<div><h4>Sex and age-related differences in outcomes of patients with acute myocardial infarction: MINOCA versus MIOCA.</h4><i>Canton L, Fedele D, Bergamaschi L, Foà A, ... Paolisso P, Pizzi C</i><br /><b>Background</b><br />To evaluate the impact of sex on acute myocardial infarction (AMI) patients\' clinical presentation and outcomes, comparing those with non-obstructive and obstructive coronary arteries (MINOCA vs MIOCA).<br /><b>Methods</b><br />We enrolled 2455 patients with AMI undergoing coronary angiography from January 2017 to September 2021. Patients were divided according to the type of AMI and sex: male (n=1593) and female (n=607) in MIOCA; male (n=87) and female (n=168) in MINOCA. Each cohort was further stratified based on age (≤/> 70 years). The primary endpoint (MAE) was a composite of all-cause death, recurrent AMI, and hospitalization for heart failure (HF) at follow-up. Secondary outcomes included: all-cause and cardiovascular death, recurrent AMI, HF re-hospitalization and stroke.<br /><b>Results</b><br />MINOCA patients were more likely to be females compared to MIOCA ones (p<0.001). The median follow-up was 28 [15-41] months. The unadjusted incidence of MAE was significantly higher in females compared to males, both in MINOCA [45 (26.8%) vs 12 (13.8%); p=0.018] and MIOCA cohorts [203 (33.4%) vs 428 (26.9%); p=0.002]. Age was an independent predictor of MAE in both cohorts. Among MINOCA patients, females ≤70-year-old had a higher incidence of MAE [18 (23.7%) vs 4 (5.9%); p=0.003] compared to male peers, mainly driven by a higher rate of re-hospitalization for HF (p=0.045) and recurrence of AMI (p=0.006). Only in this sub-group of MINOCA patients, female sex was an independent predictor of MAE (HR=3.09; 95%CI: 1.02-9.59; p=0.040). MINOCA females ≤70-year-old had worse outcomes than MIOCA female peers.<br /><b>Conclusion</b><br />MINOCA females ≤70-year-old had a significantly higher incidence of MAE, compared to males and MIOCA female peers, likely due to the different pathophysiology of the ischemic event.<br /><b>Trial registration</b><br />data were part of the ongoing observational study AMIPE: Acute Myocardial Infarction, Prognostic and Therapeutic Evaluation. ClinicalTrials.gov Identifier: NCT03883711.<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: 01 Jun 2023; epub ahead of print</small></div>

<div><h4>Poorer Survival after Out-of-Hospital Cardiac Arrest among Cancer Patients - A Population-Based Register Study.</h4><i>Hägglund HL, Jonsson M, Hedayati E, Hedman C, Djärv T</i><br /><b>Background:</b><br/>and aims</b><br />The association between cancer and survival after out-of-hospital cardiac arrest (OHCA) has not been thoroughly investigated. We aimed to address this knowledge gap using national, population-based registries.<br /><b>Methods</b><br />For this study, 30,163 OHCA patients (≥18 years) were included from the Swedish Register of Cardiopulmonary Resuscitation. Via linkage to the National Patient Registry, 2,894 patients (10%) with cancer diagnosed within 5 years prior to OHCA were identified. Differences in 30-day survival between cancer patients and controls (defined as OHCA patients without previous cancer diagnosis) were assessed related to cancer stage (locoregional vs metastasized cancer) and cancer site (i.e. lung cancer, breast cancer etc.) using logistic regression adjusted for prognostic factors. Long-term survival is presented as a Kaplan-Meier curve.<br /><b>Results</b><br />For locoregional cancer no statistically significant difference in return of spontaneous circulation (ROSC) was seen compared to controls, metastasized disease was associated with poorer chance of ROSC. Cancer was associated with lower 30-day survival for all cancers (Adjusted odds ratio, OR, 0.57, CI 0.49-0.66), locoregional cancer (Adjusted OR 0.68, CI 0.57-0.82) and metastasized cancer (Adjusted OR 0.24, CI 0.14-0.40) compared to controls. Lower 30-day survival compared to controls was seen for lung cancer, gynaecological and haematological cancers.<br /><b>Conclusion</b><br />Cancer is associated with poorer 30-day survival after OHCA. This study suggests that cancer site and disease stage are more relevant factors than cancer in general with regard to its effect on survival after OHCA.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 20 May 2023; epub ahead of print</small></div>

<div><h4>Pericardial Effusions: Perspective of the Acute Cardiac Care Physician.</h4><i>Jain CC, Reddy YNV</i><br /><AbstractText>Pericardial effusions can result in acute hemodynamic compromise and require rapid intervention. Understanding pericardial restraint is essential to determine the approach to newly identified pericardial effusions in the intensive care unit. As pericardial effusions stretch the pericardium, pericardial compliance reserve is eventually exhausted, with an exponential rise in compressive pericardial pressure. The severity of pericardial pressure increase depends on both the rapidity and volume of pericardial fluid accumulation. This increase in pericardial pressure is reflected in an increase in measured left and right sided \'filling\' pressures, but paradoxically left ventricular end diastolic volume (the true left ventricular preload) is decreased. This uncoupling of filling pressures and preload is the hallmark of pericardial restraint. When this occurs acutely from a pericardial effusion, rapid recognition and pericardiocentesis can be lifesaving. In this review, we will discuss the hemodynamics and pathophysiology of acute pericardial effusions, provide a physiological guide to determine need for pericardiocentesis in acute care, and discuss important caveats to management.</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 e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 18 May 2023; epub ahead of print</small></div>

<div><h4>The evaluation and management of coagulopathies in the intensive therapy units.</h4><i>Galli M, Angiolillo DJ</i><br /><AbstractText>Coagulopathies are common in intensive therapy units (ITU) and may represent both the cause and the consequence of a critically ill status. Because coagulopathies are associated with increased complications both in terms of increased ischemic and bleeding events, the prevention, assessment, and treatment of these clinical conditions are important issues to be considered in the ITU. In this review we explore the pathophysiological mechanisms, discuss the most common causes and provide practical recommendations on the assessment and treatment of coagulopathies in the ITU.</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 e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 12 May 2023; epub ahead of print</small></div>

<div><h4>Pulmonary embolism related refractory out-of-hospital cardiac arrest and extracorporeal cardiopulmonary resuscitation: Prague OHCA study post-hoc analysis.</h4><i>Pudil J, Rob D, Smalcova J, Smid O, ... Kovarnik T, Belohlavek J</i><br /><b>Background</b><br />Refractory out-of-hospital cardiac arrest (r-OHCA) in patients with pulmonary embolism (PE) is associated with poor outcomes. The role of extracorporeal cardiopulmonary resuscitation (ECPR) in this patient group is uncertain. This study aims to analyze clinical course, outcomes, and the effect of an invasive procedure, including ECPR, in a randomized population.<br /><b>Methods</b><br />A post-hoc analysis of a randomized controlled trial (Prague OHCA study) was conducted to evaluate the effect of ECPR vs. a standard approach in r-OHCA. A subgroup of patients with PE-related r-OHCA was identified, and procedural and outcome characteristics, including favorable neurological survival, organ donation, and complications, were compared to patients without PE.<br /><b>Results</b><br />PE was identified as a cause of r-OHCA in 24 of 256 (9.4%) enrolled patients. Patients with PE were more likely to be women (12/24 [50%] vs. 32/232 [13.8%]; p < 0.001) and presented more frequently with an initial non-shockable rhythm (23/24 [95.8%] vs. 77/232 [33.2%]; p < 0.001), as well as more severe acidosis at admission (median pH [interquartile range]; 6.83 [6.75-6.88] vs. 6.98 [6.82-7.14]; p < 0.001). Their favorable 180 - days neurological survival was significantly lower (2/24 [8.3%] vs. 66/232 [28.4%]; P = 0.049), but the proportion of accepted organ donors was higher (16.7 vs. 4.7%, p = 0.04).<br /><b>Conclusion</b><br />r-OHCA due to PE has a different presentation and inferior outcomes compared to other causes but may represent an important source of organ donations. The ECPR method did not improve patient outcomes.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 12 May 2023; epub ahead of print</small></div>

<div><h4>Strategies to Mitigate Emergency Department Crowding and Its Impact on Cardiovascular Patients.</h4><i>Baugh CW, Freund Y, Steg PG, Body R, Maron DJ, Yiadom MYMAB</i><br /><AbstractText>Emergency Department (ED) crowding is a worsening global problem caused by hospital capacity and other health system challenges. While patients across a broad spectrum of illnesses may be affected by crowding in the ED, patients with cardiovascular emergencies - such as acute coronary syndrome, malignant arrhythmias, pulmonary embolism, acute aortic syndrome, and cardiac tamponade - are particularly vulnerable. Because of crowding, patients with dangerous and time-sensitive conditions may either avoid the ED due to anticipation of extended waits, leave before their treatment is completed, or experience delays in receiving care. In this educational paper, we present the underlying causes of crowding and its impact on common cardiovascular emergencies using the input-throughput-output process framework for patient flow. In addition, we review current solutions and potential innovations to mitigate the negative effect of ED crowding on patient outcomes.</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 e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 10 May 2023; epub ahead of print</small></div>

<div><h4>Venous Excess Ultrasound Score and Acute Kidney Injury in Patients with Acute Coronary Syndrome.</h4><i>Viana-Rojas JA, Argaiz E, Robles-Ledesma M, Arias-Mendoza A, ... Lopez-Gil S, Araiza-Garaygordobil D</i><br /><b>Background</b><br />Systemic venous congestion is associated with an increased risk of acute kidney injury (AKI) in critically ill patients. Venous Excess Ultrasound Score (VExUS) has been proposed as a non-invasive score to assess systemic venous congestion. We aimed to evaluate the association between VExUS score and AKI in patients with acute coronary syndrome (ACS).<br /><b>Methods</b><br />A prospective study including patients with the diagnosis of ACS (both STE/NSTE ACS). VExUS was performed during the first 24 hours of hospital stay. Patients were classified according to the presence of systemic congestion (VExUS 0/ ≥ 1). The primary objective of the study was the occurrence of AKI, defined by KDIGO criteria.<br /><b>Results</b><br />A total of 77 patients were included. After ultrasound assessment, 31 (40.2%) patients were categorized as VExUS ≥1. VExUS ≥1 was more frequently found in inferior vs. anterior MI/NSTEMI (48.3 vs 25.8 & 22.5%, p = 0.031). At each increasing degree of VExUS, a higher proportion of patients developed AKI: VExUS = 0 (10.8%), VExUS = 1 (23.8%), VExUS = 2 (75.0%) & VExUS = 3 (100%) (p < 0.001). A significant association between VExUS ≥1 and AKI was found (OR: 6.75, 95%CI: 2.21-23.7, p = 0.001). After multivariable analysis, only VExUS ≥1 (OR 6.15; 95% CI: 1.26-29.94, p = 0.02) remained significantly associated with AKI.<br /><b>Conclusions</b><br />In patients hospitalized with ACS, VExUS score is associated with the occurrence of AKI. Further studies are needed to clarify the role of VExUS assessment in patients with ACS.<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: 08 May 2023; epub ahead of print</small></div>

<div><h4>Initial systolic blood pressure associates with systemic inflammation, myocardial injury and outcomes in patients with acute coronary syndromes.</h4><i>Winzap PA, Kraler S, Obeid S, Wenzl FA, ... Räber L, Lüscher TF</i><br /><b>Background</b><br />Outcomes after acute coronary syndromes (ACS) are determined by baseline risk profiles, including initial systolic blood pressure (sBP). Herein, we aimed to characterize ACS patients stratified by initial sBP levels and study the relation to inflammation, myocardial injury and post-ACS outcomes.<br /><b>Methods</b><br />We analysed 4\'724 prospectively recruited ACS patients according to invasively assessed sBP (<100, 100-139, and ≥140mmHg) at admission. Biomarkers of systemic inflammation (high-sensitivity C-reactive protein, hs-CRP) and myocardial injury (high-sensitivity cardiac troponin, hs-cTnT) were measured centrally. Major adverse cardiovascular events (MACE; non-fatal myocardial infarction (MI), non-fatal stroke and cardiovascular (CV) death) were externally adjudicated.<br /><b>Results</b><br />Leukocyte numbers, hs-CRP, hs-cTnT and creatine kinase (CK) levels decreased from low to high sBP strata (ptrend < 0.001). Expectedly, patients with sBP < 100mmHg developed more often cardiogenic shock (CS; p < 0.001), and had a 1.7- and 1.4-fold increased multi-variable-adjusted MACE risk at 30 days (HR 1.68, 95% CI 1.05-2.69, p = 0.031) and one year (HR 1.38, 95% CI 0.92-2.05, p = 0.117). Those with sBP < 100 mmHg and CS showed a higher leukocyte count (p < 0.001), an increased neutrophil-to-lymphocyte-ratio (p = 0.031), and higher hs-cTnT and CK levels relative to those without CS (p < 0.001 and p = 0.002, respectively), whereas hs-CRP levels did not differ. Patients who developed CS had a 3.6- and 2.9-fold increased MACE risk at 30 days (HR 3.58, 95% CI 1.77-7.24, p < 0.001) and at one year (HR 2.94 95% CI, 1.57-5.53, p < 0.001), which was attenuated after controlling for distinct inflammatory profiles.<br /><b>Conclusions</b><br />In patients with ACS, proxies of systemic inflammation and myocardial injury are inversely associated with sBP, with highest levels in those <100mmHg. If linked to high levels of cellular inflammation, these patients are prone to develop CS and are at high MACE and mortality risk.<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: 08 May 2023; epub ahead of print</small></div>

<div><h4>Serially Measured hs-cTnT, NT-proBNP, hs-CRP and GDF-15 for Risk Assessment After Acute Coronary Syndrome: the BIOMArCS Cohort.</h4><i>Gürgöze MT, Akkerhuis KM, Oemrawsingh RM, Umans VAWM, ... van Schaik RHN, Boersma E</i><br /><b>Aims</b><br />Evidence regarding the role of serial measurements of biomarkers for risk assessment in post-acute coronary syndrome (ACS) patients is limited. The aim was to explore the prognostic value of four, serially measured biomarkers in a large, real-world cohort of post-ACS patients.<br /><b>Methods and results</b><br />BIOMArCS is a prospective, multicentre, observational study in 844 post-ACS patients in whom 12,218 blood samples (median 17/patient) were obtained during one year follow-up. The longitudinal patterns of hs-cTnT, NT-proBNP, hs-CRP and GDF-15 were analysed in relation to the primary endpoint (PE) of CV mortality and recurrent ACS using multivariable joint models. Median age was 63 years, 78% were men and the PE was reached by 45 patients. The average biomarker levels were systematically higher in PE compared to PE-free patients. After adjustment for 6-months post-discharge GRACE score, 1 standard deviation increase in log[hs-cTnT] was associated with a 61% increased risk of the PE (hazard ratio[HR] 1.61, 95% confidence interval[CI] 1.02-2.44, P = 0.045) while for log[GDF-15] this was 81% (HR 1.81, 95% CI 1.28-2.70, P = 0.001). These associations remained significant after multivariable adjustment, while NT-proBNP and hs-CRP were not. Furthermore, GDF-15 level showed an increasing trend prior to the PE. (Structured Graphical Abstract).<br /><b>Conclusions</b><br />Longitudinally measured hs-cTnT and GDF-15 concentrations provide prognostic value in the risk assessment of clinically stabilized patients post-ACS.<br /><b>Clinical trial registration</b><br />The Netherlands Trial Register. Currently available at URL https://trialsearch.who.int/; Unique Identifiers: NTR1698 and NTR1106.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 25 Apr 2023; epub ahead of print</small></div>

<div><h4>Glycemic Patterns and Impact of Early Hyperglycemia in Patients with Cardiogenic Shock on Mechanical Circulatory Support.</h4><i>Nair RM, Chawla S, Mentias A, Saleem T, ... Cremer P, Menon V</i><br /><b>Background</b><br />Hyperglycemia has been an established predictor of poor outcomes in critically ill patients. The aim of the current study is to assess the pattern of early glycemic control in patients with cardiogenic shock (CS) on temporary mechanical circulatory support (MCS) and its impact on short term outcomes.<br /><b>Methods</b><br />All adult patients admitted to the Cleveland Clinic Cardiac Intensive Care Unit (CICU) between 2015 - 2019 with CS necessitating MCS with Intra-Aortic Balloon Pump (IABP), Impella or Venous Arterial- Extra Corporeal Membrane Oxygenation (VA- ECMO) exclusively for CS were retrospectively analyzed. Blood glucose values were collected for the first 72 hrs from the time of MCS insertion. Patients were categorized into three groups (group 1 = mean blood glucose (MBG) < 140, group 2 = MBG between 140-180, and group 3 = MBG >180). The primary outcome was 30-day all-cause mortality.<br /><b>Results</b><br />A total of 393 patients with CS on temporary MCS (Median age [Q1, Q3], 63 [54,70], 42% females), were admitted to our CICU during the study period. Of these, 144 patients (37%) were on IABP, 121 patients (31%) were on Impella, and 128 (32%) were on VA-ECMO. Upon stratifying the patients into groups depending on MBG during the initial time period after MCS placement, 174 patients (44%) had MBG less than 140 mg/dl, 126 patients (32%) had MBG between 140-180 mg/dl whereas 93 (24%) patients had MBG > 180 mg/dl. Overall, patients on IABP had the best glycemic control during the early period whereas those on ECMO had the highest MBG during the initial timeframe. Comparison of 30-day mortality revealed that patients with MBG >180 mg/dl had worse outcomes compared to the other two groups (p = 0.005). Multivariable logistic regression revealed that hyperglycemia was an independent predictor of poor outcomes in CS patients on MCS when undifferentiated by device type (aOR 2.27, 95% CI 1.19-4.42, p = 0.01). However, upon adjusting for the type of MCS device, this effect was no longer present.<br /><b>Conclusions</b><br />A significant proportion of patients with CS on MCS manifest early hyperglycemia regardless of diabetic status. The presence of early hyperglycemia in these patients acted predominantly as a surrogate of the underlying shock severity and was associated with worse short-term outcomes. Future studies should assess whether strategies to optimize the glycemic control in this high-risk cohort can independently improve clinical outcomes.<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: 03 Apr 2023; epub ahead of print</small></div>

<div><h4>Prognostic Implications of Left Ventricular Systolic Dysfunction in Patients with Spontaneous Coronary Artery Dissection.</h4><i>Díez-Villanueva P, García-Guimarães M, Sanz-Ruiz R, Sabaté M, ... Bastante T, Alfonso F</i><br /><b>Background</b><br />Spontaneous coronary artery dissection (SCAD) is a relatively infrequent cause of acute coronary syndrome. Clinical features, angiographic findings, management and outcomes of SCAD patients who present reduced left ventricular ejection fraction (LVEF) remain unknown.<br /><b>Methods</b><br />The Spanish multicentre prospective SCAD registry (NCT03607981), included 389 consecutive patients with SCAD. In 348 of these patients left ventricular ejection fraction (LVEF) could be assessed by echocardiography during the index admission. Characteristics and outcomes of patients with preserved LVEF (LVEF ≥50%, n=295, 85%) were compared with those with reduced LVEF (LVEF<50%, n=53, 15%).<br /><b>Results</b><br />Mean age was 54 years and 90% of patients in both groups were women. The most frequent clinical presentation in patients with reduced LVEF was ST-segment elevation myocardial infarction (62% vs. 36%, p < 0.001), especially anterior STEMI. Proximal coronary segment and multi-segment involvement were also significantly more frequent in these patients. No differences were found on initial revascularization between groups. Patients with reduced LVEF significantly received more often neurohormonal antagonist therapy, and less frequently aspirin. In-hospital events were more frequent in these patients (13% vs. 5%, p = 0.01), with higher rates of death, cardiogenic shock, ventricular arrhythmia and stroke. During a median follow-up of 28 months, the occurrence of a combined adverse event did not statistically differ between the two groups (19% vs. 12%, p = 0.13). However, patients with reduced LVEF had higher mortality (9% vs. 0.7%, p < 0.001) and readmission rates for heart failure (4% vs. 0.3%, p = 0.01).<br /><b>Conclusions</b><br />Patients with SCAD and reduced LVEF show differences in clinical characteristics and angiographic findings compared with SCAD patients with preserved LVEF. Although these patients receive specific medications at discharge, they had higher mortality and readmission rates for heart failure during follow-up.<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: 03 Apr 2023; epub ahead of print</small></div>

<div><h4>Clinical outcomes in STEMI patients undergoing percutaneous coronary interventions later than 48 hours after symptom onset.</h4><i>Rohla M, Temperli F, Siontis GCM, Klingenberg R, ... Windecker S, Räber L</i><br /><b>Background</b><br />Routine revascularisation in patients with ST-segment-elevation myocardial infarction (STEMI) presenting >48 hours after symptom onset is not recommended.<br /><b>Methods</b><br />We compared outcomes of STEMI patients undergoing percutaneous coronary intervention (PCI) according to total ischemic time. Patients included in the Bern-PCI registry and the Multicenter Special Program University Medicine ACS (SPUM-ACS) between 2009-2019 were analysed. Based on symptom-to-balloon-time, patients were categorised as early (<12 h), late (12-48 h) or very late presenters (>48 h). Co-primary endpoints were all-cause mortality and target lesion failure (TLF), a composite of cardiac death, target-vessel myocardial infarction and target-lesion revascularisation at one year.<br /><b>Results</b><br />Of 6,589 STEMI patients undergoing PCI, 73.9% were early, 17.2% late and 8.9% very late presenters. Mean age was 63.4 years, 22% were female. At one year, all-cause mortality occurred more frequently in late vs. early (5.8% vs. 4.4%, HR 1.34,95%CI 1.01-1.78, p = 0.04) and very late (6.8%) vs. early presenters (HR 1.59, 95%CI 1.12-2.25, p < 0.01). There was no excess in mortality comparing very late and late presenters (HR 1.18,95%CI 0.79-1.77, p = 0.42). TLF was more frequent in late vs. early (8.3% vs. 6.5%, HR 1.29,95%CI 1.02-1.63, p = 0.04) and very late (9.4%) vs. early presenters (HR 1.47,95%CI 1.09-1.97, p = 0.01), and similar between very late and late presenters (HR 1.14,95%CI 0.81-1.60, p = 0.46). Following adjustment, heart failure, impaired renal function and previous gastrointestinal bleeding, but not treatment delay were main drivers of outcomes.<br /><b>Conclusions</b><br />PCI >12 h after symptom onset was associated with less favourable outcomes, but very late vs. late presenters did not have an excess in events. While benefits seem uncertain, (very) late PCI appeared safe.<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: 30 Mar 2023; epub ahead of print</small></div>

<div><h4>Intraventricular conduction delays as a predictor of mortality in acute coronary syndromes.</h4><i>Lahti R, Rankinen J, Eskola M, Nikus K, Hernesniemi J</i><br /><b>Background:</b><br/>and aims</b><br />Initial proof suggests that a non-specific intraventricular conduction delay (NIVCD) is a risk factor for mortality. We explored the prognosis of intraventricular conduction delays (IVCD) - right bundle branch block (RBBB), left bundle branch block (LBBB), and the lesser-known NIVCD - in patients with acute coronary syndrome (ACS).<br /><b>Methods</b><br />This is a retrospective registry analysis of 9,749 consecutive ACS patients undergoing coronary angiography and with an ECG recording available for analysis (2007-2018). The primary outcome was cardiac mortality. Mortality and cause of death data (in ICD-10 format) were received from the Finnish national register with no losses to follow-up (until December 31, 2020). The risk associated with IVCDs was analyzed by calculating subdistribution hazard estimates (SDH; deaths due to other causes being considered competing events).<br /><b>Results</b><br />The mean age of the population was 68.3 years (SD 11.8). The median follow-up time was 6.1 years (IQR 3.3-9.4), during which 3,156 patients died. Cardiac mortality was overrepresented among IVCD patients: 76.9% for NIVCD (n = 113/147), 67.6% for LBBB (n = 96/142), 55.7% for RBBB (n = 146/262), and 50.1% for patients with no IVCD (n = 1,275/2,545). In an analysis adjusted for age and cardiac comorbidities, the risk of cardiac mortality was significantly higher in all IVCD groups than among patients with no IVCD: SDH 1.37 (1.15-1.64, p < 0.0001) for RBBB, SDH 1.63 (1.31-2.03 p < 0.0001) for LBBB, and SDH 2.68 (2.19-3.27) for NIVCD. After adjusting the analysis with left ventricular ejection fraction, RBBB and NIVCD remained significant risk factors for cardiac mortality.<br /><b>Conclusion</b><br />RBBB, LBBB, and NIVCD were associated with higher cardiac mortality in ACS patients.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 29 Mar 2023; epub ahead of print</small></div>

<div><h4>Common Congenital Heart Problems in Acute and Intensive Care.</h4><i>Buber J, Valle C, Valente AM</i><br /><AbstractText>Over the past five decades, there have been multiple advances in the treatment of congenital heart defects, resulting in an increasing population of adults living with congenital heart disease (CHD). Despite improved survival, CHD patients often have residual hemodynamic sequelae, limited physiologic reserve and are at increased risk for acute decompensation with occurrence of arrhythmias, heart failure and other medical conditions. Comorbidities occur more frequently and at an earlier age in CHD patients than in the general population. The management of the critically ill CHD patient requires an understanding of the unique aspects of congenital cardiac physiology as well as the recognition of other organ systems that may be involved. Certain patients may be candidates for mechanical circulatory support, and goals of care should be established with advanced care planning.</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 e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 28 Mar 2023; epub ahead of print</small></div>

<div><h4>Mid-regional pro-adrenomedullin and lactate levels for risk stratification in patients with out-of-hospital cardiac arrest.</h4><i>Zelniker TA, Schwall D, Hamidi F, Steinbach S, ... Frey N, Preusch MR</i><br /><b>Background</b><br />Adrenomedullin is a free circulating peptide that regulates endothelial barrier function and vascular tone. Here, we sought to study the relationship of adrenomedullin in combination with lactate and the risk of death in patients with out-of-hospital cardiac arrest (OHCA).<br /><b>Methods</b><br />Mid-regional pro-ADM (MR-proADM) and lactate concentrations were measured in OHCA patients who survived at least 24 h after return of spontaneous circulation. The outcome of interest was all-cause death. Patients were characterized by quartiles (Q) of MR-proADM and lactate concentrations. Cox models were adjusted for age, sex, shockable rhythm, bystander resuscitation, SAPS II score, and eGFR.<br /><b>Results</b><br />A total of 232 patients were included in the present study (28% women, 67 years, SAPS II score 80). The median MR-proADM and lactate levels at 24 hours were 1.4 nmol/L (IQR 0.8-2.8 nmol/L) and 1.8 mmol/L (IQR 1.3 to 3.4 mmol/L), respectively. MR-proADM concentrations correlated weakly with lactate levels (r = 0.36, P < 0.001). High (Q4) versus low (Q1-Q3) MR-proADM concentrations were significantly associated with an increased rate of death at 28 days (75.9% vs 45.4%; P < 0.001). After multivariable adjustment (including lactate levels at 24 hours), higher MR-proADM levels were significantly associated with an increased risk of death (Q4 vs. Q1-Q3: adj-HR 1.67, 95%-CI 1.12-2.50; adj-HR for 1 unit increase in standardized biomarker 1.44, 95-CI 1.19-1.73). This relationship remained significant even after further adjustment for baseline NT-proBNP and hsTnT levels. The combination of high MR-proADM and high lactate (Q4) concentration identified patients at particularly elevated risk (adj-HR 3.50; 95% CI 1.92 to 6.39).<br /><b>Conclusions</b><br />Higher MR-proADM concentrations are associated with an increased risk of death in patients with OHCA, and the combination of high MR-proADM and lactate levels identifies patients at distinctly elevated risk.<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: 21 Mar 2023; epub ahead of print</small></div>

<div><h4>In perspective: The patient at the heart of research in acute cardiovascular care.</h4><i>Thomson RJ, Warren A, Pimento S, Fan E, Proudfoot A</i><br /><AbstractText>Patient and public involvement is a fundamental part of research design and is increasingly required by research funders and regulators. In addition to the moral and ethical arguments in its favour, it has the potential to improve the accessibility and transparency of research, and to optimise study recruitment and retention. While clinical trials in acute cardiovascular care have traditionally focussed on \"hard\" outcomes, such as mortality or major adverse cardiovascular events, there is increasing recognition that these fail to capture the full breadth of patient experience. Patient-centred outcomes aim to measure things of greater value to patients, using validated tools to quantify symptoms, patient self-reports, or novel outcomes such as days alive and outside hospital. This In Perspective commentary explores the rationale behind patient and public involvement, the background to and evidence supporting the use of patient-centred outcomes, and discusses potential challenges and how they can be mitigated.</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 e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 20 Mar 2023; epub ahead of print</small></div>

<div><h4>Multi-organ Evaluation of Perfusion and Congestion Using Ultrasound in Patients with Shock.</h4><i>Tavazzi G, Spiegel R, Rola P, Price S, Corradi F, Hockstein M</i><br /><AbstractText>There is increasing evidence on the role of ultrasound in the evaluation of multi-organ hypoperfusion and congestion in patients with cardiocirculatory shock both to identify the underlying pathophysiological mechanism, to drive and monitor the treatment. The cardiac and lung ultrasound are included as integrated multiparametric approach to the very early phase of patients with hemodynamic instability/ cardiogenic shock. Splanchnic ultrasound has been mainly applied in heart failure and predominant circulatory failure. Although poorly validated in the critically ill, many ultrasound parameters have a strong physiological background to support their use in the acute setting either those that apply for heart/lung and for splanchnic organ evaluation. This review summarizes the ultrasonographic parameters that have shown evidence in literature in the diagnostic/therapeutic pathway to define the congestion/perfusion profile of the organs that are involved in the pathophysiological cascade of cardiocirculatory shock.</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 e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 16 Mar 2023; epub ahead of print</small></div>

<div><h4>Association of accompanying dyspnea with diagnosis and outcome of patients presenting with acute chest discomfort.</h4><i>Boeddinghaus J, Nestelberger T, Koechlin L, Lopez-Ayala P, ... Mueller C, APACE investigators </i><br /><b>Aim</b><br />The presence of accompanying dyspnea is routinely assessed and common in patients presenting with acute chest pain/discomfort to the emergency department (ED). We aimed to assess the association of accompanying dyspnea with differential diagnoses, diagnostic work-up and outcome.<br /><b>Methods</b><br />We enrolled patients presenting to the ED with chest pain/discomfort. Final diagnoses were adjudicated by independent cardiologists using all information including cardiac imaging. The primary diagnostic endpoint was the final diagnosis. The secondary diagnostic endpoint was the performance of high-sensitivity cardiac troponin (hs-cTn) and the European Society of Cardiology (ESC) 0/1h-algorithms for the diagnosis of myocardial infarction (MI). The prognostic endpoints were cardiovascular and all-cause mortality at two years.<br /><b>Results</b><br />Among 6045 patients, 2892/6045 (48%) had accompanying dyspnea. The prevalence of ACS in patients with versus without dyspnea was comparable (MI 22.4% vs. 21.9%, p = 0.60, unstable angina 8.7% vs. 7.9%, p = 0.29). In contrast, patients with dyspnea more often had cardiac, non-coronary disease (15.3% vs. 10.2%, p < 0.001). Diagnostic accuracy of hs-cTnT/I concentrations was not affected by the presence of dyspnea (area under the curve 0.89-0.91 in both groups) and the safety of the ESC 0/1h-algorithms was maintained with negative predictive values >99.4%. Accompanying dyspnea was an independent predictor for cardiovascular and all-cause death at two years (Hazard Ratio [HR] 1.813 [95%CI, 1.453-2.261, p < 0.01]).<br /><b>Conclusion</b><br />Accompanying dyspnea was not associated with a higher prevalence of ACS but with cardiac, non-coronary disease. While the safety of the diagnostic work-up was not affected, accompanying dyspnea was an independent predictor for cardiovascular and all-cause death.<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: 14 Mar 2023; epub ahead of print</small></div>

<div><h4>Acute heart failure presentation, management and outcomes in cancer patients: a national longitudinal study.</h4><i>Coles B, Welch CA, Motiwale RS, Teece L, ... Sweeting MJ, Adlam D</i><br /><b>Background</b><br />Currently, little evidence exists on survival and quality of care in cancer patients presenting with acute heart failure (HF). To investigate the presentation and outcomes of hospital admission with acute HF in a national cohort of patients with prior cancer.<br /><b>Methods</b><br />This retrospective, population-based cohort study, identified 221,953 patients admitted to hospital in England for HF during 2012-2018 (12,867 with a breast, prostate, colorectal or lung cancer diagnosis in the previous 10 years). We examined the impact of cancer on 1) HF presentation and in-hospital mortality, 2) place of care, 3) HF medication prescribing, and 4) post-discharge survival, using propensity score weighting and model-based adjustment.<br /><b>Results</b><br />HF presentation was similar between cancer and non-cancer patients. A lower percentage of patients with prior cancer were cared for in a cardiology ward (-2.4 percentage point difference [ppd] [95% CI -3.3, -1.6]) or were prescribed ACEi/ARB for HFrEF (-2.1 ppd [-3.3, -0.9]) than non-cancer patients. Survival after HF discharge was poor with median survival of 1.6 years in prior cancer and 2.6 years in non-cancer patients. Mortality in prior cancer patients was driven primarily by non-cancer causes (68% of post-discharge deaths).<br /><b>Conclusions</b><br />Survival in prior cancer patients presenting with acute HF was poor, with a significant proportion due to non-cancer causes of death. Despite this, cardiologists were less likely to manage cancer patients with HF. Cancer patients who develop HF were less likely to be prescribed guideline-based HF medications compared with non-cancer patients. This was particularly driven by patients with a poorer cancer prognosis.<br /><br />© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 08 Mar 2023; epub ahead of print</small></div>

<div><h4>The Fragility Index in randomised clinical trials supporting clinical practice guidelines for acute coronary syndrome: measuring robustness from a different perspective.</h4><i>Gonzalez-Del-Hoyo M, Mas-Llado C, Blaya-Peña L, Siquier-Padilla J, Peral V, Rossello X</i><br /><b>Background</b><br />In randomised clinical trials (RCTs) rejecting the null hypothesis, the fragility index (FI) yields the minimum number of participants who would need to have had a different outcome for the results of the trial to become non-significant. We evaluated the robustness of RCTs supporting ACC/AHA and ESC clinical practice guidelines (CPGs) for ST elevation myocardial infarction (STEMI) and non-ST elevation acute coronary syndrome (NSTE-ACS) using the FI.<br /><b>Methods</b><br />There were 407 RCTs among the 2128 studies cited in the 2013 and 2014 ACC/AHA and 2017 and 2020 ESC CPGs for STEMI and NSTE-ACS, respectively. The FI could be calculated in 132 RCTs (32.4%) meeting the needed criteria for its estimation (2-arm RCT, 1:1 allocation, binary outcome, p < 0.05).<br /><b>Results</b><br />The median FI was 12 (interquartile range: 4-29). Hence, a change in the outcome status of 12 patients would be needed to reverse the statistical significance of the primary endpoint in 50% of the RCTs. The FI was ≤1% than their sample size in 55.7% RCTs, whereas in 47% of RCTs, the FI was lower than the number of patients lost to follow-up. Some study design features were associated with higher FI (international, multicentre, private funding; all p < 0.05), whilst baseline patient characteristics were not substantially different by FI (e.g., age, female sex, white study participants; all p > 0.05), except for geographic enrolment (p = 0.042).<br /><b>Conclusions</b><br />FI might be useful to evaluate the robustness of those RCTs with statistically significant findings for the primary endpoint that have an impact on key guideline recommendations.<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: 07 Mar 2023; epub ahead of print</small></div>

<div><h4>Neuroprognostication after cardiac arrest: What the cardiologist should know.</h4><i>Kondziella D</i><br /><AbstractText>Two aspects are key to mastering prognostication of comatose cardiac arrest survivors: a detailed knowledge about the clinical trajectories of consciousness recovery (or lack thereof) and the ability to correctly interpret the results of multimodal investigations, which include clinical examination, EEG, neuroimaging, evoked potentials, and blood biomarkers. While the very good and the very poor ends of the clinical spectrum typically do not pose diagnostic challenges, the intermediate \"grey zone\" of post-cardiac arrest encephalopathy requires cautious interpretation of the available information and sufficiently long clinical observation. Late recovery of coma patients with initially ambiguous diagnostic results is increasingly reported, as are unresponsive patients with various forms of residual consciousness, including so-called cognitive motor dissociation, rendering prognostication of post-anoxic coma highly complex. The aim of this paper is to provide busy clinicians with a high-yield, concise overview of neuroprognostication after cardiac arrest, emphasizing notable developments in the field since 2020.</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 e-mail: journals.permissions@oup.com.<br /><br /><small>Eur Heart J Acute Cardiovasc Care: 03 Mar 2023; epub ahead of print</small></div>