Journal: Eur Heart J Acute Cardiovasc Care

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Abstract

Extending the No Objective Testing Rules to Patients triaged by the ESC 0/1-Hour Algorithms.

Ratmann PD, Boeddinghaus J, Nestelberger T, Lopez-Ayala P, ... Buser A, Mueller C
Background
After rule-out of non-ST elevation myocardial infarction (NSTEMI) with the European Society of Cardiology (ESC) 0/1h-algorithms, it is unclear which patients require further anatomical or functional cardiac testing.
Objective
To test the safety and efficacy of the no-objective-testing (NOT)-rules after NSTEMI rule-out by the ESC 0/1h-algorithms.
Methods
International, prospective, diagnostic multicenter study enrolling adult patients presenting with chest pain to the emergency department. Central adjudication of final diagnosis by two independent cardiologists using information including cardiac imaging. Primary endpoints were the safety and efficacy of the NOT-rules for the rule-out of major adverse cardiovascular events (MACE). Secondary endpoints included 365-day and 2-year MACE.
Results
Among 4804 and 4569 patients with available 0/1h high-sensitivity cardiac troponin (hs-cTn)T-Elecsys or hs-cTnI-Architect concentrations, 2783 (58%) and 2252 (49%) were eligible for application of the NOT-rules after rule-out of NSTEMI by the ESC hs-cTnT/I-0/1h-algorithm. The first rule identified 26% of patients with a sensitivity of 100% (95%CI 98.3-100%) and a negative predictive value (NPV) of 100% (95%CI, n.c.). The second and third rules both identified 31% of patients with a sensitivity of 99.5% (95%CI 97.4-99.9%) and a NPV of 99.9% (95%CI 99.2-99.9%). Similar findings emerged for hs-cTnI. High safety was confirmed for rule-out of 365-day and 2-year MACE and proven to be superior to the HEART Score.
Conclusion
All three NOT-rules performed very well for rule-out of MACE. The third NOT-rule best balanced feasibility, safety, and efficacy by identifying nearly one out of three patients as low-risk and may not require further cardiac testing.

© 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.

Eur Heart J Acute Cardiovasc Care: 30 Sep 2022; epub ahead of print
Ratmann PD, Boeddinghaus J, Nestelberger T, Lopez-Ayala P, ... Buser A, Mueller C
Eur Heart J Acute Cardiovasc Care: 30 Sep 2022; epub ahead of print | PMID: 36179255
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Abstract

Cardiogenic shock severity and mortality in patients receiving venoarterial extracorporeal membrane oxygenator support.

Jentzer JC, Baran DA, Bohman JK, van Diepen S, ... Drakos SG, Tonna JE
Background
Shock severity predicts mortality in patients with cardiogenic shock (CS). We evaluated the association between pre-cannulation Society for Cardiovascular Angiography and Interventions (SCAI) shock classification and mortality among patients receiving venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support for CS.
Methods
We included Extracorporeal Life Support Organization (ELSO) Registry patients from 2010 to 2020 who received VA ECMO for CS. SCAI shock stage was assigned based on hemodynamic support requirements prior to ECMO initiation. In-hospital mortality was analyzed using multivariable logistic regression.
Results
We included 12106 unique VA ECMO patient-runs with a median age of 57.9 (interquartile range 46.8, 66.1) years and 31.8% were females; 3472 (28.7%) were post-cardiotomy. The distribution of SCAI shock stages at ECMO initiation was: B, 821 (6.8%); C, 7518 (62.1%); D, 2973 (24.6%); and E, 794 (6.6%). During the index hospitalization, 6681 (55.2%) patients died. In-hospital mortality increased incrementally with SCAI shock stage (adjusted OR 1.24 per SCAI shock stage, 95% CI 1.17-1.32, p < 0.001): B, 47.5%; C, 52.8%; D, 60.8%; E, 65.1%. A higher SCAI shock stage was associated with increased in-hospital mortality in key subgroups, although the SCAI shock classification was only predictive of mortality in non-surgical (medical) CS, and not in post-cardiotomy CS.
Conclusions
The severity of shock prior to cannulation is a strong predictor of in-hospital mortality in patients receiving VA ECMO for CS. Using the pre-cannulation SCAI shock classification as a risk stratification tool can help clinicians refine prognostication for ECMO recipients and guide future investigations to improve outcomes.

© 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.

Eur Heart J Acute Cardiovasc Care: 29 Sep 2022; epub ahead of print
Jentzer JC, Baran DA, Bohman JK, van Diepen S, ... Drakos SG, Tonna JE
Eur Heart J Acute Cardiovasc Care: 29 Sep 2022; epub ahead of print | PMID: 36173885
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Abstract

Predictors and Outcome of Electrical Storm induced Cardiogenic Shock.

Incognito C, Martens P, Hedley J, Parker JD, ... Hussein A, Tang WHW
Background
Limited information is available about the short and long-term outcomes in electrical storm (ES)-induced cardiogenic shock (CS) and its predictors.
Methods
This is a retrospective, single-center cohort study of consecutive patients with ES admitted to the Cardiac Intensive Care Unit between 2015 and 2020. The proportion of ES patients who developed CS was adjudicated, and clinical predictors of in-hospital ventricular arrhythmia (VA)-related mortality and one-year all-cause mortality were investigated.
Results
Of the 214 patients with ES, 33.6% developed CS. Left ventricular ejection fraction, admission lactate, absence of an implantable-cardioverter defibrillator, and admission central venous pressure were independently associated with development of CS (p < 0.03 for all). Based on these variables, a FLIC-score was developed (https://riskcalc.org/FLICscore/) to predict ES-induced CS (AUC = 0.949, with AUC = 0.954 in a validation cohort, both p < 0.001). Patients who developed CS had a 11.3-fold (95% CI 2.7-12.8) increased odds for in-hospital VA-related mortality and 9.4-fold (95% CI 4.0-22.4) increased odds for in hospital all-cause mortality. A FLIC-score above 0.62 was associated with a 6.2- and 5.8-fold increased odds for respectively similar endpoints. Patients with ES-induced CS received more treatment modalities to manage the ES (4.5 ± 1.8 vs 2.3 ± 1.2, p < 0.001) and had longer length of stay (14 [8-27] vs 8 [5-13], p < 0.001) than patients without CS. Interestingly if patients with ES-induced CS survived to discharge, their outcomes were similar to those without CS at one year.
Conclusion
Cardiogenic shock in ES is a frequent and potentially life-threatening complication with high short-term mortality. A novel risk score could identify patient at risk, generating a potential for early risk-based interventions.

© 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.

Eur Heart J Acute Cardiovasc Care: 29 Sep 2022; epub ahead of print
Incognito C, Martens P, Hedley J, Parker JD, ... Hussein A, Tang WHW
Eur Heart J Acute Cardiovasc Care: 29 Sep 2022; epub ahead of print | PMID: 36173893
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Abstract

Predictors and Associated Clinical Outcomes of Low Cardiac Output Syndrome Following Cardiac Surgery: Insights from the LEVO-CTS Trial.

Kochar A, Zheng Y, van Diepen S, Mehta RH, ... Goodman SG, Fremes S
Background
High-risk cardiac surgery is commonly complicated by low cardiac output syndrome (LCOS) which is associated with high mortality. There are limited data derived from multi-center studies with adjudicated endpoints describing factors associated with LCOS and its downstream clinical outcomes.
Methods
The Levosimendan in Patients with Left Ventricular Systolic Dysfunction Undergoing Cardiac Surgery Requiring Cardiopulmonary Bypass (LEVO-CTS) trial evaluated prophylactic levosimendan versus placebo in patients with a reduced ejection fraction undergoing coronary artery bypass grafting and/or valve surgery. We conducted a pre-specified analysis on LCOS which was characterized by a four-part definition. We constructed a multivariable logistical regression model to evaluate risk factors associated with LCOS and performed Cox proportional hazards modeling to determine the association of LCOS with 90-day mortality.
Results
A total of 186 (22%) of 849 patients in the LEVO-CTS trial developed LCOS. Factors most associated with a higher adjusted risk of LCOS were pre-operative ejection fraction (OR 1.26; 95% CI: 1.08-1.46 per 5% decrease) and age (OR 1.13; 95% CI: 1.04-1.24 per 5-year increase) whereas isolated CABG surgery (OR 0.44, 95% CI: 0.31-0.64) and levosimendan use (OR 0.65; 95% CI: 0.46-0.92) were associated with a lower risk of LCOS. Patients with LCOS had worse outcomes, including renal replacement therapy at 30-days (10% vs. 1%) and 90-day mortality (16% vs. 3%, adjusted HR of 5.04, 95% CI: 2.66-9.55).
Conclusions
LCOS is associated with a high risk of post-operative mortality in high risk cardiac surgery.

© The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Eur Heart J Acute Cardiovasc Care: 26 Sep 2022; epub ahead of print
Kochar A, Zheng Y, van Diepen S, Mehta RH, ... Goodman SG, Fremes S
Eur Heart J Acute Cardiovasc Care: 26 Sep 2022; epub ahead of print | PMID: 36156131
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Abstract

Impact of congestion and perfusion status in the emergency department on severity of decompensation and short-term prognosis in patients with acute heart failure.

Espinosa B, Llorens P, Gil V, Jacob J, ... Miró Ò, ICA-SEMES Research Group
Objectives
To assess whether symptoms/signs of congestion and perfusion in acute heart failure (AHF) evaluated at patient arrival to the emergency department (ED) can predict the severity of decompensation and short-term outcomes.
Methods
We included patients from the Epidemiology of Acute Heart Failure Emergency Registry (EAHFE Registry). We registered 7 clinical surrogates of congestion and 5 of hypoperfusion. Patients were grouped according to severity of congestion/hypoperfusion. We assessed the need for hospitalization, in-hospital all-cause mortality for patients needing hospitalization, and prolonged hospitalization for patients surviving the decompensation episode. Outcomes were adjusted for patient characteristics and the coexistence of congestion and hypoperfusion.
Results
We analyzed 18,120 patients (median = 83 years, IQR = 76-88; women = 55.7%). 72% presented >2 signs/symptoms of congestion and 18% had at least 1 sign/symptom of hypoperfusion. 75% were hospitalized with in-hospital death in 9% and prolonged hospitalization in 47% discharged alive. The presence of congestion/hypoperfusion were independently associated with poorer outcomes. An increase in the number of signs/symptoms of congestion was associated with increased risk of hospitalization (p < 0.001) and prolonged stay (p = 0.011), but not mortality (p = 0.06). Increased signs/symptoms of hypoperfusion was associated with hospitalization (p < 0.001) and mortality (p < 0.001), but not prolonged stay (p = 0.227). In the combined model, including congestion and hypoperfusion, both had additive effects on hospitalization, in-hospital mortality was driven by hypoperfusion and no differences were observed for prolonged hospitalization.
Conclusion
The presence of congestion/hypoperfusion at ED arrival is a simple clinical marker associated with a higher risk of severity/adverse short-term outcomes.

© The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Eur Heart J Acute Cardiovasc Care: 22 Sep 2022; epub ahead of print
Espinosa B, Llorens P, Gil V, Jacob J, ... Miró Ò, ICA-SEMES Research Group
Eur Heart J Acute Cardiovasc Care: 22 Sep 2022; epub ahead of print | PMID: 36137176
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Abstract

Clinical governance of patients with acute coronary syndromes.

Leonardi S, Montalto C, Carrara G, Casella G, ... Visconti LO, Campo G
Aims
Using the principles of clinical governance, a patient-centred approach intended to promote holistic quality improvement, we designed a prospective, multicentre study in patients with acute coronary syndrome (ACS). We aimed to verify and quantify consecutive inclusion and describe relative and absolute effects of indicators of quality for diagnosis and therapy.
Methods and results
Administrative codes for invasive coronary angiography and acute myocardial infarction were used to estimate the ACS universe. The ratio between the number of patients included and the estimated ACS universe was the consecutive index. Co-primary quality indicators were timely reperfusion in patients admitted with ST-elevation ACS and optimal medical therapy at discharge. Cox-proportional hazard models for 1-year death with admission and discharge-specific covariates quantified relative risk reductions and adjusted number needed to treat (NNT) absolute risk reductions. Hospital codes tested had a 99.5% sensitivity to identify ACS universe. We estimated that 7344 (95% CI: 6852-7867) ACS patients were admitted and 5107 were enrolled-i.e. a consecutive index of 69.6% (95% CI 64.9-74.5%), which varied from 30.7 to 79.2% across sites. Timely reperfusion was achieved in 22.4% (95% CI: 20.7-24.1%) of patients, was associated with an adjusted hazard ratio (HR) for 1-year death of 0.60 (95% CI: 0.40-0.89) and an adjusted NNT of 65 (95% CI: 44-250). Corresponding values for optimal medical therapy were 70.1% (95% CI: 68.7-71.4%), HR of 0.50 (95% CI: 0.38-0.66), and NNT of 98 (95% CI: 79-145).
Conclusion
A comprehensive approach to quality for patients with ACS may promote equitable access of care and inform implementation of health care delivery.
Registration
ClinicalTrials.Gov ID NCT04255537.

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

Eur Heart J Acute Cardiovasc Care: 19 Sep 2022; epub ahead of print
Leonardi S, Montalto C, Carrara G, Casella G, ... Visconti LO, Campo G
Eur Heart J Acute Cardiovasc Care: 19 Sep 2022; epub ahead of print | PMID: 36124872
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Abstract

Fluid management in acute kidney injury: from evaluating fluid responsiveness towards assessment of fluid tolerance.

Argaiz ER, Rola P, Haycock KH, Verbrugge FH
Despite the widespread use of intravenous fluids in acute kidney injury (AKI), solid evidence is lacking. Intravenous fluids mainly improve AKI due to true hypovolaemia, which is difficult to discern at the bedside unless it is very pronounced. Empiric fluid resuscitation triggered only by elevated serum creatinine levels or oliguria is frequently misguided, especially in the presence of fluid intolerance syndromes such as increased extravascular lung water, capillary leak, intra-abdominal hypertension, and systemic venous congestion. While fluid responsiveness tests clearly identify patients who will not benefit from fluid administration (i.e. those without an increase in cardiac output), the presence of fluid responsiveness does not guarantee that fluid therapy is indicated or even safe. This review calls for more attention to the concept of fluid tolerance, incorporating it into a practical algorithm with systematic venous Doppler ultrasonography assessment to use at the bedside, thereby lowering the risk of detrimental kidney congestion in AKI.

© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Acute Cardiovasc Care: 07 Sep 2022; epub ahead of print
Argaiz ER, Rola P, Haycock KH, Verbrugge FH
Eur Heart J Acute Cardiovasc Care: 07 Sep 2022; epub ahead of print | PMID: 36069621
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Abstract

Early drop in systolic blood pressure is associated with poor diuretic response and prognosis in patients with acute heart failure.

Dotare T, Maeda D, Matsue Y, Sunayama T, ... Yamamoto M, Minamino T
Aims
Although an excessive drop in systolic blood pressure (SBP) during acute heart failure (AHF) negatively impacts prognosis, the association between changes in SBP and the diuretic response (DR) is unclear. We aimed to clarify the association between an early drop in SBP and DR/prognosis in patients with AHF.
Methods and results
This was a sub-analysis of the REALITY-AHF study, which registered patients with AHF admitted through emergency departments (EDs). An early SBP drop was defined as the difference between baseline SBP and the lowest value during the first 48 h of hospitalization. DR was defined as the urine output achieved per 40 mg of intravenous furosemide administered. SBP was measured on admission, at 90 min, and 6, 24, and 48 h after admission. Patients were divided into four groups according to their median SBP drop and DR: greater SBP drop/poor DR (n = 322), smaller SBP drop/poor DR (n = 409), greater SBP drop/good DR (n = 419), and smaller SBP drop/good DR (n = 314). The study included 1,464 patients. A greater SBP drop/poor DR was associated with higher baseline SBP and vasodilator use. Multivariable linear regression analysis showed that a greater drop in SBP was associated with poorer DR following adjustment for potential covariates. Cox proportional hazards analysis demonstrated that a greater SBP drop/poor DR was independently associated with 1-year mortality. Both SBP and DR changes were independently associated with prognosis.
Conclusion
An early drop in SBP during the first 48 h of hospitalization was associated with poor DR and 1-year mortality in patients with AHF.
Clinical trial registration
URL: http://www.umin.ac.jp/ctr/Unique identifier: UMIN000014105.

© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Acute Cardiovasc Care: 05 Sep 2022; epub ahead of print
Dotare T, Maeda D, Matsue Y, Sunayama T, ... Yamamoto M, Minamino T
Eur Heart J Acute Cardiovasc Care: 05 Sep 2022; epub ahead of print | PMID: 36063446
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Abstract

Short-term outcomes by chronic betablocker treatment in patients presenting to emergency departments with acute heart failure: BB-EAHFE.

Jacob J, Haro A, Tost J, Rossello X, ... Miró Ò, ICA-SEMES Research Group
Aims
To evaluate the association between chronic treatment with betablockers (BB) and the severity of decompensation and short-term outcomes of patients with acute heart failure (AHF).
Methods and results
We consecutively included all patients presenting with AHF to 45 Spanish emergency departments (ED) during six different time-periods between 2007 and 2018. Patients were stratified according to whether they were on chronic treatment with BB at the time of ED consultation. Those receiving BB were compared (adjusted odds ratio-OR-with 95% confidence interval-CI-) with those not receiving BB group in terms of in-hospital and 7-day all-cause mortality, need for hospitalization, and prolonged length of stay (≥7 days). Among the 17 923 recruited patients (median age: 80 years; 56% women), 7795 (43%) were on chronic treatment with BB. Based on the MEESSI-AHF risk score, those on BB were at lower risk. In-hospital mortality was observed in 1310 patients (7.4%), 7-day mortality in 765 (4.3%), need for hospitalization in 13 428 (75.0%), and prolonged length of stay (43.3%). After adjustment for confounding, those on chronic BB were at lower risk for in-hospital all-cause mortality (OR = 0.85, 95% CI = 0.79-0.92, P < 0.001); 7-day all-cause mortality (OR = 0.77, 95% CI = 0.70-0.85, P < 0.001); need for hospitalization (OR = 0.89, 95% CI = 0.85-0.94, P < 0.001); prolonged length of stay (OR = 0.90, 95% CI = 0.86-0.94, P < 0.001). A propensity matching approach yielded consistent findings.
Conclusion
In patients presenting to ED with AHF, those on BB had better short-term outcomes than those not receiving BB.

© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Acute Cardiovasc Care: 26 Aug 2022; epub ahead of print
Jacob J, Haro A, Tost J, Rossello X, ... Miró Ò, ICA-SEMES Research Group
Eur Heart J Acute Cardiovasc Care: 26 Aug 2022; epub ahead of print | PMID: 36018216
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Abstract

Angiographic outcome in patients treated with deferred stenting after ST-segment elevation myocardial infarction-results from DANAMI-3-DEFER.

Nepper-Christensen L, Kelbæk H, Ahtarovski KA, Høfsten DE, ... Engstrøm T, Lønborg J
Aims
Stent implantation during primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) occasionally results in flow disturbances and distal embolization, which may cause adverse clinical outcomes. Deferred stent implantation seems to reduce the impairment on myocardial function, although the mechanisms have not been clarified. We sought to evaluate whether deferred stenting could reduce flow disturbance in patients treated with primary PCI.
Methods and results
Patients with STEMI included in the DANAMI-3-DEFER trial were randomized to deferred versus immediate stent implantation. The primary and secondary outcomes of this substudy were the incidences of slow/no reflow and distal embolization. A total of 1205 patients were included. Deferred stenting (n = 594) resulted in lower incidences of distal embolization [odds ratio (OR) 0.67, 95% confidence interval (CI) 0.46-0.98, P = 0.040] and slow/no reflow (OR 0.60, 95%CI 0.37-0.97, P = 0.039). In high-risk subgroups, the protective effect was greatest in patients >65 years of age (slow/no reflow: OR 0.36, 95% CI 0.17-0.72, P = 0.004 and distal embolization: OR 0.34, 95% CI 0.18-0.63, P = 0.001), in patients presenting with occluded culprit artery at admission (slow/no reflow: OR 0.33, 95% CI 0.16-0.65, P = 0.001 and distal embolization: OR 0.54, 95% CI 0.31-0.96, P = 0.036) and in patients with thrombus grade >3 (slow/no reflow: OR 0.37, 95% CI 0.20-0.67, P = 0.001 and distal embolization: OR 0.39, 95% CI 0.24-0.64, P < 0.001) with a significant P for interaction for all.
Conclusion
Deferred stent implantation reduces the incidences of slow/no reflow and distal embolization, especially in older patients and in those with total coronary occlusion or high level of thrombus burden.

© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Acute Cardiovasc Care: 25 Aug 2022; epub ahead of print
Nepper-Christensen L, Kelbæk H, Ahtarovski KA, Høfsten DE, ... Engstrøm T, Lønborg J
Eur Heart J Acute Cardiovasc Care: 25 Aug 2022; epub ahead of print | PMID: 36006808
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Abstract

Soluble urokinase-type plasminogen activator receptor improves early risk stratification in cardiogenic shock.

Hongisto M, Lassus J, Tarvasmäki T, Sans-Roselló J, ... Harjola VP, CardShock Study Investigators and the GREAT Network
Aims
Soluble urokinase-type plasminogen activator receptor (suPAR) is a biomarker reflecting the level of immune activation. It has been shown to have prognostic value in acute coronary syndrome and heart failure as well as in critical illness. Considering the complex pathophysiology of cardiogenic shock (CS), we hypothesized suPAR might have prognostic properties in CS as well. The aim of this study was to assess the kinetics and prognostic utility of suPAR in CS.
Methods and results
SuPAR levels were determined in serial plasma samples (0-96 h) from 161 CS patients in the prospective, observational, multicentre CardShock study. Kinetics of suPAR, its association with 90-day mortality, and additional value in risk-stratification were investigated. The median suPAR-level at baseline was 4.4 [interquartile range (IQR) 3.2-6.6)] ng/mL. SuPAR levels above median were associated with underlying comorbidities, biomarkers reflecting renal and cardiac dysfunction, and higher 90-day mortality (49% vs. 31%; P = 0.02). Serial measurements showed that survivors had significantly lower suPAR levels at all time points compared with nonsurvivors. For risk stratification, suPAR at 12 h (suPAR12h) with a cut-off of 4.4 ng/mL was strongly associated with mortality independently of established risk factors in CS: OR 5.6 (95% CI 2.0-15.5); P = 0.001) for death by 90 days. Adding suPAR12h > 4.4 ng/mL to the CardShock risk score improved discrimination identifying high-risk patients originally categorized in the intermediate-risk category.
Conclusion
SuPAR associates with mortality and improves risk stratification independently of other previously known risk factors in CS patients.

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

Eur Heart J Acute Cardiovasc Care: 11 Aug 2022; epub ahead of print
Hongisto M, Lassus J, Tarvasmäki T, Sans-Roselló J, ... Harjola VP, CardShock Study Investigators and the GREAT Network
Eur Heart J Acute Cardiovasc Care: 11 Aug 2022; epub ahead of print | PMID: 35949144
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Abstract

Effectiveness and safety of P2Y12 inhibitors in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention: a nationwide registry-based study.

Godtfredsen SJ, Kragholm KH, Leutscher P, Jørgensen SH, ... Torp-Pedersen C, Pareek M
Aims
To compare the effectiveness and safety of clopidogrel, ticagrelor, and prasugrel in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI).
Methods and results
Nationwide, registry-based study of STEMI patients treated with primary PCI (2011-17) and subsequently with aspirin and a P2Y12 inhibitor. The effectiveness outcome was major adverse cardiovascular events (MACE) defined as a composite of recurrent myocardial infarction, repeat revascularization, stroke, or cardiovascular death at 12 months. The safety outcome was bleeding requiring hospitalization at 12 months. Multivariable logistic regression with average treatment effect modeling was used to calculate absolute and relative risks for outcomes standardized to the distributions of demographic characteristics of all included subjects. We included 10 832 patients; 1 697 were treated with clopidogrel, 7 508 with ticagrelor, and 1,627 with prasugrel. Median ages were 66, 63, and 59 years (P < 0.001). Standardized relative risks of MACE were 0.75 for ticagrelor vs. clopidogrel (95% confidence interval [CI], 0.64-0.83), 0.84 for prasugrel vs. clopidogrel (95% CI, 0.73-0.94), and 1.12 for prasugrel vs. ticagrelor (95% CI, 1.00-1.24). Standardized relative risks of bleeding were 0.77 for ticagrelor vs. clopidogrel (95% CI, 0.59-0.93), 0.89 for prasugrel vs. clopidogrel (95% CI, 0.64-1.15), and 1.17 for prasugrel vs. ticagrelor (95% CI, 0.89-1.45).
Conclusion
Ticagrelor and prasugrel were associated with lower risks of MACE after STEMI than clopidogrel, and ticagrelor was associated with a marginal reduction compared with prasugrel. The risk of bleeding was lower with ticagrelor compared with clopidogrel, but did not significantly differ between ticagrelor and prasugrel.

© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Acute Cardiovasc Care: 11 Aug 2022; epub ahead of print
Godtfredsen SJ, Kragholm KH, Leutscher P, Jørgensen SH, ... Torp-Pedersen C, Pareek M
Eur Heart J Acute Cardiovasc Care: 11 Aug 2022; epub ahead of print | PMID: 35950769
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Abstract

Epidemiology, monitoring, and treatment strategy in cardiogenic shock. A multinational cross-sectional survey of ESC-acute cardiovascular care association research section.

Tavazzi G, Rossello X, Grand J, Gierlotka M, ... Hassager C, Price S
Aims
Cardiogenic shock (CS) is a life-threatening condition burdened by mortality in up to 50% of cases. Few recommendations exist with intermediate-low level of evidence on CS management and no data on adherence across centres exist. We performed a survey to frame CS management at multinational level.
Methods and results
An international cross-sectional survey was created and approved by European Society of Cardiology-Acute Cardiovascular Care Association board. A total of 337 responses from 60 countries were obtained. Data were assessed by the hospital level of care of the participants. The most common cause of CS was AMI (AMI-CS-79.9%) with significant difference according to hospital levels (P = 0.001), followed by acutely decompensated heart failure (HF) (13.4%), myocarditis (3.5%), and de novo HF (1.75%). In 37.8%, percutaneous coronary intervention (PCI) is performed to all CS-patients as a standard approach, whereas 42.1% used PCI if electrocardiogram suggestive of ischaemia and 20.1% only if Universal definition of myocardial infarction criteria are fulfilled. Management (catecholamine titration and mechanical circulatory support escalation) is driven by mean arterial pressure (87.1%), echocardiography (84.4%), and lactate levels (83.4%). Combination of vasopressor and inotrope is chosen with the same frequency (37.7%) than inotrope alone as first-line pharmacological therapy (differences amongst hospital levels; P > 0.5). Noradrenaline is first-line vasopressor (89.9%) followed by dopamine (8.5%), whereas dobutamine is confirmed as the first-line inotrope (65.9%).
Conclusion
Cardiogenic shock management is heterogenous and often not adherent to current recommendations. Quality improvement on an international level with evidence-based quality indicators should be developed to standardize diagnostic and therapeutic pathways.

© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Acute Cardiovasc Care: 09 Aug 2022; epub ahead of print
Tavazzi G, Rossello X, Grand J, Gierlotka M, ... Hassager C, Price S
Eur Heart J Acute Cardiovasc Care: 09 Aug 2022; epub ahead of print | PMID: 35941730
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Impact:
Abstract

Chest pain workup in the presence of atrial fibrillation: impacts on troponin testing, myocardial infarction diagnoses, and long-term prognosis.

Lancini D, Greenslade J, Martin P, Prasad S, ... Than M, Cullen L
Aims
Patients presenting to the emergency department (ED) with chest pain require evaluation for acute coronary syndrome (ACS). Atrial fibrillation (AF) can lead to troponin (cTn) elevation in the absence of ACS. There is limited evidence informing the impact of AF on the diagnostic performance of cTn testing for the diagnosis of Type 1 myocardial infarction (T1MI), or the association between AF and long-term outcomes in this context.
Methods and results
This study used the IMPACT and ADAPT study databases to compile a combined cohort of 3496 adults presenting to ED with chest pain between 2007 and 2014, with early cTn testing during ED workup. The mean age was 56.6 years, and 40.2% were female. Outcomes included adjudicated diagnoses for the index admission and mortality to 1-year after presentation. The specificity of initial cTn testing for T1MI diagnosis was lower for patients in AF compared with those not in AF (79.2% vs. 95.4%, P < 0.001), largely due to a relative increase in Type 2 myocardial infarction diagnoses. Sensitivity for T1MI did not differ between patients with or without AF (88.5% vs. 91.5%, P = 0.485). AF was associated with increased 1-year mortality (10.4% vs. 2.3%, P < 0.001), although this was not significant on multivariable analysis.
Conclusion
The specificity of serial cTn testing for the diagnosis of T1MI in patients presenting to ED with chest pain is reduced in the presence of AF. Further studies are needed to establish whether optimised cTn thresholds for patients with AF can improve workup and outcomes.

© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Acute Cardiovasc Care: 04 Aug 2022; epub ahead of print
Lancini D, Greenslade J, Martin P, Prasad S, ... Than M, Cullen L
Eur Heart J Acute Cardiovasc Care: 04 Aug 2022; epub ahead of print | PMID: 35925661
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Abstract

Acute valvular emergencies.

Bernard S, Deferm S, Bertrand PB
Acute valvular emergencies represent an important cause of cardiogenic shock. However, their clinical presentation and initial diagnostic testing are often non-specific, resulting in delayed diagnosis. Moreover, metabolic disarray or haemodynamic instability may result in too great a risk for emergent surgery. This review will focus on the aetiology, clinical presentation, diagnostic findings, and treatment options for patients presenting with native acute left-sided valvular emergencies. In addition to surgery, options for medical therapy, mechanical circulatory support, and novel percutaneous interventions are discussed.

© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Acute Cardiovasc Care: 01 Aug 2022; epub ahead of print
Bernard S, Deferm S, Bertrand PB
Eur Heart J Acute Cardiovasc Care: 01 Aug 2022; epub ahead of print | PMID: 35912478
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Abstract

Catheter-directed interventions for pulmonary embolism.

Kochar A, Bergmark BA
Pulmonary embolism (PE) is common, life-threatening, and often recurrent among survivors. The clinical manifestations of PE range from incidental detection to sudden death, with approximately one-third of PE deaths occurring suddenly. State-of-the-art management of acute PE relies on early detection, risk stratification based on clinical, imaging, and biomarker criteria, and multidisciplinary decision-making. The primary goal of catheter-directed interventions for acute PE is to interrupt the cycle of right ventricular failure, hypoperfusion, and oxygen supply/demand imbalance by increasing the cross-sectional area of the patent pulmonary vasculature, thereby lowering resistance and alleviating V/Q mismatch. Innovations in percutaneous interventions have led to several approaches described in this review: rheolytic thrombectomy, catheter-directed thrombolysis, and aspiration or mechanical thrombectomy. The central challenge moving forward will be integrating growing clinical trial evidence into multidisciplinary, individualized care pathways meeting the diverse clinical needs of patients presenting with acute PE.

© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Acute Cardiovasc Care: 29 Jul 2022; epub ahead of print
Kochar A, Bergmark BA
Eur Heart J Acute Cardiovasc Care: 29 Jul 2022; epub ahead of print | PMID: 35905304
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Abstract

Elevated cardiac troponin I and short-term mortality in patients with acute type A aortic dissection.

Liu S, Song C, Bian X, Wang H, ... Yuan S, Dou K
Aims
To explore the association between elevated cardiac troponin I (cTnI) on 30-day mortality in patients with acute type A aortic dissection (ATAAD).
Methods and results
A total of 1321 consecutive patients who were admitted to the emergency department of Fuwai Hospital from January 2016 to December 2020 were enrolled. Patients had computed tomography-confirmed ATAAD and were measured serum cTnI on admission. Patients were divided into the troponin-positive (cTnI > 0.02 ng/mL) or the troponin-negative group (cTnI ≤ 0.02 ng/mL). Troponin was detected by PATHFAST instrument produced by Medins Co., Ltd., and the reference range of normal value is 0-0.02 ng/mL. A total of 522 out of 1321 patients (39.5%) in our study had elevated cTnI, who had higher 30-day mortality rate compared with the troponin-negative group (44.4% vs. 19.4% P < 0.0001). Multivariate logistic regression results showed that elevated cTnI was an independent risk indicator for 30-day mortality (odds ratio: 2.582; 95% confidence interval: 1.357-4.914; P = 0.0039). The addition of elevated cTnI level to a clinical-based risk prediction model resulted in significant incremental prognostic value (AUC difference: 0.0261).
Conclusion
Elevated cTnI is common in patients with ATAAD, and is associated with increased 30-day mortality risk.

© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Acute Cardiovasc Care: 29 Jul 2022; epub ahead of print
Liu S, Song C, Bian X, Wang H, ... Yuan S, Dou K
Eur Heart J Acute Cardiovasc Care: 29 Jul 2022; epub ahead of print | PMID: 35905196
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Abstract

Influence of the healthcare pathway on the outcome of patients with infective endocarditis.

Arregle F, Iline N, Giorgi R, Philip M, ... Drancourt M, Habib G
Aims
To determine the prognosis of patients treated for infective endocarditis (IE) according to their healthcare pathway. To assess how the ESC guidelines are implemented concerning the performance of transoesophageal echocardiography, the use of antibiotic therapy, and the performance of valve surgery; and to compare the epidemiological profile of IE according to the type of centres in which the patients are hospitalized.
Methods and results
In a prospective multicentric study including 22 hospitals in the South-East of France, 342 patients were classified into three groups according to their healthcare pathway: 119 patients diagnosed and taken care entirely in a reference centre or hospital with cardiac surgery [Referral Center (RC) group], 111 patients diagnosed and initially taken care in a non-RC (NRC), then referred in a centre including cardiac surgery [transferred to the Referral Center (TRC) group] and 112 patients totally taken care in the NRC (NRC group). One-year mortality was 26% (88 deaths) and was not significantly different between Groups 1 and 2 (20 vs. 21%, P = 0.83). Patients in the NRC group had a higher mortality (37%) compared with patients in the RC and TRC groups (P < 0.001). ESC guidelines were not implemented similarly depending on the healthcare pathway (P = 0.04). Patients in the NRC group were significantly older (P < 0.001) and had more comorbidities (P < 0.001) than patients treated in referral centres.
Conclusion
Prognosis of patients with IE is influenced by their healthcare pathway. Patients treated exclusively in NRC have a worse prognosis than patients treated in referral or surgical centres.

© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Acute Cardiovasc Care: 28 Jul 2022; epub ahead of print
Arregle F, Iline N, Giorgi R, Philip M, ... Drancourt M, Habib G
Eur Heart J Acute Cardiovasc Care: 28 Jul 2022; epub ahead of print | PMID: 35900233
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Abstract

Prediction of right ventricular failure after left ventricular assist device implantation: role of vasodilator challenge.

Cacioli G, Polizzi V, Ciabatti M, Cristiano E, ... Sbaraglia F, Musumeci F
Aims
Pulmonary artery pulsatility index (PAPi) is an indicator of right ventricular (RV) function and an independent predictor of right ventricular failure (RVF) following left ventricular assist device (LVAD) implantation. Administration of vasodilator challenge during right heart catheterization (RHC) could reduce RV workload allowing a better assessment of its functional reserve.
Methods and results
Patients undergoing LVAD implantation at our Institution between May 2013 and August 2021 were enrolled. Only patients who had undergone RHC and vasodilator challenge with sodium nitroprusside were analyzed. We collected all available clinical, instrumental, and haemodynamic parameters, at baseline and after nitroprusside infusion and evaluated potential associations with post-LVAD RVF. Of the 54 patients analyzed, 19 (35%) developed RVF after LVAD implantation. Fractional area change (FAC) (OR: 0.647, CI: 0.481-0.871; P = 0.004), pulmonary artery systolic pressure (PASP) (OR: 0.856, CI: 0.761-0.964; P = 0.010), and post-sodium nitroprusside (NTP) PAPi (OR: 0.218, CI: 0.073-0.653; P = 0.006) were independent predictors of post-LVAD RVF. The model combining FAC, PASP, and post-NTP PAPi demonstrated a predictive accuracy of 90.7%. Addition of post-NTP PAPi significantly increased the predictive accuracy of the European Registry for Patients with Mechanical Circulatory Support right-sided heart failure risk score [79.4 vs. 70.4%; area under the curve (AUC): 0.841 vs. 0.724, P = 0.022] and the CRITT score (79.6% vs. 74%; AUC: 0.861 vs. 0.767 P = 0.033).
Conclusion
Post-NTP PAPi has observed to be an independent predictor of RVF following LVAD implantation. Dynamic assessment of PAPi using a vasodilator challenge may represent a method of testing RV functional reserve in candidates for LVAD implantation. Larger and prospective studies are needed to confirm this hypothesis.

© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Acute Cardiovasc Care: 22 Jul 2022; epub ahead of print
Cacioli G, Polizzi V, Ciabatti M, Cristiano E, ... Sbaraglia F, Musumeci F
Eur Heart J Acute Cardiovasc Care: 22 Jul 2022; epub ahead of print | PMID: 35866303
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Abstract

Doppler-derived haemodynamics performed during admission echocardiography predict in-hospital mortality in cardiac intensive care unit patients.

Jentzer JC, Tabi M, Wiley BM, Lanspa MJ, Anavekar NS, Oh JK
Aims
Cardiac point-of-care ultrasound (CV-POCUS) has become a fundamental part for the assessment of patients admitted to cardiac intensive care units (CICU). We sought to refine the practice of CV-POCUS by identifying 2D and Doppler-derived measurements from bedside transthoracic echocardiograms (TTEs) performed in the CICU that are associated with mortality.
Methods and results
We retrospectively included Mayo Clinic CICU patients admitted from 2007 to 2018 and assessed the TTEs performed within 1 day of CICU admission, including Doppler and 2D measurements of left and right ventricular function. Logistic regression and classification and regression tree (CART) analysis were used to determine the association between TTE variables with in-hospital mortality. A total of 6957 patients were included with a mean age of 68.0 ± 14.9 years (37.0% females). A total of 609 (8.8%) patients died in the hospital. Inpatient deaths group had worse biventricular systolic function [left ventricular ejection fraction (LVEF) 48.2 ± 16.0% vs. 38.7 ± 18.2%, P < 0.0001], higher filling pressures, and lower forward flow. The strongest TTE predictors of hospital mortality were left ventricular outflow tract velocity-time integral [LVOT VTI, adjusted OR 0.912 per 1 cm higher, 95% confidence interval (CI) 0.883-0.942, P < 0.0001] followed by medial mitral E/e\' ratio (adjusted OR 1.024 per 1 unit higher, 95% CI 1.010-1.039, P = 0.0011). Classification and regression tree analysis identified LVOT VTI <16 cm as the most important TTE predictor of mortality.
Conclusions
Doppler-derived haemodynamic TTE parameters have a strong association with mortality in the CICU, particularly LVOT VTI <16 cm or mitral E/e\' ratio >15. The incorporation of these simplified Doppler-derived haemodynamics into admission CV-POCUS facilitates early risk stratification and strengthens the clinical yield of the ultrasound exam.

© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Acute Cardiovasc Care: 19 Jul 2022; epub ahead of print
Jentzer JC, Tabi M, Wiley BM, Lanspa MJ, Anavekar NS, Oh JK
Eur Heart J Acute Cardiovasc Care: 19 Jul 2022; epub ahead of print | PMID: 35851395
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Abstract

Hospital procedural volume and outcomes with catheter-directed intervention for pulmonary embolism: a nationwide analysis.

Sedhom R, Elbadawi A, Megaly M, Jaber WA, ... Mamas MA, Elgendy IY
Aims
There is limited data on the association between hospital catheter-directed intervention (CDI) volume and outcomes among patients with acute pulmonary embolism (PE).
Methods and results
The Nationwide Readmissions Database years 2016-2019 was utilized to identify hospitalizations undergoing CDI for acute PE. Hospitals were divided into tertiles based on annual CDI volume; low-volume (1-3 procedures), moderate-volume (4-12 procedures) and high-volume (>12 procedures). The primary outcome was all-cause in-hospital mortality. Among 1 436 382 PE admissions, 2.6% underwent CDI; 5.6% were in low-volume, 17.3% in moderate-volume and 77.1% in high-volume hospitals. There was an inverse relationship between hospital CDI volume and in-hospital mortality (coefficient  -0.344, P < 0.001). On multivariable regression analysis, hospitals with high CDI volume were associated with lower in-hospital mortality compared with hospitals with low CDI volume (adjusted odds ratio [OR] 0.71; 95% confidence interval [CI] 0.53, 0.95). Additionally, there was an inverse association between CDI volume and length of stay (LOS) (regression coefficient -0.023, 95% CI -0.027, -0.019) and cost (regression coefficient -74.6, 95% CI -98.8, -50.3). There were no differences in major bleeding and 30-day unplanned readmission rates between the three groups.
Conclusion
In this contemporary observational analysis of PE admissions undergoing CDI, there was an inverse association between hospital CDI volume and in-hospital mortality, LOS, and cost. Major bleeding and 30-day unplanned readmission rates were similar between the three groups.

© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Acute Cardiovasc Care: 13 Jul 2022; epub ahead of print
Sedhom R, Elbadawi A, Megaly M, Jaber WA, ... Mamas MA, Elgendy IY
Eur Heart J Acute Cardiovasc Care: 13 Jul 2022; epub ahead of print | PMID: 35830539
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Impact:
Abstract

New-onset atrial fibrillation in intensive care: epidemiology and outcomes.

Bedford JP, Ferrando-Vivas P, Redfern O, Rajappan K, ... Watkinson PJ, Doidge JC
Aims
New-onset atrial fibrillation (NOAF) is common in patients treated on an intensive care unit (ICU), but the long-term impacts on patient outcomes are unclear. We compared national hospital and long-term outcomes of patients who developed NOAF in ICU with those who did not, before and after adjusting for comorbidities and ICU admission factors.
Methods and results
Using the RISK-II database (Case Mix Programme national clinical audit of adult intensive care linked with Hospital Episode Statistics and mortality data), we conducted a retrospective cohort study of 4615 patients with NOAF and 27 690 matched controls admitted to 248 adult ICUs in England, from April 2009 to March 2016. We examined in-hospital mortality; hospital readmission with atrial fibrillation (AF), heart failure, and stroke up to 6 years post discharge; and mortality up to 8 years post discharge. Compared with controls, patients who developed NOAF in the ICU were at a higher risk of in-hospital mortality [unadjusted odds ratio (OR) 3.22, 95% confidence interval (CI) 3.02-3.44], only partially explained by patient demographics, comorbidities, and ICU admission factors (adjusted OR 1.50, 95% CI 1.38-1.63). They were also at a higher risk of subsequent hospitalization with AF [adjusted cause-specific hazard ratio (aCHR) 5.86, 95% CI 5.33-6.44], stroke (aCHR 1.47, 95% CI 1.12-1.93), and heart failure (aCHR 1.28, 95% CI 1.14-1.44) independent of pre-existing comorbidities.
Conclusion
Patients who develop NOAF during an ICU admission are at a higher risk of in-hospital death and readmissions to hospital with AF, heart failure, and stroke than those who do not.

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

Eur Heart J Acute Cardiovasc Care: 06 Jul 2022; epub ahead of print
Bedford JP, Ferrando-Vivas P, Redfern O, Rajappan K, ... Watkinson PJ, Doidge JC
Eur Heart J Acute Cardiovasc Care: 06 Jul 2022; epub ahead of print | PMID: 35792651
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Impact:

This program is still in alpha version.