusion</b><br />Doxycycline prior to PPCI neither reduced IS acutely or at 6 months nor attenuated adverse LV remodeling. These data raise safety concerns regarding doxycycline use in STEMI for infarct modulation and healing.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 26 Dec 2022; epub ahead of print</small></div>
Noaman S, Neil C, O'Brien J, Frenneaux M, ... Taylor A, Chan W
Eur Heart J Acute Cardiovasc Care: 26 Dec 2022; epub ahead of print | PMID: 36567466
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<div><h4>Global myocardial oedema in resuscitated out-of-hospital cardiac arrest patients assessed by cardiac magnetic resonance - a pilot study.</h4><i>Klein A, Grand J, Meyer M, Wiberg S, ... Kjaergaard J, Hassager C</i><br /><b>Background</b><br />Myocardial dysfunction is well described after out-of-hospital cardiac arrest (OHCA), however, the underlying mechanisms are not yet understood. We hypothesised that this dysfunction is associated to a global myocardial oedema. Using cardiac magnetic resonance (CMR), we assessed the presence of such oedema early after successful resuscitation from OHCA.<br /><b>Methods</b><br />Comatose patients resuscitated from OHCA and admitted to the cardiac intensive care unit were consecutively included and underwent CMR in general anaesthesia within 36 hours after cardiac arrest with anaesthetic support. To assess global myocardial oedema, T1 and T2 segmented maps were generated from three representative short axis slices, and values from each segment were then used to determine a mean global T1 and T2 time for each patient. Healthy subjects were used as controls.<br /><b>Results</b><br />CMR was obtained in 16 patients and compared to 9 controls. The OHCA patients were 60 ± 9 years old, and acute myocardial infarction was diagnosed in 6 cases. On admission, left ventricular ejection fraction assessed by transthoracic echocardiography was 35 ± 15%, and this improved significantly to 43 ± 14% during hospitalisation (p < 0.05). Mean global T1 and T2 time was significantly higher in OHCA patients compared to the control group (1071 ms vs. 999 ms, p = 0.002, and 52 ms vs. 46 ms, p < 0.001, respectively), and this difference remained significant when segments involved in the myocardial infarction were excluded.<br /><b>Conclusion</b><br />Assessed with CMR, we for the first time document an early global myocardial oedema in patients successfully resuscitated from OHCA.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 26 Dec 2022; epub ahead of print</small></div>
Klein A, Grand J, Meyer M, Wiberg S, ... Kjaergaard J, Hassager C
Eur Heart J Acute Cardiovasc Care: 26 Dec 2022; epub ahead of print | PMID: 36567498
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<div><h4>Association between B-lines on Lung Ultrasound, Invasive Hemodynamics and Prognosis in Acute Heart Failure Patients.</h4><i>Imanishi J, Maeda T, Ujiro S, Masuda M, ... Todoroki T, Okuda M</i><br /><b>Aims</b><br />Increased left atrial pressure leads to pulmonary congestion. Although the B-lines in lung ultrasound (LUS) are useful in detecting pulmonary congestion, data regarding the association between B-lines and invasive hemodynamics are inconsistent. This study aimed to explore the correlation of the B-line count by LUS with pulmonary capillary wedge pressure (PCWP) stratified for preserved and reduced ejection fraction (EF) in acute heart failure patients.<br /><b>Methods and results</b><br />We performed a prospective observational study on 116 hospitalized patients with acute heart failure (mean age, 75.2 ± 10.3 years), who underwent right heart catheterization before discharge. LUS was performed in eight zones within 4 h of right heart catheterization and compared with PCWP separately in each EF group. Cardiac events were recorded 1 year after discharge. PCWP revealed a clear pivot point at which the B-lines began to increase in the overall cohort and each EF. Specific thresholds of the increase in B-lines were identified at 19 and 25 mmHg for preserved and reduced EF, respectively. Residual congestion at discharge was defined as the presence of ≥6 B-lines. Patients with residual congestion had a higher risk for cardiac events than those without residual congestion (hazard ratio, 12.6; 95% CI, 4.71-33.7; log-rank, P < 0.0001).<br /><b>Conclusions</b><br />A clear pivot point was associated with increased B-lines count in PCWP at 19 and 25 mmHg for preserved and reduced EF, respectively. Moreover, the increased B-line count above the defined cutoff used to quantify residual congestion was associated with significantly worse outcomes.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 22 Dec 2022; epub ahead of print</small></div>
Imanishi J, Maeda T, Ujiro S, Masuda M, ... Todoroki T, Okuda M
Eur Heart J Acute Cardiovasc Care: 22 Dec 2022; epub ahead of print | PMID: 36548965
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<div><h4>Artificial intelligence-augmented electrocardiography for left ventricular systolic dysfunction in patients undergoing high-sensitivity cardiac troponin T.</h4><i>De Michieli L, Knott JD, Attia ZI, Ola O, ... Jaffe AS, Sandoval Y</i><br /><b>Background:</b><br/>and aims</b><br />Our goal was to evaluate a previously validated artificial intelligence-augmented electrocardiography (AI-ECG) screening tool for left ventricular systolic dysfunction (LVSD) in patients undergoing high-sensitivity cardiac troponin T (hs-cTnT).<br /><b>Methods</b><br />Retrospective application of AI-ECG for LVSD in emergency department (ED) patients undergoing hs-cTnT. AI-ECG scores (0-1) for probability of LVSD (left ventricular ejection fraction ≤ 35%) were obtained. An AI-ECG score ≥0.256 indicates a positive screen. The primary endpoint was a composite of post-discharge major adverse cardiovascular events (MACE) at 2-years follow-up.<br /><b>Results</b><br />Among 1977 patients, 248 (13%) had a positive AI-ECG. As compared to patients with a negative AI-ECG, those with a positive AI-ECG had a higher risk for MACE (48% vs. 21%, p < 0.0001, adjusted HR 1.39, 95% CI 1.11-1.75). This was largely because of a higher rate of deaths (32 vs. 14%, p < 0.0001; adjusted HR 1.26, 95% 0.95-1.66) and heart failure hospitalizations (26% vs. 6.1%, p < 0.001; adjusted HR 1.75, 95% CI 1.25-2.45). Together, hs-cTnT and AI-ECG resulted in the following MACE rates and adjusted HRs: hs-cTnT < 99th percentile and negative AI-ECG: 116/1176 (11%) (reference), hs-cTnT < 99th percentile and positive AI-ECG: 28/107 (26%) (adjusted HR 1.54, 95% CI 1.01-2.36), hs-cTnT > 99th percentile and negative AI-ECG: 233/553 (42%) (adjusted HR 2.12, 95% CI 1.66, 2.70), and hs-cTnT > 99th percentile and positive AI-ECG: 91/141 (65%) (adjusted HR 2.83, 95% CI 2.06, 3.87).<br /><b>Conclusions</b><br />Among ED patients evaluated with hs-cTnT, a positive AI-ECG for LVSD identifies patients at high risk for MACE. The conjoint use of hs-cTnT and AI-ECG facilitates risk-stratification.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 20 Dec 2022; epub ahead of print</small></div>
De Michieli L, Knott JD, Attia ZI, Ola O, ... Jaffe AS, Sandoval Y
Eur Heart J Acute Cardiovasc Care: 20 Dec 2022; epub ahead of print | PMID: 36537652
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<div><h4>LidocAine Versus Opioids In MyocarDial infarction: The AVOID-2 randomised controlled trial.</h4><i>Fernando H, Nehme Z, Milne C, O\'Brien J, ... Stub D, AVOID 2 Investigators</i><br /><b>Background</b><br />Opioid analgesia has been shown to interfere with the bioavailability of oral P2Y12 inhibitors prompting the search for safe and effective non-opioid analgesics to treat ischemic chest pain.<br /><b>Methods</b><br />The AVOID-2 trial was a prospective, phase II, prehospital, open-label, non-inferiority, randomized controlled trial enrolling patients with suspected STEACS with moderate to severe pain (numerical rating scale (NRS) at least 5/10). Intravenous lidocaine (maximum dose 300 mg) or intravenous fentanyl (up to 50 µg every 5 min) were administered as prehospital analgesia. The co-primary endpoints were prehospital pain reduction and adverse events requiring intervention. Secondary endpoints included peak cardiac troponin I, cardiac MRI (cMRI) assessed myocardial infarct size and clinical outcomes to 30 days.<br /><b>Results</b><br />A total of 308 patients were enrolled. The median reduction in pain score (NRS) was 4 versus. 3 in the fentanyl and lidocaine arms respectively for the primary efficacy endpoint (estimated median difference -1 (95% confidence interval -1.58, -0.42, p = 0.5 for non-inferiority, p = 0.001 for inferiority of lidocaine). Adverse events requiring intervention occurred in 49% vs. 36% in the fentanyl and lidocaine arms which met non-inferiority and superiority favouring lidocaine (p = 0.016 for superiority). No significant differences in myocardial infarct size and clinical outcomes at 30 days were seen.<br /><b>Conclusions</b><br />IV Lidocaine did not meet criteria for non-inferiority with lower prehospital pain reduction than fentanyl but was safe and better tolerated as analgesia in STEMI. Future trials testing non-opioid analgesics in STEMI and whether opioid avoidance improves clinical outcomes are needed.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 10 Dec 2022; epub ahead of print</small></div>
Fernando H, Nehme Z, Milne C, O'Brien J, ... Stub D, AVOID 2 Investigators
Eur Heart J Acute Cardiovasc Care: 10 Dec 2022; epub ahead of print | PMID: 36494194
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<div><h4>Management of comatose survivors of out-of-hospital cardiac arrest in Europe: current treatment practice and adherence to guidelines A Survey by the Association for Acute CardioVascular Care (ACVC) of the ESC, joint with European Resuscitation Council (ERC), European Society for Emergency Medicine (EUSEM) and European Society of Intensive Medicine (ESICM).</h4><i>Jorge-Perez P, Nikolaou N, Donadello K, Khoury A, ... Price S, Grand J</i><br /><b>Introduction</b><br />International guidelines give recommendations for management of comatose out-of-hospital cardiac arrest (OHCA) survivors. We aimed to investigate adherence to guidelines and disparities of treatment of OHCA in hospitals in Europe.<br /><b>Methods</b><br />A web-based, multi-institutional, multinational survey in Europe was conducted using an electronic platform with a predefined questionnaire developed by experts in post-resuscitation care. The survey was disseminated to all members of the societies via email, social medias, websites, and newsletters in June of 2021.<br /><b>Results</b><br />Of 252 answers received, 237 responses from different units were included and 166 (70%) were from cardiac arrest centres. First-line vasopressor used was noradrenaline in 195 (83%) and first line inotrope was dobutamine in 148 (64%) of the responses. Echocardiography is available 24/7 in 204 (87%) of institutions. Targeted temperature management was used in 160 (75%) of institutions for adult comatose survivors of OHCA with an initial shockable rhythm. Invasive or external cooling-methods with feedback were used in 72 cardiac arrest centres (44%) and in 17 (24%) of non-cardiac arrest centres (p < 0,0003). A target temperature between 32-34 °C was preferred by 46 centres (21%); a target between 34-36 °C by 103 centres (52%); and <37.5°C by 35 (16%). Multimodal neuroprognostication was poorly implemented and follow-up at 3 months after discharge was done in 71 (30%) institutions.<br /><b>Conclusion</b><br />Post-resuscitation care is not well established and varies among centres in European hospitals. Cardiac arrest centres have a higher coherence with guidelines compared to respondents from non-cardiac arrest centres. The overall inconsistency in approaches and deviation from recommendations could be a focus for improvement.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 02 Dec 2022; epub ahead of print</small></div>
Abstract
<div><h4>What acute cardiac care physicians need to know from the latest 2022 ESC Guidelines for Ventricular Tachycardia and Sudden Cardiac Death.</h4><i>Goette A, Lip GYH, Gorenek B</i><br /><AbstractText>The present paper summarizes and comments on the latest 2022 ESC guidelines on ventricular tachycardia and sudden cardiac death. Most relevant recommendations for acute cardiovascular care physicians are addressed, particularly, in the fields of coronary artery disease, dilated cardiomyopathy and inflammatory diseases. New recommendations encompass the implantation of a defibrillator (ICD) in the setting of an acute myocarditis. Furthermore, the pathophysiology of electrical storm including involved molecular pathways as well as the angry Purkinje fiber syndrome are presented and discussed.</AbstractText><br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 01 Dec 2022; epub ahead of print</small></div>
Goette A, Lip GYH, Gorenek B
Eur Heart J Acute Cardiovasc Care: 01 Dec 2022; epub ahead of print | PMID: 36449983
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<div><h4>Intra-arrest Partial Carbon Dioxide Level and Favorable Neurological Outcome after Out-of-Hospital Cardiac Arrest: A Nationwide Multicenter Observational Study in Japan (the JAAM-OHCA Registry).</h4><i>Matsuyama T, Ohta B, Kiyohara K, Kitamura T</i><br /><b>Background</b><br />Little is known about whether guideline-recommended ventilation during cardiopulmonary resuscitation result in optimal partial carbon dioxide (pCO2) levels or favorable outcomes. This study aimed to evaluate the association between intra-arrest pCO2 level and the outcome after out-of-hospital cardiac arrest (OHCA).<br /><b>Methods</b><br />We performed a secondary analysis of a multicenter observational study, including adult patients with OHCA who did not achieve a return of spontaneous circulation (ROSC) upon hospital arrival and whose blood gas analysis was performed before the ROSC between June 2014 and December 2017. The patients were categorized into four quartiles based on their intra-arrest carbon dioxide levels: quartiles 1 (<66.0 mmHg), 2 (66.1-87.2 mmHg), 3 (87.3-113.5 mmHg), and 4 (≥113.6 mmHg). The primary outcome was 1-month survival with favorable neurological outcomes defined as cerebral performance category 1 or 2. Multivariate logistic regression analysis was used to evaluate the association between pCO2 and favorable neurological outcomes.<br /><b>Results</b><br />During the study period, 20,913 patients were eligible for the analysis. The proportion of favorable neurological outcomes was 1.8% (90/5,133), 0.7% (35/5,232), 0.4% (19/5,263), and 0.2% (9/5,285) in quartiles 1, 2, 3, and 4, respectively. Multivariable logistic regression analysis demonstrated that the probability of favorable neurological outcome decreased with increased intra-arrest carbon dioxide levels (i.e., Q1 versus Q4, adjusted odds ratio 0.25, 95% confidence interval 0.16-0.55, P for trend <0.001).<br /><b>Conclusion</b><br />Lower intra-arrest pCO2 levels were associated with a favorable neurological outcome.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 30 Nov 2022; epub ahead of print</small></div>
Matsuyama T, Ohta B, Kiyohara K, Kitamura T
Eur Heart J Acute Cardiovasc Care: 30 Nov 2022; epub ahead of print | PMID: 36447370
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<div><h4>Resuscitative transoesophageal echocardiography performed by emergency physicians in the emergency department - insights from a one-year period.</h4><i>Poppe M, Magnet IA, Clodi C, Mueller M, ... Roeggla M, Schriefl C</i><br /><b>Objective</b><br />Transoesophageal echocardiography (TOE) has increasingly been described as a possible complementary and point-of-care approach for patients with cardiac arrest (CA). It provides information about potentially reversible causes, prognosis and allows monitoring of resuscitation efforts without affecting ongoing chest compressions. The aim of this study was to assess the feasibility of TOE performed by emergency physicians (EP) during CA in an emergency department (ED).<br /><b>Methods</b><br />This prospective study was performed at the Department of Emergency Medicine at the Medical University of Vienna from 02/2020 to 02/2021. All patients ≥18 years old presenting with ongoing resuscitation efforts were screened. After exclusion of potential contraindications, a TOE exam was performed and documented by EPs according to a standardized 4-view imaging protocol. The primary endpoint represents feasibility defined as successful probe insertion and acquisition of interpretable images.<br /><b>Results</b><br />Of 99 patients with ongoing non-traumatic CA treated in the ED, a total of 62 patients were considered to be examined by TOE. The examination was feasible in 57 patients (92%) (female, 14 [25%], mean age 53 ± 13, witnessed collapse 48 [84%]). Within these, the examiners observed 51 major findings in 32 different patients (66%). In 21 patients (37%) these findings led to a direct change of therapy. In 18 patients (32%), the examiner found ventricular contractions without detectable pulse. No TOE-related complications were found.<br /><b>Conclusion</b><br />Our findings suggest that EPs may be able to acquire and interpret TOE images in the majority of patients during cardiac arrest using a standardized 4-view imaging protocol.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 29 Nov 2022; epub ahead of print</small></div>
Poppe M, Magnet IA, Clodi C, Mueller M, ... Roeggla M, Schriefl C
Eur Heart J Acute Cardiovasc Care: 29 Nov 2022; epub ahead of print | PMID: 36443280
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<div><h4>Soluble ST2 in plasma is associated with post-procedural no-or-slow-reflow after PCI in ST-elevation myocardial infarction.</h4><i>Sondergaard FT, Beske RP, Frydland M, Møller JE, ... Engstrøm T, Hassager C</i><br /><b>Background</b><br />The no-or-slow-reflow phenomenon after primary percutaneous coronary intervention (pPCI) is associated with more extensive myocardial injury in ST-elevation myocardial infarction (STEMI) patients. Soluble suppression of tumorigenicity 2 (sST2) is released in acute myocardial response to injury, and an increase in plasma level in the initial phase of STEMI is associated with increased mortality and risk of heart failure.We have therefore explored the association of pre-intervention plasma sST2 with the post-procedural no-or-slow-reflow phenomenon in patients with STEMI.<br /><b>Method</b><br />We included consecutive patients with verified STEMI from two tertiary heart centers. Blood samples were collected at admission before angiography. Post-procedural coronary flow was assessed according to thrombolysis in myocardial infarction (TIMI) classification for STEMI. Patients were divided into two groups: Post-procedural TIMI 0- 2 as no-or-slow-reflow and TIMI 3 as normal reflow. The association between sST2 and TIMI flow was explored using multiple logistic regression.<br /><b>Results</b><br />1,607 patients with available TIMI flow classification were included in the analysis. Normal reflow was seen in 1,520 (94.6%) while 87 (5.4%) had no-or-slow-reflow. No-or-slow-reflow patients had higher all-cause 30-day mortality (10 (11%) vs. 65 (4.3%), p = 0.006). Preprocedural sST2 was higher in the no-or-slow-flow group (47 ng/mL (IQR 33 - 83) vs. 39 ng/mL (IQR 29-55, p < 0.001) and was independently associated with post-procedural no-or-slow-flow (two-fold sST2 increase: OR 1.44 (1.15-1.78, p = 0.0012)).<br /><b>Conclusion</b><br />In patients with STEMI, the sST2 level at admission before coronary angiography is independently associated with the post-procedural no-or-slow-reflow phenomenon.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 10 Nov 2022; epub ahead of print</small></div>
Sondergaard FT, Beske RP, Frydland M, Møller JE, ... Engstrøm T, Hassager C
Eur Heart J Acute Cardiovasc Care: 10 Nov 2022; epub ahead of print | PMID: 36355574
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<div><h4>Care of patients with ST-Elevation MI: an international analysis of Quality Indicators in the Acute Coronary Syndrome (ACS) STEMI Registry of the EURObservational Research Programme (EORP) and ACVC and EAPCI Associations of the European Society of Cardiology (ESC) in 11,462 patients.</h4><i>Ludman P, Zeymer U, Danchin N, Kala P, ... Maggioni AP, Weidinger F</i><br /><b>Aims</b><br />To use Quality Indicators to study the management of ST segment elevation myocardial infarction (STEMI) in different regions.<br /><b>Methods and results</b><br />Prospective cohort study of STEMI within 24 hours of symptom onset (11,462 patients, 196 centres, 26 ESC member and 3 affiliated countries). The median delay between arrival at a PCI centre and primary PCI was 40 min (IQR 20 to 74) with 65.8% receiving PCI within guideline recommendation of 60 min. A third of patients (33.2%) required transfer from their initial hospital to one that could perform emergency PCI for whom only 27.2% were treated within the quality indicator recommendation of 120 mins. Radial access was used in 56.6% of all primary PCI, but with large geographic variation, from 76.4% to 9.1%. Statins were prescribed at discharge to 98.7% of patients, with little geographic variation. Of patients with a history of heart failure or a documented LVEF ≤40%, 84.0% were discharged on an ACEI/ARB and 88.7% were discharged on beta blockers.<br /><b>Conclusions</b><br />Care for STEMI shows wide geographic variation in the receipt of timely primary PCI, and is in contrast with the more uniform delivery of guideline-recommended pharmacotherapies at time of hospital discharge.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 08 Nov 2022; epub ahead of print</small></div>
Abstract
<div><h4>Initial Hospital Length of Stay and Long-Term Survival of Patients Successfully Resuscitated Using ECPR for Refractory Out-of-Hospital Cardiac Arrest.</h4><i>Alexy T, Kalra R, Kosmopoulos M, Bartos JA, ... Tsangaris A, Yannopoulos D</i><br /><b>Background</b><br />The long-term outcomes of patients treated with extracorporeal cardiopulmonary resuscitation (ECPR) for refractory ventricular tachycardia/ventricular fibrillation (VT/VF) out-of-hospital cardiac arrest (OHCA) remain poorly defined. The purpose of this study was to describe the hospital length of stay and long-term survival of patients who were successfully rescued with ECPR after refractory VT/VF OHCA.<br /><b>Methods</b><br />In this retrospective cohort study, the length of index admission and long-term survival of patients treated with ECPR after OHCA at a single center were evaluated. In a sensitivity analysis, survival of patients managed with left ventricular assist device (LVAD) implantation or heart transplantation during the same period was also evaluated.<br /><b>Results</b><br />Between 1/1/2016 and 12/1/2020, 193 patients were transferred for ECPR considerations and 160 underwent peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) cannulation. Of these, 54 (33.7%) survived the index admission. These survivors required a median 16 days of intensive care and 24 days total hospital stay. The median follow-up time of the survivors was 1,216 [683, 1461] days. 79.6% and 72.2% were alive at one and four years, respectively. Most deaths within the first year occurred among the patients requiring discharge to a long-term acute care facility. Overall survival rates at four years were similar in the ECPR and LVAD cohorts (p = 0.30) but were significantly higher for transplant recipients (p < 0.001).<br /><b>Conclusions</b><br />This data suggest that the lengthy index hospitalization required to manage OHCA patients with ECPR is rewarded by excellent long-term clinical outcomes in an expert ECPR program.<br /><br />© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 07 Nov 2022; epub ahead of print</small></div>
Alexy T, Kalra R, Kosmopoulos M, Bartos JA, ... Tsangaris A, Yannopoulos D
Eur Heart J Acute Cardiovasc Care: 07 Nov 2022; epub ahead of print | PMID: 36346080
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This program is still in alpha version.