Journal: Eur Heart J Acute Cardiovasc Care

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Abstract

Utility of shock index in 24,636 patients presenting with acute coronary syndrome.

El-Menyar A, Al Habib KF, Zubaid M, Alsheikh-Ali AA, ... Ullah A, Suwaidi JA
Background
Shock index is a bedside reflection of integrated response of the cardiovascular and nervous systems. We aimed to evaluate the utility of shock index (heart rate/systolic blood pressure) in patients presenting with acute coronary syndrome (ACS).
Methods
We analyzed pooled data from seven Arabian Gulf registries; these ACS registries were carried out in seven countries (Qatar, Bahrain, Kuwait, UAE, Saudi Arabia, Oman and Yemen) between 2005 and 2017. A standard uniform coding strategy was used to recode each database using each registry protocol and clinical research form. Patients were categorized into two groups based on their initial shock index (low . high shock index). Optimal shock index cutoff was determined according to the receiver operating characteristic curve (ROC). Primary outcome was hospital mortality.
Results
A total of 24,636 ACS patients met the inclusion criteria with a mean age 57±13 years. Based on ROC analysis, the optimal shock index was 0.80 (83.5% had shock index <0.80 and 16.5% had shock index ≥0.80). In patients with high shock index, 55% had ST-elevation myocardial infarction and 45% had non-ST-elevation myocardial infarction. Patients with high shock index were more likely to have diabetes mellitus, late presentation, door to electrocardiogram >10 min, symptom to Emergency Department > 3 h, anterior myocardial infarction, impaired left ventricular function, no reperfusion post-therapy, recurrent ischemia/myocardial infarction, tachyarrhythmia and stroke. However, high shock index was associated significantly with less chest pain, less thrombolytic therapy and less primary percutaneous coronary intervention. Shock index correlated significantly with pulse pressure (= -0.52), mean arterial pressure (= -0.48), Global Registry of Acute Coronary Events score ( =0.41) and Thrombolysis In Myocardial Infarction simple risk index (= -0.59). Shock index ≥0.80 predicted mortality in ACS with 49% sensitivity, 85% specificity, 97.6% negative predictive value and 0.6 negative likelihood ratio. Multivariate regression analysis showed that shock index was an independent predictor for in-hospital mortality (adjusted odds ratio (aOR) 3.40, <0.001), heart failure (aOR 1.67, <0.001) and cardiogenic shock (aOR 3.70, <0.001).
Conclusions
Although shock index is the least accurate of the ones tested, its simplicity may argue in favor of its use for early risk stratification in patients with ACS. The utility of shock index is equally good for ST-elevation myocardial infarction and non-ST-elevation acute coronary syndrome. High shock index identifies patients at increased risk of in-hospital mortality and urges physicians in the Emergency Department to use aggressive management.



Eur Heart J Acute Cardiovasc Care: 07 Nov 2019:2048872619886307; epub ahead of print
El-Menyar A, Al Habib KF, Zubaid M, Alsheikh-Ali AA, ... Ullah A, Suwaidi JA
Eur Heart J Acute Cardiovasc Care: 07 Nov 2019:2048872619886307; epub ahead of print | PMID: 31702396
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Abstract

Prognostic relevance of pericardial effusion in STEMI patients treated by primary percutaneous coronary intervention: a 10-year single-centre experience.

Albani S, Fabris E, Stolfo D, Falco L, ... Perkan A, Sinagra G
Background
Pericardial effusion is frequent in the acute phase of ST-segment elevation myocardial infarction. However, its prognostic role in the era of primary percutaneous coronary intervention is not completely understood.
Methods
We investigated the association between pericardial effusion, assessed by transthoracic echocardiography, and survival in a large cohort of ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention, enrolled in the Trieste primary percutaneous coronary intervention registry from January 2007 to March 2017. Multivariable analysis and a propensity score approach were performed.
Results
A total of 1732 ST-segment elevation myocardial infarction patients were included. Median follow-up was 45 (interquartile range 19-79) months. Pericardial effusion was present in 246 patients (14.2%). Thirty-day all-cause mortality was similar between patients with and without pericardial effusion (7.8% vs. 5.4%, =0.15), whereas crude long-term survival was worse in patients with pericardial effusion (26.2% vs. 17.7%, ≤0.01). However, at multivariable analyses the presence of pericardial effusion was not associated with long-term mortality (hazard ratio 1.26, 95% confidence interval 0.86-1.82, =0.22). Matching based on propensity scores confirmed the lack of association between pericardial effusion and both 30-day (hazard ratio 1, 95% confidence interval 0.42-2.36, =1) and long-term (hazard ratio 1.14, 95% confidence interval 0.74-1.78, =0.53) all-cause mortality. Patients with pericardial effusion experienced a higher incidence of free wall rupture (2.8% vs. 0.5%, <0.0001) independently of the entity of pericardial effusion.
Conclusions
In acute ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention, the onset of pericardial effusion after ST-segment elevation myocardial infarction is not independently associated with short and long-term higher mortality. Free wall rupture has to be considered rare compared to the fibrinolytic era and occurs more frequently in patients with pericardial effusion, suggesting a close monitoring of these patients in the early post-primary percutaneous coronary intervention phase.



Eur Heart J Acute Cardiovasc Care: 06 Nov 2019:2048872619884858; epub ahead of print
Albani S, Fabris E, Stolfo D, Falco L, ... Perkan A, Sinagra G
Eur Heart J Acute Cardiovasc Care: 06 Nov 2019:2048872619884858; epub ahead of print | PMID: 31696727
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Abstract

Impact of body temperature at admission on inhospital outcomes in patients with takotsubo syndrome: insights from the Tokyo Cardiovascular Care Unit Network Registry.

Kimura A, Yoshikawa T, Isogai T, Tanaka H, ... Yamamoto T, Takayama M
Background
Takotsubo syndrome occasionally occurs in patients with fever due to underlying diseases. However, the impact of body temperature on inhospital prognosis of patients with takotsubo syndrome remains unknown.
Methods
Using the patient cohort in the Tokyo Cardiovascular Care Unit Network Registry from 2013 to 2015, we identified 421 eligible patients whose data on body temperature at admission were available and classified them into three groups: high body temperature group (≥37.5°C; =27), normal body temperature group (36.0-37.4°C; =319), and low body temperature group (≤35.9°C; =75). We compared the patient characteristics and inhospital outcomes among the three groups.
Results
On admission, the high body temperature group showed a higher proportion of men and preceding physical triggers, higher heart and respiratory rates, and higher C-reactive protein level than the other groups. Inhospital all-cause mortality was significantly higher in the high body temperature group than in the normal or low body temperature group (18.5% vs. 2.2% vs. 4.0%, respectively, <0.001). Both cardiac mortality (11.1% vs. 1.3% vs. 1.3%, =0.001) and non-cardiac mortality (7.4% vs. 0.9% vs. 2.7%, =0.031) were also significantly higher in the high body temperature group. Multivariable logistic regression analysis showed that high body temperature (reference: normal body temperature) was significantly associated with higher inhospital mortality (adjusted odds ratio 4.22; 95% confidence interval 1.15-15.51; =0.030).
Conclusions
Our findings suggest that high body temperature at admission is a strong predictor of inhospital mortality in patients with takotsubo syndrome. Febrile takotsubo syndrome patients may need to be managed with recognition of life-threatening conditions from the time of diagnosis, no matter what the causes of fever are.



Eur Heart J Acute Cardiovasc Care: 05 Nov 2019:2048872619886313; epub ahead of print
Kimura A, Yoshikawa T, Isogai T, Tanaka H, ... Yamamoto T, Takayama M
Eur Heart J Acute Cardiovasc Care: 05 Nov 2019:2048872619886313; epub ahead of print | PMID: 31691595
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Abstract

National trends in coronary intensive care unit admissions, resource utilization, and outcomes.

Woolridge S, Alemayehu W, Kaul P, Fordyce CB, ... Armstrong PW, van Diepen S
Background
Emerging evidence suggests that coronary intensive care units are evolving into intensive care environments with an increasing burden of non-cardiovascular illness, but previous studies have been limited to older populations or single center experiences.
Methods
Canadian national health-care data was used to identify all patients ≥18 years admitted to dedicated coronary intensive care units (2005-2015) and admissions were categorized as primary cardiac or non-cardiac. The outcomes of interest included longitudinal trends in admission diagnoses, critical care therapies, and all-cause in-hospital mortality.
Results
Among the 373,992 patients admitted to a coronary intensive care unit, minimal changes in the proportion of patients admitted with a primary cardiac (88.2% to 86.9%; <0.001) and non-cardiac diagnoses (11.8% to 13.1%; <0.001) were observed. Among cardiac admissions, a temporal increase in the proportion of ST-segment elevation myocardial infarction (19.4% to 24.1%, <0.001), non-ST-segment elevation myocardial infarction (14.6% to 16.2%, <0.001), heart failure (7.3% to 8.4%, <0.001), shock (4.9% to 5.7%, <0.001), and decline in unstable angina (4.9% to 4.0%, <0.001) and stable coronary diseases (21.3% to 12.4%, <0.001) was observed. The proportion of patients requiring critical care therapies (57.8% to 63.5%, <0.001) including mechanical ventilation (9.6% to 13.1%, <0.001) increased. In-hospital mortality rates for patients with primary cardiac (4.9% to 4.4%; adjusted odds ratio 0.71, 95% confidence interval 0.63-0.79) and non-cardiac (17.8% to 16.1%; adjusted odds ratio 0.84, 0.73-0.97) declined; results were consistent when stratified by academic vs community hospital, and by the presence of on-site percutaneous coronary intervention.
Conclusion
In a national dataset we observed a changing case-mix among patients admitted to a coronary intensive care unit, though the proportion of patients with a primary cardiac diagnosis remained stable. There was an increase in clinical acuity highlighted by critical care therapies, but in-hospital mortality rates for both primary cardiac and non-cardiac conditions declined across all hospitals. Our findings confirm the changing coronary intensive care unit case-mix and have implications for future coronary intensive care unit training and staffing.



Eur Heart J Acute Cardiovasc Care: 29 Oct 2019:2048872619883400; epub ahead of print
Woolridge S, Alemayehu W, Kaul P, Fordyce CB, ... Armstrong PW, van Diepen S
Eur Heart J Acute Cardiovasc Care: 29 Oct 2019:2048872619883400; epub ahead of print | PMID: 31663772
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Abstract

The HEART score in the era of the European Society of Cardiology 0/1-hour algorithm.

Cortés M, Haseeb S, Lambardi F, Arbucci R, ... Trivi M, Costabel JP
Background
The European Society of Cardiology\'s 0/1-hour algorithm improves the early triage of patients towards \"rule-out\" or \"rule-in\" of non-ST-segment elevation myocardial infarction. The HEART score is a risk stratification tool for patients with undifferentiated chest pain. We sought to evaluate the performance of the European Society of Cardiology 0/1-hour algorithm and the HEART score to evaluate chest pain patients in the emergency department.
Methods
In this prospective study, we applied the European Society of Cardiology 0/1-hour algorithm and the HEART score in 1355 consecutive patients who presented to the emergency department with symptoms suggestive of acute coronary syndrome without ST-segment elevation. Patients were followed for non-ST-segment elevation myocardial infarctions and major adverse cardiac events at 30 days: death, non-ST-segment elevation myocardial infarction, or unplanned coronary revascularization.
Results
The European Society of Cardiology 0/1-hour algorithm classified 921 (68.0%) patients as \"rule-out\" and the HEART score classified 686 (50.6%) patients as \"low-risk\". The 30-day incidence of non-ST-segment elevation myocardial infarctions was 0.32% in the European Society of Cardiology 0/1-hour algorithm \"rule-out\" patients versus 0.29% in the HEART score \"low-risk\" patients (=0.75). The rate of major adverse cardiac events was 7.7% in the European Society of Cardiology 0/1-hour algorithm \"rule-out\" patients versus 1.1% in the HEART score \"low-risk\" patients (<0.001).
Conclusion
The European Society of Cardiology 0/1-hour algorithm identified more patients with low risk of non-ST-segment elevation myocardial infarctions at 30 days whereas for major adverse cardiac events, the HEART score had a greater capacity to detect low-risk patients.



Eur Heart J Acute Cardiovasc Care: 27 Oct 2019:2048872619883619; epub ahead of print
Cortés M, Haseeb S, Lambardi F, Arbucci R, ... Trivi M, Costabel JP
Eur Heart J Acute Cardiovasc Care: 27 Oct 2019:2048872619883619; epub ahead of print | PMID: 31657616
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Abstract

HEART score improves efficiency of coronary computed tomography angiography in patients suspected of acute coronary syndrome in the emergency department.

Arslan M, Schaap J, Rood PP, Nieman K, ... Dubois EA, Dedic A
Aims
Coronary computed tomography angiography is increasingly employed in the emergency department for suspected acute coronary syndrome patients. The HEART score has been proposed for initial risk stratification in these patients. The aim of this study was to investigate the diagnostic value and efficiency of the HEART score before coronary computed tomography angiography.
Methods and results
We included patients suspected of acute coronary syndrome who underwent coronary computed tomography angiography in the emergency department. Based on the HEART score, patients were stratified as low-risk (HEART≤3), intermediate-risk (HEART4-6) and high-risk (HEART≥7). We assessed coronary computed tomography angiography for the presence of significant coronary artery disease (>50% stenosis). The primary outcome, the level of major adverse cardiac events, was a composite endpoint of all-cause mortality, acute coronary syndrome or coronary revascularisation within 30 days. The study population consisted of 340 patients (mean age: 55.6±10.1 years, 44.7% women), major adverse cardiac events occurred in 45 (13.2%) patients. The incidence of major adverse cardiac events in patients stratified as low-risk (35.0%), intermediate-risk (56.8%) and high-risk (8.2%) was 3.4%, 12.4% and 60.7%, respectively. All four low-risk patients with major adverse cardiac events had a HEART score of three. An algorithm where coronary computed tomography angiography is reserved for patients with HEART 3-6 resulted in a sensitivity of 97.8%, specificity of 84.1%, negative predictive value of 99.6% and positive predictive value of 48.4%, while reducing the need for coronary computed tomography angiography by 22% (=75).
Conclusion
The predictive value of coronary computed tomography angiography for 30-day major adverse cardiac events in suspected acute coronary syndrome patients is good, and reserving coronary computed tomography angiography for HEART score 3-6 patients reduces the number of needed coronary computed tomography angiograms without affecting diagnostic accuracy.



Eur Heart J Acute Cardiovasc Care: 23 Oct 2019:2048872619882424; epub ahead of print
Arslan M, Schaap J, Rood PP, Nieman K, ... Dubois EA, Dedic A
Eur Heart J Acute Cardiovasc Care: 23 Oct 2019:2048872619882424; epub ahead of print | PMID: 31647305
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Abstract

Efficacy and safety of vorapaxar for secondary prevention in low body weight in patients with atherosclerosis: analyses from the TRA 2°P-TIMI 50 Trial.

Xu H, Bonaca MP, Goodrich E, Scirica BM, Morrow DA
Background
Vorapaxar inhibits the thrombin-mediated activation of platelets, reduces thrombotic events in patients with myocardial infarction or peripheral arterial disease while increasing bleeding. In the TRA 2°P-TIMI 50 trial, we observed a nominally significant interaction between low body weight and the reduced efficacy of vorapaxar.
Methods
We investigated the relationship between body weight and the efficacy and safety of vorapaxar within a multinational, randomized, double-blind, placebo-controlled trial of vorapaxar in patients with atherosclerosis. This analysis was performed among 20,138 patients with a clinical indication for vorapaxar.
Results
Compared with patients weighing 60 kg or more, patients weighing less than 60 kg were older, more frequently women, Asian and had renal insufficiency (each <0.001). The efficacy of vorapaxar with respect to cardiovascular death, myocardial infarction and stroke showed a significant interaction with patients\' weight (<0.03). However among patients younger than 65 years, vorapaxar reduced the primary endpoint regardless of weight (weight ≥60 kg: 6.4% vs. 8.1%, hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.65-0.86; weight <60 kg: 5.4% vs. 7.2%, HR 0.75, 95% CI 0.37-1.49, =0.98). Among patients aged 65 years and older, the efficacy of vorapaxar diminished in patients weighing less than 60 kg (high weight: 10.4% vs. 12.6%, HR 0.81, 95% CI 0.69-0.95; low weight: 16.1% vs. 9.0%, HR 1.62, 95% CI 0.95-2.76, =0.01). The relative increase in bleeding with vorapaxar was not modified by weight (all >0.05).
Conclusions
Vorapaxar reduced vascular events and improved net clinical outcome regardless of body weight in younger patients. Elderly patients with low weight may not be good candidates for aggressive secondary prevention with vorapaxar added to standard therapy.
Clinical trial registration
URL: http://www.clinicaltrials.gov Unique identifier: NCT00526474.



Eur Heart J Acute Cardiovasc Care: 22 Oct 2019:2048872619883354; epub ahead of print
Xu H, Bonaca MP, Goodrich E, Scirica BM, Morrow DA
Eur Heart J Acute Cardiovasc Care: 22 Oct 2019:2048872619883354; epub ahead of print | PMID: 31642690
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Abstract

Prognostic relevance of GRACE risk score in Takotsubo syndrome.

Scudiero F, Arcari L, Cacciotti L, De Vito E, ... Di Mario C, Parodi G
Background
Takotsubo syndrome is an increasingly recognised cardiac condition that clinically mimics an acute coronary syndrome, but data regarding its prognosis remain controversial. It is currently unknown whether acute coronary syndrome risk scores could effectively be applied to Takotsubo syndrome patients. This study aims to assess whether the Global Registry of Acute Coronary Events (GRACE) score can predict clinical outcome in Takotsubo syndrome and to compare the prognosis with matched acute coronary syndrome patients.
Methods
A total of 561 Takotsubo syndrome patients was included in this prospective registry. According to the GRACE score, the population was divided into quartiles. The primary endpoint was all-cause mortality and the secondary endpoints were cardiocerebrovascular events (a composite of all-cause mortality, cardiovascular death, recurrence of Takotsubo syndrome and stroke).
Results
The median GRACE risk score was 139±27. Takotsubo syndrome patients with a higher GRACE risk score mostly have a higher rate of physical triggers and lower left ventricular ejection fraction on admission. During long-term follow-up, all-cause mortality rates were 5%, 11%, 12% and 22%, respectively, in the first, second, third and fourth quartile (<0.001). After multivariate analysis, the GRACE risk score was found to be a strong predictor of all-cause mortality (odds ratio (OR) 1.68, 95% confidence interval (CI) 1.28-2.20; =0.001) and cardiocerebrovascular events (OR 1.63, 95% CI 1.26-2.11; =0.001). Moreover, all-cause mortality in Takotsubo syndrome patients was comparable with the matched acute coronary syndrome cohort.
Conclusion
In Takotsubo syndrome, the GRACE risk score allows us to predict all-cause mortality and cardiocerebrovascular events at long-term follow-up.



Eur Heart J Acute Cardiovasc Care: 22 Oct 2019:2048872619882363; epub ahead of print
Scudiero F, Arcari L, Cacciotti L, De Vito E, ... Di Mario C, Parodi G
Eur Heart J Acute Cardiovasc Care: 22 Oct 2019:2048872619882363; epub ahead of print | PMID: 31642689
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Abstract

Recurrence of angina after ST-segment elevation myocardial infarction: the role of coronary microvascular obstruction.

Montone RA, Vetrugno V, Santacroce G, Del Buono MG, ... Niccoli G, Crea F
Background
The recurrence of angina after percutaneous coronary intervention affects 20-35% of patients with stable coronary artery disease; however, few data are available in the setting of ST-segment elevation myocardial infarction. We evaluated the relation between coronary microvascular obstruction and the recurrence of angina at follow-up.
Methods
We prospectively enrolled patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention. Microvascular obstruction was defined as thrombolysis in myocardial infarction flow less than 3 or 3 with myocardial blush grade less than 2. The primary endpoint was the recurrence of angina at follow-up. Moreover, angina status was evaluated by the Seattle angina questionnaire summary score (SAQSS). Therapy at follow-up and the occurrence of major adverse cardiovascular events were also collected.
Results
We enrolled 200 patients. Microvascular obstruction occurred in 52 (26%) of them. Follow-up (mean time 25.17±9.28 months) was performed in all patients. Recurrent angina occurred in 31 (15.5%) patients, with a higher prevalence in patients with microvascular obstruction compared with patients without microvascular obstruction (13 (25.0%) vs. 18 (12.2%), =0.008). Accordingly, SAQSS was lower and the need for two or more anti-anginal drugs was higher in patients with microvascular obstruction compared with patients without microvascular obstruction. At multiple linear regression analysis a history of previous acute coronary syndrome and the occurrence of microvascular obstruction were the only independent predictors of a worse SAQSS. Finally, the occurrence of major adverse cardiovascular events was higher in patients with microvascular obstruction compared with patients without microvascular obstruction.
Conclusions
The recurrence of angina in ST-segment elevation myocardial infarction patients treated with primary percutaneous coronary intervention is an important clinical issue. The occurrence of microvascular obstruction portends a worse angina status and is associated with the use of more anti-anginal drugs.



Eur Heart J Acute Cardiovasc Care: 15 Oct 2019:2048872619880661; epub ahead of print
Montone RA, Vetrugno V, Santacroce G, Del Buono MG, ... Niccoli G, Crea F
Eur Heart J Acute Cardiovasc Care: 15 Oct 2019:2048872619880661; epub ahead of print | PMID: 31617387
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Abstract

Editor\'s Choice- Impact of identifying precipitating factors on 30-day mortality in acute heart failure patients.

Rossello X, Gil V, Escoda R, Jacob J, ... Miró Ò,
Background
The aim of this study was to describe the prevalence and prognostic value of the most common triggering factors in acute heart failure.
Methods
Patients with acute heart failure from 41 Spanish emergency departments were recruited consecutively in three time periods between 2011 and 2016. Precipitating factors were classified as: (a) unrecognized; (b) infection; (c) atrial fibrillation; (d) anaemia; (e) hypertension; (f) acute coronary syndrome; (g) non-adherence; and (h) two or more precipitant factors. Unadjusted and adjusted logistic regression models were used to assess the association between 30-day mortality and each precipitant factor. The risk of dying was further evaluated by week intervals over the 30-day follow-up to assess the period of higher vulnerability for each precipitant factor.
Results
Approximately 69% of our 9999 patients presented with a triggering factor and 1002 died within the first 30 days (10.0%). The most prevalent factors were infection and atrial fibrillation. After adjusting for 11 known predictors, acute coronary syndrome was associated with higher 30-day mortality (odds ratio (OR) 1.87; 95% confidence interval (CI) 1.02-3.42), whereas atrial fibrillation (OR 0.75; 95% CI 0.56-0.94) and hypertension (OR 0.34; 95% CI 0.21-0.55) were significantly associated with better outcomes when compared to patients without precipitant. Patients with infection, anaemia and non-compliance were not at higher risk of dying within 30 days. These findings were consistent across gender and age groups. The 30-day mortality time pattern varied between and within precipitant factors.
Conclusions
Precipitant factors in acute heart failure patients are prevalent and have a prognostic value regardless of the patient\'s gender and age. They can be managed with specific treatments and can sometimes be prevented.



Eur Heart J Acute Cardiovasc Care: 29 Sep 2019; 8:667-680
Rossello X, Gil V, Escoda R, Jacob J, ... Miró Ò,
Eur Heart J Acute Cardiovasc Care: 29 Sep 2019; 8:667-680 | PMID: 31436133
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Abstract

Incremental costs of high intensive care utilisation in patients hospitalised with heart failure.

van Diepen S, Tran DT, Ezekowitz JA, Schnell G, ... McAlister FA, Kaul P
Aims
Registries have reported large inter-hospital differences in intensive care unit admission rates for patients with acute heart failure, but little is known about the potential economic impact of over-admission of low-risk patients with heart failure to higher cost intensive care units. We described the variability in intensive care unit admission practices, the provision of critical care therapies, and estimated the potential national cost savings if all hospitals adopted low intensive care unit admission practices for patients admitted with heart failure.
Methods
Using a national population health dataset, we identified 349,693 heart failure admission hospitalisations with a primary diagnosis of heart failure between 2007 and 2016. Hospitals were categorised as low (first quartile), medium (second and third quartile) and high (fourth quartiles) intensive care unit utilisation.
Results
The mean intensive care unit admission rate was 16.4% (inter-hospital range 0.3-51%) including 5.4% in low, 14.5% in medium and 30% in high utilisation hospitals. Intensive care unit therapies in low, medium and high intensive care unit utilisation hospitals were 54.5%, 45.1% and 24.1% (<0.001), respectively and the inhospital mortality rate was not significantly different. The proportion of hospital costs incurred by intensive care unit care was 7.8% in low, 19.8% in medium and 28.2% in high (<0.001) admission hospitals. The potential cost savings of altering intensive care unit utilisation practices for patients with heart failure was CAN$234.8m over the study period.
Conclusions
In a national cohort of patients hospitalised with heart failure, we observed that low intensive care unit utilisation centres had lower hospital costs with no differences in mortality rates. The development of standardised admission criteria for high-cost and high acuity intensive care unit beds could reduce costs to the healthcare system.



Eur Heart J Acute Cardiovasc Care: 29 Sep 2019; 8:660-666
van Diepen S, Tran DT, Ezekowitz JA, Schnell G, ... McAlister FA, Kaul P
Eur Heart J Acute Cardiovasc Care: 29 Sep 2019; 8:660-666 | PMID: 30977391
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Abstract

Beta-blockers for post-acute coronary syndrome mid-range ejection fraction: a nationwide retrospective study.

Montenegro Sá F, Carvalho R, Ruivo C, Santos LG, ... Morais J,
Background
Patients with mid-range ejection fraction (40-49%) are in focus due to the newly defined entity of heart failure with mid-range ejection fraction. Acute coronary syndromes are a major aetiology for heart failure with mid-range ejection fraction. We aim to evaluate which therapeutic decisions are associated with inhospital survival benefit in post-acute coronary syndrome patients categorised according to the ejection fraction.
Methods and results
The authors analysed a cohort of a multicentre national registry enrolling acute coronary syndrome patients between 2010 and 2016, classified according to their ejection fraction before hospital discharge. Patients with previously known heart failure or with no ejection fraction evaluation were excluded. A total of 9429 patients were included and categorised in three groups: (a) ejection fraction of 50% or greater (=6113, 65%); (b) ejection fraction of 40-49% (=1926, 20%); and (c) ejection fraction less than 40% (=1390, 15%). The primary endpoint was inhospital mortality. To eliminate confounding factors, a multivariate logistic regression analysis was conducted, including acute coronary syndrome type, baseline characteristics, pharmacological treatment, clinical data, laboratory data and coronary anatomy when known. The overall inhospital mortality was 2.8% (=263): 0.9% (=53) in group 1, 2.4% (=37) in group 2 and 11.4% (=159) in group 3. After multivariate analysis, an invasive strategy had a positive impact in all groups, inhospital beta-blocker administration had a positive impact for groups 2 and 3, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and spironolactone had a positive impact on group 3.
Conclusion
Post-acute coronary syndrome mid-range ejection fraction patients represent an intermediate risk group in which beta-blocker administration was associated with inhospital survival benefit. An invasive strategy was a survival predictor for all groups, regardless of ejection fraction category.



Eur Heart J Acute Cardiovasc Care: 29 Sep 2019; 8:599-605
Montenegro Sá F, Carvalho R, Ruivo C, Santos LG, ... Morais J,
Eur Heart J Acute Cardiovasc Care: 29 Sep 2019; 8:599-605 | PMID: 30714389
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Abstract

Hyponatremia at discharge is associated with adverse prognosis in acute heart failure syndromes with preserved ejection fraction: a report from the JASPER registry.

Sato Y, Yoshihisa A, Oikawa M, Nagai T, ... Takeishi Y, Anzai T
Introduction
Hyponatremia predicts adverse prognosis in patients with heart failure in particular with reduced ejection fraction. In contrast, it has recently been reported that hyponatremia on admission is not a predictor of post-discharge mortality in patients with heart failure with preserved ejection fraction. We investigated the prognostic impact of hyponatremia at discharge in patients with heart failure with preserved ejection fraction and its clinical characteristics.
Methods and results
The Japanese Heart Failure Syndrome with Preserved Ejection Fraction (JASPER) registry is a nationwide, observational, prospective registration of consecutive Japanese patients hospitalised with heart failure with preserved ejection fraction and left ventricular ejection fraction of 50% or greater. Five hundred consecutive patients were enrolled in this analysis. We divided the patients into two groups based on their sodium serum levels at discharge: hyponatremia group (sodium <135 mEq/L, =50, 10.0%) and control group (sodium ⩾135 mEq/L, =450, 90.0%). This present analysis had two primary endpoints: all-cause death and all-cause death or rehospitalisation for heart failure. At discharge, the hyponatremia group had lower systolic blood pressure (110.0 mmHg vs. 114.5 mmHg, =0.014) and higher levels of urea nitrogen (31.9 mg/dL vs. 24.2 mg/dL, =0.032). In the Kaplan-Meier analysis, more patients in the hyponatremia group reached the primary endpoints than those in the control group (log rank <0.01, respectively). In the Cox proportional hazard analysis, hyponatremia at discharge was a predictor of the two endpoints (all-cause death, hazard ratio 2.708, 95% confidence interval 1.557-4.708, P<0.001; all-cause death or rehospitalisation for heart failure, hazard ratio 1.829, 95% confidence interval 1.203-2.780, =0.005).
Conclusions
Hyponatremia at discharge is associated with adverse prognosis in hospitalised patients with heart failure with preserved ejection fraction.



Eur Heart J Acute Cardiovasc Care: 29 Sep 2019; 8:623-633
Sato Y, Yoshihisa A, Oikawa M, Nagai T, ... Takeishi Y, Anzai T
Eur Heart J Acute Cardiovasc Care: 29 Sep 2019; 8:623-633 | PMID: 30667275
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Abstract

Clinical impact of mineralocorticoid receptor antagonists treatment after acute coronary syndrome in the real world: A propensity score matching analysis.

Agra-Bermejo R, Cordero A, Rodríguez-Mañero M, García Acuña JM, ... Cid Álvarez B, González-Juanatey JR
Background
Recent studies suggest that the benefit of mineralocorticoid receptor antagonists in the acute coronary syndrome setting is controversial. The aim of this study was to examine the current long-term prognostic benefit of mineralocorticoid receptor antagonists in patients with acute coronary syndrome.
Material and methods
We conducted a retrospective cohort study of 8318 consecutive acute coronary syndrome patients. Baseline patient characteristics were examined and a follow-up period was established for registry of death, major cardiovascular adverse events and heart failure re-hospitalization. We performed a propensity-matching analysis to draw up two groups of patients paired according to whether or not they had been treated with mineralocorticoid receptor antagonists. The prognostic value of mineralocorticoid receptor antagonists to predict events during follow-up was analysed using Cox regression.
Results
Among the study participants, only 524 patients (6.3%) were discharged on mineralocorticoid receptor antagonists. Patients on mineralocorticoid receptor antagonists had a different clinical and pharmacological profile. These differences disappeared after the propensity score analysis. The median follow-up was 40.7 months. After the propensity score analysis, the cardiovascular mortality and heart failure readmission rates were similar between patients who were discharged on mineralocorticoid receptor antagonists and those whose not. The use of mineralocorticoid receptor antagonists was only associated with a reduction in major cardiovascular adverse events (hazard ratio=0.83, 95% confidence interval 0.69-0.97, =0.001).
Conclusions
Our results do not corroborate the long-term benefit of mineralocorticoid receptor antagonists to improve survival after acute coronary syndrome in a large cohort of patients with heart failure or reduced left ventricular ejection fraction and diabetes. Their prescription was associated with a significantly lower incidence of major cardiovascular adverse events during the long-term follow-up without effect on heart failure development.



Eur Heart J Acute Cardiovasc Care: 29 Sep 2019; 8:652-659
Agra-Bermejo R, Cordero A, Rodríguez-Mañero M, García Acuña JM, ... Cid Álvarez B, González-Juanatey JR
Eur Heart J Acute Cardiovasc Care: 29 Sep 2019; 8:652-659 | PMID: 30117745
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Impact:
Abstract

Change of BNP between admission and discharge after ST-elevation myocardial infarction (Killip I) improves risk prediction of heart failure, death, and recurrent myocardial infarction compared to single isolated measurement in addition to the GRACE score.

Carvalho LSF, Bogniotti LAC, de Almeida OLR, E Silva JCQ, ... Coelho OR, Sposito AC
Objective
In ST-elevation myocardial infarction, 7-15% of patients admitted as Killip I will develop symptomatic heart failure or decreased ejection fraction. However, available clinical scores do not predict the risk of severe outcomes well, such as heart failure, recurrent myocardial infarction, and sudden death in these Killip I individuals. Therefore, we evaluated whether one vs two measurements of BNP would improve prediction of adverse outcomes in addition to the GRACE score in ST-elevation myocardial infarction/Killip I individuals.
Methods
Consecutive patients with ST-elevation myocardial infarction/Killip I (=167) were admitted and followed for 12 months. The GRACE score was calculated and plasma BNP levels were obtained in the first 12 h after symptom onset (D1) and at the fifth day (D5).
Results
Fifteen percent of patients admitted as Killip I developed symptomatic heart failure and/or decreased ejection fraction in 12 months. The risk of developing symptomatic heart failure or ejection fraction <40% at 30 days was increased by 8.7-fold (95% confidence interval: 1.10-662, =0.046) per each 100 pg/dl increase in BNP-change. Both in unadjusted and adjusted Cox-regressions, BNP-change as a continuous variable was associated with incident sudden death/myocardial infarction at 30 days (odds ratio 1.032 per each increase of 10 pg/dl, 95% confidence interval: 1.013-1.052, <0.001), but BNP-D1 was not. The GRACE score alone showed a moderate C-statistic=0.709 (=0.029), but adding BNP-change improved risk discrimination (C-statistic=0.831, =0.001). Net reclassification confirmed a significant improvement in individual risk prediction by 33.4% (95% confidence interval: 8-61%, =0.034). However, GRACE +BNP-D1 did not improve risk reclassification at 30 days compared to GRACE (=0.8). At 12 months, BNP-change was strongly associated with incident sudden death/myocardial infarction, but not BNP-D1.
Conclusions
Only BNP-change following myocardial infarction was associated with poorer short- and long-term outcomes. BNP-change also improves risk reclassification in addition to the GRACE score.



Eur Heart J Acute Cardiovasc Care: 29 Sep 2019; 8:643-651
Carvalho LSF, Bogniotti LAC, de Almeida OLR, E Silva JCQ, ... Coelho OR, Sposito AC
Eur Heart J Acute Cardiovasc Care: 29 Sep 2019; 8:643-651 | PMID: 29359586
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Impact:
Abstract

An East-West comparison of self-care barriers in heart failure.

Lim SL, Chan SP, Lee KY, Ching A, ... Lam CS, Collins SP
Background
Barriers in heart failure self-care contribute to heart failure hospitalizations, but geographic differences have not been well-studied. We aimed to compare self-care barriers in heart failure patients managed at tertiary centers in an Eastern (Singapore) versus a Western (USA) nation.
Methods
Acute heart failure patients were prospectively assessed with a standardized instrument comprising of 47 distinct self-care barriers. The multi-equation generalized structural equation model was used to evaluate for geographic differences in barriers experienced, and association of barriers with outcomes.
Results
Patient-related factors accounted for six out of 10 most prevalent self-care barriers among the 90 patients, with a median number of 11 barriers reported per patient. The Western patients reported a higher level of barriers when compared with their Eastern counterparts (median (interquartile range) 15 (9-24) versus 9 (4-16), =0.001), after adjusting for demographics and co-morbidities. Many of these differences could be explained by geographic differences between the countries. There was no significant difference identified in all-cause mortality (19.4% versus 10.2%) and heart failure re-hospitalization (41.9% versus 45.8%) at six months between the groups.
Conclusions
Self-care barriers are highly prevalent among acute heart failure patients, and differ substantially between East and West, but were not associated with geographic differences in outcomes.



Eur Heart J Acute Cardiovasc Care: 29 Sep 2019; 8:615-622
Lim SL, Chan SP, Lee KY, Ching A, ... Lam CS, Collins SP
Eur Heart J Acute Cardiovasc Care: 29 Sep 2019; 8:615-622 | PMID: 29283270
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Impact:
Abstract

Predictors of subsequent myocardial infarction, stroke, and death in stable post-myocardial infarction patients: A nationwide cohort study.

Chen DY, Li CY, Hsieh MJ, Chen CC, ... Chang CJ, Wen MS
Background
This study investigated the predictors of subsequent cardiovascular events in stable post-myocardial infarction patients in Taiwan.
Methods
A total of 11,183 patients were recruited who had survived one year post-myocardial infarction without subsequent events of recurrent myocardial infarction or stroke from the Taiwan National Health Insurance Research Database. Their composite cardiovascular event rates were identified.
Results
The composite cardiovascular events rate in three year follow-up in the post-myocardial infarction population was 13.8%. Corresponding event rates were 5.8% recurrent myocardial infarction, 5.0% stroke, and 5.2% death. Independent factors associated with a higher risk of ischemic events or death included heart failure (hazard ratio (HR)=1.19), hypertension (HR=1.16), age (65-75 vs <65 years: HR=1.29; 75-85 vs <65 years: HR=1.50; >85 vs <65 years: HR=1.70), diabetes (HR=1.33), prior stroke (HR=1.24), chronic kidney disease (HR=1.4), atrial fibrillation (HR=1.27), and underutilization of guideline-based medication (HR=1.73). Composite risk for myocardial infarction, stroke and death increased progressively from 4.9% in patients with zero risk factor to 100.0% in patients with eight risk factors.
Conclusions
For acute myocardial infarction patients surviving one year without subsequent events of recurrent myocardial infarction or stroke, the risk of cardiovascular events remained high. Eight predictors identified patients at increased risk for subsequent cardiovascular events within the next three years. These results suggest an unmet need, particularly in patients with additional risk factors.



Eur Heart J Acute Cardiovasc Care: 29 Sep 2019; 8:634-642
Chen DY, Li CY, Hsieh MJ, Chen CC, ... Chang CJ, Wen MS
Eur Heart J Acute Cardiovasc Care: 29 Sep 2019; 8:634-642 | PMID: 28895425
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Impact:
Abstract

Association of admission and discharge anemia status with outcomes in patients hospitalized for acute decompensated heart failure: Differences between patients with preserved and reduced ejection fraction.

Kajimoto K, Minami Y, Otsubo S, Sato N
Background
In acute decompensated heart failure patients with a preserved or reduced ejection fraction, the association of admission and discharge anemia status with outcomes remains unclear.
Methods and results
Of the 4842 patients enrolled in the Acute Decompensated Heart Failure Syndromes (ATTEND) registry, 4433 patients (2017 with a preserved and 2416 with a reduced ejection fraction) were examined to investigate associations among the anemia status at admission and discharge (no anemia, developed anemia, resolved anemia, or persistent anemia), a preserved or reduced ejection fraction and the primary endpoint (all-cause death and readmission for heart failure). In the preserved ejection fraction group, adjusted analysis showed that either developed or persistent anemia was associated with a significantly higher risk of the primary endpoint relative to no anemia (hazard ratio: 1.53; 95% confidence interval (CI): 1.11-2.11; =0.009 and hazard ratio: 1.60; 95% CI: 1.26-2.04; <0.001, respectively), but there was no association between resolved anemia and the primary endpoint (hazard ratio: 0.98; 95% CI: 0.67-1.45; =0.937). In the reduced ejection fraction group, either developed or resolved anemia was associated with a tendency toward higher risk of the primary endpoint relative to no anemia (hazard ratio: 1.29; 95% CI: 0.95-1.62; =0.089, and hazard ratio: 1.31; 95% CI: 0.96-1.77; =0.085, respectively), while persistent anemia was associated with a significantly higher risk of the primary endpoint relative to no anemia (hazard ratio: 1.36; 95% CI: 1.12-1.65; =0.002).
Conclusions
In acute decompensated heart failure patients, the association of admission and discharge anemia status with outcomes differs markedly between patients with a preserved or reduced ejection fraction.



Eur Heart J Acute Cardiovasc Care: 29 Sep 2019; 8:606-614
Kajimoto K, Minami Y, Otsubo S, Sato N
Eur Heart J Acute Cardiovasc Care: 29 Sep 2019; 8:606-614 | PMID: 28879773
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Impact:
Abstract

Heterogeneous impact of body mass index on in-hospital mortality in acute heart failure syndromes: An analysis from the ATTEND Registry.

Yoshihisa A, Sato T, Kajimoto K, Sato N, Takeishi Y
Background
Although the obesity paradox may vary depending upon clinical background factors such as age, gender, aetiology of heart failure and comorbidities, the reasons underlying the heterogeneous impact of body mass index (BMI) on in-hospital cardiac mortality under various conditions in patients with acute heart failure syndromes (AHFSs) remain unclear.
Methods
Among 4617 hospitalised patients with AHFSs enrolled in the Acute Decompensated Heart Failure Syndromes (ATTEND) registry, the patient characteristics and in-hospital cardiac mortality rates in those with low BMI (BMI <25 kg/m,  = 3263) were compared to those with high BMI (BMI ⩾25 kg/m,  = 1354).
Results
Compared to the high-BMI group, the low-BMI group was significantly older, less likely to be male and to have hypertensive or idiopathic dilated aetiologies and more likely to have valvular aetiologies and a history of prior hospitalisation for AHFS. The low-BMI group also had lower prevalence rates of diabetes, dyslipidaemia, hypertension and atrial fibrillation and higher prevalence rates of anaemia and chronic obstructive pulmonary disease. In addition, cardiac mortality was significantly higher in the low-BMI group than in the high-BMI group (5.5 vs. 1.5%, < 0.001). Logistic regression analysis demonstrated that low BMI was a predictor of cardiac mortality (odds ratio: 3.89, 95% confidence interval: 2.44-6.21). In subgroup analyses, the impact of BMI on cardiac mortality differed depending on the presence of hypertensive aetiology, hypertension, chronic obstructive pulmonary disease and hyponatremia (all < 0.05), although there were no interactions between the impacts of BMI and age, gender, other aetiologies, prior hospitalisation, diabetes, anaemia, cardio-renal function and in-hospital management.
Conclusion
It is necessary to appreciate the obesity paradox in AHFS patients, and a patient\'s heterogeneous background should also be considered.



Eur Heart J Acute Cardiovasc Care: 29 Sep 2019; 8:589-598
Yoshihisa A, Sato T, Kajimoto K, Sato N, Takeishi Y
Eur Heart J Acute Cardiovasc Care: 29 Sep 2019; 8:589-598 | PMID: 28361568
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Impact:
Abstract

Systematic investment in the delivery of guideline-coherent therapy reduces mortality and overall costs in patients with ST-elevation myocardial infarction: Results from the Stent for Life economic model for Romania, Portugal, Basque Country and Kemerovo region.

Wein B, Bashkireva A, Au-Yeung A, Yoculan A, ... Wijns W, Naber CK
Aims
The Stent for Life initiative aims at the reduction of mortality in patients with ST-elevation myocardial infarction by enhancing timely access to primary percutaneous coronary intervention. To assess the associated health and socioeconomic impact, the Stent for Life economic project was launched and applied to four model regions: Romania, Portugal, the Basque Country in Spain, and the Kemerovo region in the Russian Federation.
Methods and results
The Stent for Life economic model is based on a decision tree that incorporates primary percutaneous coronary intervention rates and mortality. Healthcare costs and indirect costs caused by loss of productivity were estimated. A baseline scenario simulating the status quo was compared to the Stent for Life scenario which integrated changes initiated by the Stent for Life programme. In the four model regions, primary percutaneous coronary intervention numbers rose substantially between 29-303%, while ST-elevation myocardial infarction mortality was reduced between 3-10%. Healthcare costs increased by 8% to 70%. Indirect cost savings ranged from 2-7%. Net societal costs were reduced in all model regions by 2-4%.
Conclusion
The joint effort of the Stent for Life initiative and their local partners successfully saves lives. Moreover, the increase in healthcare costs was outweighed by indirect cost savings, leading to a net cost reduction in all four model regions. These findings demonstrate that systematic investments to improve the access of ST-elevation myocardial infarction patients to guideline-coherent therapy is beneficial, not only for the individual, but also for the society at large.



Eur Heart J Acute Cardiovasc Care: 25 Sep 2019:2048872619853959; epub ahead of print
Wein B, Bashkireva A, Au-Yeung A, Yoculan A, ... Wijns W, Naber CK
Eur Heart J Acute Cardiovasc Care: 25 Sep 2019:2048872619853959; epub ahead of print | PMID: 31557050
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Impact:
Abstract

The complement lectin pathway protein MAp19 and out-of-hospital cardiac arrest: Insights from two randomized clinical trials.

Bro-Jeppesen J, Jeppesen AN, Haugaard S, Troldborg A, ... Hvas AM, Thiel S
Aim
Activation of the complement system is known to be a potent inducer of systemic inflammation, which is an important component of post-cardiac arrest syndrome. Mannan-binding-lectin associated protein of 19 kDa (MAp19) is suggested to be a regulatory component of the lectin pathway of complement activation. The aims of this study were to describe serial levels of MAp19 protein in comatose survivors of out-of-hospital cardiac arrest (OHCA), to evaluate the effect of two different regimes of targeted temperature management and to investigate the possible association between levels of MAp19 and mortality.
Methods
In this post-hoc study, we analysed data from two large randomized controlled studies: \'Targeted temperature management at 33 degrees C versus 36 degrees C after cardiac arrest\' (TTM) and \'Targeted temperature management for 48 versus 24 h and neurological outcome after out-of-hospital cardiac arrest\' (TTH). We measured serial levels of MAp19 in 240 patients within 72 h after OHCA and in 82 healthy controls. The effect of targeted temperature management on MAp19 levels was analysed according to temperature allocation in main trials.
Results
MAp19 levels were significantly lower in OHCA patients within 48 h after OHCA (-values <0.001) compared with healthy controls. A target temperature at 33°C compared with 36°C for 24 h was associated with significantly lower levels of MAp19 (-57 ng/mL (95% confidence interval (CI): -97 to -16 mg/mL), =0.006). Target temperature at 33°C for 48 h compared with 24 h was not associated with a difference in MAp19 levels (-31 ng/mL (95% CI: -120 to 60 mg/mL), =0.57). Low MAp19 levels at admission were associated with higher 30-day mortality (12% . 38%,=0.0008), also in adjusted analysis (two-fold higher, hazard ratio =0.48 (95% CI: 0.31 to 0.75), =0.001). Analysis of MAp19 levels at 24-72 h showed they were not associated with 30-day mortality.
Conclusion
Survivors after OHCA have lower levels of MAp19 protein compared with healthy controls. A targeted temperature management at 33°C compared with 36°C was associated with significantly lower MAp19 levels, whereas target temperature at 33°C for 48 h compared with 24 h did not influence MAp19 protein levels. Low MAp19 levels at admission were independently associated with increased mortality.



Eur Heart J Acute Cardiovasc Care: 19 Sep 2019:2048872619870031; epub ahead of print
Bro-Jeppesen J, Jeppesen AN, Haugaard S, Troldborg A, ... Hvas AM, Thiel S
Eur Heart J Acute Cardiovasc Care: 19 Sep 2019:2048872619870031; epub ahead of print | PMID: 31538810
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Impact:
Abstract

Prognostic implications of microcirculatory perfusion versus macrocirculatory perfusion in cardiogenic shock: a CULPRIT-SHOCK substudy.

Wijntjens GW, Fengler K, Fuernau G, Jung C, ... Thiele H, Piek JJ
Background
After early revascularisation, restoration of macrocirculatory perfusion parameters is the primary objective in the management of cardiogenic shock complicated acute myocardial infarction. Nevertheless, vital organ perfusion may be compromised at the systemic microcirculatory level, even in patients with preserved macrohaemodynamics. Microvascular perfusion was shown to have independent prognostic value for early mortality. The present study aims to compare the prognostic value of microcirculatory versus macrocirculatory perfusion parameters.
Methods
This substudy of the culprit lesion-only percutaneous coronary intervention versus multivessel percutaneous coronary intervention in cardiogenic shock (CULPRIT-SHOCK) trial examined the sublingual capillary network using videomicroscopy post-percutaneous coronary intervention to determine the proportion of perfused capillaries (<20 µm) and perfused capillary density. Thirty-day follow-up was performed to obtain the occurrence of a combined clinical endpoint of all-cause death and renal replacement therapy.
Results
Videomicroscopy measurements were performed in 66 patients. There was a significant adjusted association between microcirculatory perfusion parameters and the combined clinical endpoint (proportion of perfused capillaries: =0.020; perfused capillary density: =0.035), whereas there was no significant adjusted association between macrocirculatory perfusion parameters and the combined clinical endpoint (systolic blood pressure: =0.205). Normotensive patients with compromised microcirculatory perfusion parameters had a higher risk of the combined clinical endpoint than normotensive patients with preserved microcirculatory perfusion parameters (proportion of perfused capillaries: Breslow =0.014; perfused capillary density: Breslow =0.076).
Conclusions
There is a significant and independent association between microcirculatory perfusion parameters perfused capillary density and proportion of perfused capillaries and the combined clinical endpoint of all-cause death and renal replacement therapy at 30 days follow-up. In patients with loss of haemodynamic coherence between microcirculatory and macrocirculatory perfusion parameters, microcirculatory perfusion parameters confer dominant prognostic value.



Eur Heart J Acute Cardiovasc Care: 12 Sep 2019:2048872619870035; epub ahead of print
Wijntjens GW, Fengler K, Fuernau G, Jung C, ... Thiele H, Piek JJ
Eur Heart J Acute Cardiovasc Care: 12 Sep 2019:2048872619870035; epub ahead of print | PMID: 31517505
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Impact:
Abstract

Prognostic impact of percutaneous coronary intervention in octogenarians with non-ST elevation myocardial infarction: A report from SWEDEHEART.

Völz S, Petursson P, Angerås O, Odenstedt J, ... Råmunddal T, Omerovic E
Aims
Percutaneous coronary intervention (PCI) improves outcomes in non-ST elevation acute coronary syndromes (NSTE-ACSs). Octogenarians, however, were underrepresented in the pivotal trials. This study aimed to assess the effect of PCI in patients ≥80 years old.
Methods and results
We used data from the SWEDEHEART registry for all hospital admissions at eight cardiac care centres within Västra Götaland County. Consecutive patients ≥80 years old admitted for NSTE-ACS between January 2000 and December 2011 were included. We performed instrumental variable analysis with propensity score. The primary endpoint was all-cause mortality at 30 days and one year after index hospitalization. During the study period 5200 patients fulfilled the inclusion criteria. In total, 586 (11.2%) patients underwent PCI, the remaining 4613 patients were treated conservatively. Total mortality at 30 days was 19.4% (1007 events) and 39.4% (1876 events) at one year. Thirty-day mortality was 20.7% in conservatively treated patients and 8.5% in the PCI group (adjusted odds ratio 0.34; 95% confidence interval 0.12-0.97,= 0.044). One-year mortality was 42.1% in the conservatively treated group and 16.3% in the PCI group (adjusted odds ratio 0.97; 95% confidence interval 0.36-2.51,= 0.847).
Conclusions
PCI in octogenarians with NSTE-ACS was associated with a lower risk of mortality at 30 days. However, this survival benefit was not sustained during the entire study-period of one-year.



Eur Heart J Acute Cardiovasc Care: 12 Sep 2019:2048872619877287; epub ahead of print
Völz S, Petursson P, Angerås O, Odenstedt J, ... Råmunddal T, Omerovic E
Eur Heart J Acute Cardiovasc Care: 12 Sep 2019:2048872619877287; epub ahead of print | PMID: 31517503
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Impact:
Abstract

Does helicopter transport delay prehospital transfer for STEMI patients in rural areas? Findings from the CRAC France PCI registry.

Hakim R, Revue E, Saint Etienne C, Marcollet P, ... Grammatico-Guillon L, Rangé G
Aims
The aim of this study was to analyse delays in emergency medical system transfer of ST-segment elevation myocardial infarction (STEMI) patients to percutaneous coronary intervention (PCI) centres according to transport modality in a rural French region.
Methods and results
Data from the prospective multicentre CRAC / France PCI registry were analysed for 1911 STEMI patients: 410 transferred by helicopter and 1501 by ground transport. The primary endpoint was the percentage of transfers with first medical contact to primary percutaneous coronary intervention within the 90 minutes recommended in guidelines. The secondary endpoint was time of first medical contact to primary percutaneous coronary intervention. With helicopter transport, time of first medical contact to primary percutaneous coronary intervention in under 90 minutes was less frequently achieved than with ground transport (9.8% vs. 37.2%; odds ratio 5.49; 95% confidence interval 3.90; 7.73; <0.0001). Differences were greatest for transfers under 50 km (13.7% vs. 44.7%; <0.0001) and for primary transfers (22.4% vs. 49.6%; <0.0001). The median time from first medical contact to primary percutaneous coronary intervention and from symptom onset to primary percutaneous coronary intervention (total ischaemic time) were significantly higher in the helicopter transport group than in the ground transport group (respectively, 137 vs. 103 minutes; <0.0001 and 261 vs. 195 minutes; <0.0001). There was no significant difference in inhospital mortality between the helicopter and ground transport groups (6.9% vs. 6.6%; =0.88).
Conclusions
Helicopter transport of STEMI patients was five times less effective than ground transport in maintaining the 90-minute first medical contact to primary percutaneous coronary intervention time recommended in guidelines, particularly for transfer distances less than 50 km.



Eur Heart J Acute Cardiovasc Care: 30 Aug 2019:2048872619848976; epub ahead of print
Hakim R, Revue E, Saint Etienne C, Marcollet P, ... Grammatico-Guillon L, Rangé G
Eur Heart J Acute Cardiovasc Care: 30 Aug 2019:2048872619848976; epub ahead of print | PMID: 31475563
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Impact:
Abstract

Current status of the management and outcomes of acute aortic dissection in Japan: Analyses of nationwide Japanese Registry of All Cardiac and Vascular Diseases-Diagnostic Procedure Combination data.

Yamaguchi T, Nakai M, Sumita Y, Miyamoto Y, ... Ueda Y, Ogino H
Background
Despite recent advances in the diagnosis and management, the mortality of acute aortic dissection remains high. This study aims to clarify the current status of the management and outcome of acute aortic dissection in Japan.
Methods
A total of 18,348 patients with acute aortic dissection (type A: 10,131, type B: 8217) in the Japanese Registry of All Cardiac and Vascular Diseases database between April 2012-March 2015 were studied. Characteristics, clinical presentation, management, and in-hospital outcomes were analyzed.
Results
Seasonal onset variation (autumn- and winter-dominant) was found in both types. More than 90% of patients underwent computed tomography for primary diagnosis. The overall in-hospital mortality of types A and B was 24.3% and 4.5%, respectively. The mortality in type A patients managed surgically was significantly lower than in those not receiving surgery (11.8% (799/6788) vs 49.7% (1663/3343); <0.001). The number of cases managed endovascularly in type B increased 2.2-fold during the period, and although not statistically significant, the mortality gradually decreased (5.2% to 4.1%, =0.49). Type A showed significantly longer length of hospitalization (median 28 days) and more than five times higher medical costs (6.26 million Japanese yen) than those in type B. The mean Barthel index at discharge was favorable in both type A (89.0±22.6) and type B (92.6±19.0). More than two-thirds of type A patients and nearly 90% of type B patients were directly discharged home.
Conclusions
This nationwide study elucidated the clinical features and outcomes in contemporary patients with acute aortic dissections in real-world clinical practice in Japan.



Eur Heart J Acute Cardiovasc Care: 27 Aug 2019:2048872619872847; epub ahead of print
Yamaguchi T, Nakai M, Sumita Y, Miyamoto Y, ... Ueda Y, Ogino H
Eur Heart J Acute Cardiovasc Care: 27 Aug 2019:2048872619872847; epub ahead of print | PMID: 31460772
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Impact:
Abstract

Vulnerability to cardiac arrest in patients with ST elevation myocardial infarction: Is it time or patient dependent? Results from a nationwide observational study.

Salah M, Gevaert S, Coussement P, Beauloye C, ... Saenen J, Claeys MJ
Aim
Cardiac arrest is a common complication of ST elevation myocardial infarction and is associated with high mortality. We evaluated whether vulnerability to cardiac arrest follows a circadian rhythm and whether it is related to specific patient characteristics.
Methods
A total of 24,164 ST elevation myocardial infarction patients who were admitted to 60 Belgian hospitals between 2008-2017 were analysed. The proportion of patients with cardiac arrest before initiation of reperfusion therapy was calculated for different time periods (hour of the day, months, seasons) and related to patient characteristics using stepwise logistic regression analysis.
Results
Cardiac arrest occurred in 10.8% of the ST elevation myocardial infarction patients at a median of 65 min (interquartile range 33-138 min) after onset of pain. ST elevation myocardial infarction patients with cardiac arrest showed a biphasic pattern with one peak in the morning and one peak in the late afternoon. Multivariate analysis identified the following independent factors associated with cardiac arrest: cardiogenic shock (odds ratio=28), left bundle branch block (odds ratio=3.7), short (<180 min) ischaemic period (odds ratio=2.2), post-meridiem daytime presentation (odds ratio=1.4), anterior infarction (odds ratio=1.3). Overall in-hospital mortality was 30% for cardiac arrest patients versus 3.7% for non-cardiac arrest patients (<0.0001).
Conclusion
In the present study population, cardiac arrest in ST elevation myocardial infarction showed an atypical circadian rhythm with not only a morning peak but also a second peak in the late afternoon, suggesting that cardiac arrest and ST elevation myocardial infarction triggers are, at least partially, different. In addition, specific patient characteristics, such as short ischaemic period, cardiogenic shock and left bundle branch block, increase the vulnerability to cardiac arrest.



Eur Heart J Acute Cardiovasc Care: 26 Aug 2019:2048872619872127; epub ahead of print
Salah M, Gevaert S, Coussement P, Beauloye C, ... Saenen J, Claeys MJ
Eur Heart J Acute Cardiovasc Care: 26 Aug 2019:2048872619872127; epub ahead of print | PMID: 31452398
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Impact:
Abstract

Sex differences in crude mortality rates and predictive value of intensive care unit-based scores when applied to the cardiac intensive care unit.

Herscovici R, Mirocha J, Salomon J, Merz NB, Cercek B, Goldfarb M
Background
Limited data exists regarding sex differences in outcome and predictive accuracy of intensive care unit-based scoring systems when applied to cardiac intensive care unit patients.
Methods
We reviewed medical records of patients admitted to cardiac intensive care unit from 1 January 2011-31 December 2016. Sex differences in mortality rates and the performance of intensive care unit-based scoring systems in predicting in-hospital mortality were analyzed. Calibration was assessed by the Hosmer-Lemeshow test and locally weighted scatterplot smoothing curves. Discrimination was assessed using the c statistic and receiver-operating characteristic curve.
Results
Among 6963 patients, 2713 (39%) were women. Overall in-hospital and cardiac intensive care unit mortality rates were similar in women and men (9.1% vs 9.4%, =0.67 and 5.9% vs 6%, =0.88, respectively) and in age and major diagnosis subgroups. Of the scoring systems, Acute Physiology and Chronic Health Evaluation III and Sequential Organ Failure Assessment had poor calibration (Hosmer-Lemeshowvalue <0.001), while Simplified Acute Physiology Score II performed better (Hosmer-Lemeshowvalue 0.09), in both women and men. All scores had good discrimination (C statistics >0.8). In the subgroups of acute myocardial infarction and heart failure patients, all scores had good calibration (Hosmer-Lemeshow >0.001) and discrimination (C statistic >0.8) while in diagnosis subgroups with highest mortality, the calibration varied among scores and by sex, and discrimination was poor.
Conclusions
No sex differences in mortality were seen in cardiac intensive care unit patients. The mortality predictive value of intensive care unit-based scores is limited in both sexes and variable among different subgroups of diagnoses.



Eur Heart J Acute Cardiovasc Care: 26 Aug 2019:2048872619872129; epub ahead of print
Herscovici R, Mirocha J, Salomon J, Merz NB, Cercek B, Goldfarb M
Eur Heart J Acute Cardiovasc Care: 26 Aug 2019:2048872619872129; epub ahead of print | PMID: 31452378
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Impact:
Abstract

Residual platelet reactivity after pre-treatment with ticagrelor prior to primary percutaneous coronary intervention is associated with suboptimal myocardial reperfusion.

Roule V, Heudel T, Lemaitre A, Bignon M, ... Blanchart K, Beygui F
Background
The evidence of a clinical benefit of P2Y12 inhibitor pre-treatment in primary percutaneous coronary intervention (PCI) and the relation between the level of platelet inhibition and myocardial reperfusion with newer potent P2Y12 inhibitors remain unclear. We aimed to assess the relationship between platelet reactivity at the time of primary PCI after pre-treatment with aspirin and ticagrelor and the post-PCI myocardial blush grade (MBG).
Methods
We prospectively included 61 patients. Platelet reaction units for ticagrelor (PRU) and aspirin reaction units (ARU) were measured using the point-of-care test VerifyNow before PCI. The high on-ticagrelor (PRU >208) and on-aspirin (ARU ⩾ 550) platelet reactivity (HPR and HaPR) were assessed. Patients were divided into two groups according to MBG 3 or <3.
Results
MBG 3 was identified in 28 (46%) patients. Mean PRU was lower in such patients as compared with those with MBG <3 (155.82 ± 90.91 . 227.42 ± 65.18; =0.001) while mean ARU was similar between groups. HPR and HaPR were observed in 30 (49.2%) and 11 patients (18%), respectively. HPR but not HaPR was more frequent in the group with impaired MBG (66.7 . 28.6%; =0.003 and 21.214.3%; =0.48 respectively).
Conclusion
Our study shows that higher PRU and the subsequent HPR at the time of primary PCI, after pretreatment with ticagrelor, are the only correlates of post PCI MBG. These findings support the earliest possible loading with ticagrelor prior to primary PCI.



Eur Heart J Acute Cardiovasc Care: 11 Aug 2019:2048872619860214; epub ahead of print
Roule V, Heudel T, Lemaitre A, Bignon M, ... Blanchart K, Beygui F
Eur Heart J Acute Cardiovasc Care: 11 Aug 2019:2048872619860214; epub ahead of print | PMID: 31402681
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Impact:
Abstract

Editor\'s Choice- Pathophysiology and therapy of myocardial ischaemia/reperfusion syndrome.

Rossello X, Lobo-Gonzalez M, Ibanez B

There is a need to find interventions able to reduce the extent of injury in reperfused ST-segment elevation myocardial infarction (STEMI) beyond timely reperfusion. In this review, we summarise the clinical impact of STEMI from epidemiological, clinical and biological perspectives. We also revise the pathophysiology underlying the ischaemia/reperfusion syndrome occurring in reperfused STEMI, including the several players involved in this syndrome, such as cardiomyocytes, microcirculation and circulating cells. Interventions aimed to reduce the resultant infarct size, known as cardioprotective therapies, are extensively discussed, putting the focus on both mechanical interventions (i.e. ischaemic conditioning) and promising pharmacological therapies, such as early intravenous metoprolol, exenatide and other glucose modulators, N-acetylcysteine as well as on some other classic therapies which have failed to be translated to the clinical arena. Novel targets for evolving therapeutic interventions to ameliorate ischaemia/reperfusion injury are also discussed. Finally, we highlight the necessity to improve the study design of future randomised clinical trials in the field, as well as to select patients better who can most likely benefit from cardioprotective interventions.



Eur Heart J Acute Cardiovasc Care: 30 Jul 2019; 8:443-456
Rossello X, Lobo-Gonzalez M, Ibanez B
Eur Heart J Acute Cardiovasc Care: 30 Jul 2019; 8:443-456 | PMID: 31172789
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Impact:
Abstract

Copeptin to rule out myocardial infarction in Blacks versus Caucasians.

Beri N, Daniels LB, Jaffe A, Mueller C, ... Vilke G, Maisel A
Background
Copeptin in combination with troponin has been shown to have incremental value for the early rule-out of myocardial infarction, but its performance in Black patients specifically has never been examined. In light of a potential for wider use, data on copeptin in different relevant cohorts are needed. This is the first study to determine whether copeptin is equally effective at ruling out myocardial infarction in Black and Caucasian races.
Methods
This analysis of the CHOPIN trial included 792 Black and 1075 Caucasian patients who presented to the emergency department with chest pain and had troponin-I and copeptin levels drawn.
Results
One hundred and forty-nine patients were diagnosed with myocardial infarction (54 Black and 95 Caucasian). The negative predictive value of copeptin at a cut-off of 14 pmol/l (as in the CHOPIN study) for myocardial infarction was higher in Blacks (98.0%, 95% confidence interval (CI) 96.2-99.1%) than Caucasians (94.1%, 95% CI 92.1-95.7%). The sensitivity at 14 pmol/l was higher in Blacks (83.3%, 95% CI 70.7-92.1%) than Caucasians (53.7%, 95% CI 43.2-64.0%). After controlling for age, hypertension, heart failure, chronic kidney disease and body mass index in a logistic regression model, the interaction term had avalue of 0.03. A cut-off of 6 pmol/l showed similar sensitivity in Caucasians as 14 pmol/l in Blacks.
Conclusions
This is the first study to identify a difference in the performance of copeptin to rule out myocardial infarction between Blacks and Caucasians, with increased negative predictive value and sensitivity in the Black population at a cut-off of 14 pmol/l. This also holds true for non-ST-segment elevation myocardial infarction and, although numbers were small, similar trends exist in the normal troponin population. This may have significant implications for early rule-out strategies using copeptin.



Eur Heart J Acute Cardiovasc Care: 30 Jul 2019; 8:395-403
Beri N, Daniels LB, Jaffe A, Mueller C, ... Vilke G, Maisel A
Eur Heart J Acute Cardiovasc Care: 30 Jul 2019; 8:395-403 | PMID: 29737180
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Impact:
Abstract

Weekend effect in acute coronary syndrome: A meta-analysis of observational studies.

Kwok CS, Al-Dokheal M, Aldaham S, Rushton C, ... Timmis A, Mamas MA
Background
The effect of a weekend compared with a weekday hospital admission on patient outcomes after an acute coronary syndrome is unclear. This study aims to determine whether collectively there is a weekend effect in acute coronary syndrome.
Method
We conducted a systematic review and meta-analysis of cohort studies examining the association between weekend compared to weekday admission at any time of the day and early mortality (in-hospital or 30-day). A search was performed on Medline and Embase and relevant studies were pooled using random effects meta-analysis for risk of early mortality. Additional analyses were performed considering only more recent studies (conducted after 2005) and by patient group (ST-elevation myocardial infarction [STEMI] or non-STEMI [NSTEMI]), as well as meta-regression according to starting year and mean year of study.
Results
A total of 18 studies were included with over 14 million participants incorporating 3 million weekend and over 11.5 million weekday admissions and the rates of mortality were 19.2% and 23.4%, respectively. The pooled results of all 18 studies suggest that weekend admission was associated with a small increased risk of early mortality (odds ratio [OR] 1.06, 95% confidence interval [CI] 1.03-1.09). The results for subgroups of STEMI and NSTEMI cohorts were not statistically significant and timing of admission after 2005 had minimal influence on the results (OR 1.06, 95% CI 0.95-1.17).
Conclusions
There is a small weekend effect for admission with acute coronary syndrome that has persisted over time.



Eur Heart J Acute Cardiovasc Care: 30 Jul 2019; 8:432-442
Kwok CS, Al-Dokheal M, Aldaham S, Rushton C, ... Timmis A, Mamas MA
Eur Heart J Acute Cardiovasc Care: 30 Jul 2019; 8:432-442 | PMID: 29498538
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Impact:
Abstract

A direct comparison of decision rules for early discharge of suspected acute coronary syndromes in the era of high sensitivity troponin.

Chew PG, Frost F, Mullen L, Fisher M, ... Jones J, Khand A
Background
We tested the hypothesis that a single high sensitivity troponin at limits of detection (LOD HSTnT) (<5 ng/l) combined with a presentation non-ischaemic electrocardiogram is superior to low-risk Global Registry of Acute Coronary Events (GRACE) (<75), Thrombolysis in Myocardial Infarction (TIMI) (≤1) and History, ECG, Age, Risk factors and Troponin (HEART) score (≤3) as an aid to early, safe discharge for suspected acute coronary syndrome.
Methods
In a prospective cohort study, risk scores were computed in consecutive patients with suspected acute coronary syndrome presenting to the Emergency Room of a large English hospital. Adjudication of myocardial infarction, as per third universal definition, involved a two-physician, blinded, independent review of all biomarker positive chest pain re-presentations to any national hospital. The primary and secondary outcome was a composite of type 1 myocardial infarction, unplanned coronary revascularisation and all cause death (MACE) at six weeks and one year.
Results
Of 3054 consecutive presentations with chest pain 1642 had suspected acute coronary syndrome (52% male, median age 59 years, 14% diabetic, 20% previous myocardial infarction). Median time from chest pain to presentation was 9.7 h. Re-presentations occurred in eight hospitals with 100% follow-up achieved. Two hundred and eleven (12.9%) and 279 (17%) were adjudicated to suffer MACE at six weeks and one year respectively. Only HEART ≤3 (negative predictive value MACE 99.4%, sensitivity 97.6%, %discharge 53.4) and LOD HSTnT strategy (negative predictive value MACE 99.8%, sensitivity 99.5%, %discharge 36.9) achieved pre-specified negative predictive value of >99% for MACE at six weeks. For type 1 myocardial infarction alone the negative predictive values at six weeks and one year were identical, for both HEART ≤3 and LOD HSTnT at 99.8% and 99.5% respectively.
Conclusion
HEART ≤3 or LOD HSTnT strategy rules out short and medium term myocardial infarction with ≥99.5% certainty, and short-term MACE with >99% certainty, allowing for early discharge of 53.4% and 36.9% respectively of suspected acute coronary syndrome. Adoption of either strategy has the potential to greatly reduce Emergency Room pressures and minimise follow-up investigations. Very early presenters (<3 h), due to limited numbers, are excluded from these conclusions.



Eur Heart J Acute Cardiovasc Care: 30 Jul 2019; 8:421-431
Chew PG, Frost F, Mullen L, Fisher M, ... Jones J, Khand A
Eur Heart J Acute Cardiovasc Care: 30 Jul 2019; 8:421-431 | PMID: 29480016
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Impact:
Abstract

Spontaneous coronary artery dissection: Acute findings on coronary computed tomography angiography.

Tweet MS, Akhtar NJ, Hayes SN, Best PJ, Gulati R, Araoz PA
Background
The coronary computed tomography angiography features of acute spontaneous coronary artery dissection, an important cause of acute coronary syndrome in young women, have not been assessed.
Methods
The \"Virtual\" Multicenter Mayo Clinic Spontaneous Coronary Artery Dissection Registry was established in 2010 and includes retrospective and prospective patient data. Retrospective assessment of acute coronary computed tomography angiography images was performed for 14 patients (16 vessels) who had images performed within two days of invasive coronary angiography diagnosis of acute spontaneous coronary artery dissection.
Results
Four pertinent diagnostic coronary features of acute spontaneous coronary artery dissection were observed in order of prevalence: 1) abrupt luminal stenosis (64%); 2) intramural hematoma (50%); 3) tapered luminal stenosis (36%); and 4) dissection (14%). Additional findings include epicardial fat stranding (42%), coronary tortuosity (29%), and coronary bridge (14%). Fifty percent of patients had myocardial hypoperfusion in the myocardial distribution of the dissected coronary artery.
Conclusions
We define key coronary computed tomography angiography features of acute spontaneous coronary artery dissection, the most common of which are abrupt luminal stenosis and intramural hematoma. Importantly, intramural hematoma appears similar to noncalcified atherosclerotic plaque, emphasizing the importance of invasive coronary angiography for acute diagnosis of spontaneous coronary artery dissection until the sensitivity and specificity of coronary computed tomography angiography is better understood.



Eur Heart J Acute Cardiovasc Care: 30 Jul 2019; 8:467-475
Tweet MS, Akhtar NJ, Hayes SN, Best PJ, Gulati R, Araoz PA
Eur Heart J Acute Cardiovasc Care: 30 Jul 2019; 8:467-475 | PMID: 29376398
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Impact:
Abstract

Diagnostic accuracy of functional, imaging and biochemical tests for patients presenting with chest pain to the emergency department: A systematic review and meta-analysis.

Iannaccone M, Gili S, De Filippo O, D\'Amico S, ... Gaita F, D\'Ascenzo F
Background
Non-invasive ischaemia tests and biomarkers are widely adopted to rule out acute coronary syndrome in the emergency department. Their diagnostic accuracy has yet to be precisely defined.
Methods
Medline, Cochrane Library CENTRAL, EMBASE and Biomed Central were systematically screened (start date 1 September 2016, end date 1 December 2016). Prospective studies (observational or randomised controlled trial) comparing functional/imaging or biochemical tests for patients presenting with chest pain to the emergency department were included.
Results
Overall, 77 studies were included, for a total of 49,541 patients (mean age 59.9 years). Fast and six-hour highly sensitive troponin T protocols did not show significant differences in their ability to detect acute coronary syndromes, as they reported a sensitivity and specificity of 0.89 (95% confidence interval 0.79-0.94) and 0.84 (0.74-0.9) vs 0.89 (0.78-0.94) and 0.83 (0.70-0.92), respectively. The addition of copeptin to troponin increased sensitivity and reduced specificity, without improving diagnostic accuracy. The diagnostic value of non-invasive tests for patients without troponin increase was tested. Coronary computed tomography showed the highest level of diagnostic accuracy (sensitivity 0.93 (0.81-0.98) and specificity 0.90 (0.93-0.94)), along with myocardial perfusion scintigraphy (sensitivity 0.85 (0.77-0.91) and specificity 0.92 (0.83-0.96)). Stress echography was inferior to coronary computed tomography but non-inferior to myocardial perfusion scintigraphy, while exercise testing showed the lower level of diagnostic accuracy.
Conclusions
Fast and six-hour highly sensitive troponin T protocols provide an overall similar level of diagnostic accuracy to detect acute coronary syndrome. Among the non-invasive ischaemia tests for patients without troponin increase, coronary computed tomography and myocardial perfusion scintigraphy showed the highest sensitivity and specificity.



Eur Heart J Acute Cardiovasc Care: 30 Jul 2019; 8:412-420
Iannaccone M, Gili S, De Filippo O, D'Amico S, ... Gaita F, D'Ascenzo F
Eur Heart J Acute Cardiovasc Care: 30 Jul 2019; 8:412-420 | PMID: 29350536
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Impact:
Abstract

A single centre prospective cohort study addressing the effect of a rule-in/rule-out troponin algorithm on routine clinical practice.

Marjot J, Kaier TE, Henderson K, Hunter L, Marber MS, Perera D
Aims
In 2015, the European Society of Cardiology introduced new guidelines for the diagnosis of acute coronary syndromes in patients presenting without persistent ST-segment elevation. These guidelines included the use of high-sensitivity troponin assays for \'rule-in\' and \'rule-out\' of acute myocardial injury at presentation (using a \'0 hour\' blood test). Whilst these algorithms have been extensively validated in prospective diagnostic studies, the outcome of their implementation in routine clinical practice has not been described. The present study describes the change in the patient journey resulting from implementation of such an algorithm in a busy innercity Emergency Department.
Methods and results
Data were prospectively collected from electronic records at a large Central London hospital over seven months spanning the periods before, during and after the introduction of a new high-sensitivity troponin rapid diagnostic algorithm modelled on the European Society of Cardiology guideline. Over 213 days, 4644 patients had high-sensitivity troponin T measured in the Emergency Department. Of these patients, 40.4% could be \'ruled-out\' based on the high-sensitivity troponin T concentration at presentation, whilst 7.6% could be \'ruled-in\'. Adoption of the algorithm into clinical practice was associated with a 37.5% increase of repeat high-sensitivity troponin T measurements within 1.5 h for those patients classified as \'intermediate risk\' on presentation.
Conclusions
Introduction of a 0 hour \'rule-in\' and \'rule-out\' algorithm in routine clinical practice enables rapid triage of 48% of patients, and is associated with more rapid repeat testing in intermediate risk patients.



Eur Heart J Acute Cardiovasc Care: 30 Jul 2019; 8:404-411
Marjot J, Kaier TE, Henderson K, Hunter L, Marber MS, Perera D
Eur Heart J Acute Cardiovasc Care: 30 Jul 2019; 8:404-411 | PMID: 29199434
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Impact:
Abstract

Risk assessment for infected endocarditis in bacteremia patients: When is transesophageal echocardiography needed?

Longobardo L, Klemm S, Cook M, Ravenna V, ... Mengesha T, Khandheria BK
Aims
Echocardiography is the main technique for the diagnosis of endocarditis in patients withbacteremia (SAB), but a consensus about performing transthoracic echocardiography or transesophageal echocardiography (TEE) as first-line tests is currently lacking. Recently, a new scoring system has been proposed by Palraj et al. to guide the use of TEE in this population. Our aim was to validate this scoring system or modify it, if necessary.
Methods and results
Data from SAB patients admitted from 2012 to 2014 were collected. We tested the Palraj scores to stratify patients\' risk for endocarditis. Moreover, we analyzed our population to identify any other possible clinical predictors of endocarditis not included in the score. Endocarditis was diagnosed in 38 of 205 patients (18.5%). Palraj\'s score was effective in the detection of patients at high risk of endocarditis. In addition, we identified the presence of cardiac devices, prolonged bacteremia and intravenous drug abuse (IVDA) as elements strongly correlated with endocarditis. Two scoring systems (Day-1 and Day-5) were derived including IVDA as a variable. Using a Day-1 cut-off value ≥5 and a Day-5 cut-off value ≥2, the \'modified Palraj\'s score\' showed sensitivities of 42.1% and 97.0% and specificities of 88.6% and 32.0% for Day-1 and Day-5 scores, respectively.
Conclusion
We modify and expand upon an effective scoring system to identify SAB patients at high risk for endocarditis in order to guide use of TEE. The inclusion of IVDA in the criteria for the calculation of the scores improves its effectiveness.



Eur Heart J Acute Cardiovasc Care: 30 Jul 2019; 8:476-484
Longobardo L, Klemm S, Cook M, Ravenna V, ... Mengesha T, Khandheria BK
Eur Heart J Acute Cardiovasc Care: 30 Jul 2019; 8:476-484 | PMID: 29064261
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Abstract

Comparison of distinctive clinical and cardiac magnetic resonance features between ST elevation myocardial infarction patients with incomplete myocardial rupture and those with moderate to severe pericardial effusion.

Pineda V, Figueras J, Moral S, Bañeras J, ... Evangelista A, García-Dorado D
Background
Whether patients with incomplete myocardial rupture (IMR) present distinctive clinical and cardiac magnetic resonance features from those with moderate-severe pericardial effusion (⩾10 mm (PE)) remains unknown.
Methods
We compared the clinical, angiographic and cardiac magnetic resonance characteristics of nine patients with IMR (diagnosed angiographically and/or by cardiac magnetic resonance) with 29 with PE, and also with 38 without IMR or PE with evidence of transmural necrosis (reference group) matched for age, gender and year of admission.
Results
Patients with IMR were younger than those with PE (<0.001) but the two groups shared a higher rate of admission delay (78% and 41%) than those without IMR/PE (5%, <0.001) and lower frequency of reperfusion therapy (44%, 55% and 100%, respectively, <0.001). Thirteen patients with PE (45%) but only one IMR (11%) presented recurrent chest pain. IMR patients tended to present smaller infarct size at cardiac magnetic resonance (=0.153 and 0.036) and number of segments with ⩾75% necrosis than PE patients and those without IMR/PE (=0.098 and 0.029, respectively). Ten PE patients presented cardiac tamponade (35%). A control 2D-echocardiogram performed within two years in 71 patients (93%) documented a pseudoaneurysm in one PE and in one IMR patient.
Conclusions
IMR is generally silent and occurs in younger patients with smaller infarct size than those with PE although both present late and are often untreated with reperfusion therapy. These findings may warrant imaging assessment in ST elevation myocardial infarction patients with delayed admission, particularly in absence of reperfusion, to rule out an IMR.



Eur Heart J Acute Cardiovasc Care: 30 Jul 2019; 8:457-466
Pineda V, Figueras J, Moral S, Bañeras J, ... Evangelista A, García-Dorado D
Eur Heart J Acute Cardiovasc Care: 30 Jul 2019; 8:457-466 | PMID: 28730842
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Impact:
Abstract

Mechanical circulatory support in cardiogenic shock from acute myocardial infarction: Impella CP/5.0 versus ECMO.

Karami M, den Uil CA, Ouweneel DM, Scholte NT, ... Jewbali LS, Henriques JP
Background
Short-term mechanical circulatory support devices are increasingly used in cardiogenic shock after acute myocardial infarction. As no randomised evidence is available, the choice between high-output Impella or extra-corporeal membrane oxygenation (ECMO) is still a matter of debate. Real-life data are necessary to assess adverse outcomes and to help guide the treatment decision between the different devices. The purpose of this study was to compare characteristics and clinical outcomes of Impella CP/5.0 with ECMO support in patients with cardiogenic shock from myocardial infarction.
Methods
A retrospective, two-centre study was performed on all cardiogenic shock from myocardial infarction patients with Impella CP/5.0 or ECMO support, from 2006 until 2018. The primary outcome was 30-day mortality. Potential baseline imbalance between the groups was adjusted using inverse probability treatment weighting, and survival analysis was performed with an adjusted log-rank test. Secondarily, the occurrence of device-related complications (limb ischaemia, access site-related bleeding, access site-related infection) was evaluated.
Results
A total of 128 patients were included (Impella, =90; ECMO, =38). The 30-day mortality was similar for both groups (53% vs. 49%, =0.30), also after adjustment for potential baseline imbalance between the groups (weighted log-rank =0.16). Patients with Impella support had significantly fewer device-related complications than patients treated with ECMO (respectively, 17% vs. 40%, <0.01).
Conclusions
Patients treated with Impella CP/5.0 or ECMO for cardiogenic shock after myocardial infarction did not differ in 30-day mortality. More device-related complications occurred with ECMO compared to Impella support.



Eur Heart J Acute Cardiovasc Care: 28 Jul 2019:2048872619865891; epub ahead of print
Karami M, den Uil CA, Ouweneel DM, Scholte NT, ... Jewbali LS, Henriques JP
Eur Heart J Acute Cardiovasc Care: 28 Jul 2019:2048872619865891; epub ahead of print | PMID: 31353918
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Impact:
Abstract

RAPID-CPU: a prospective study on implementation of the ESC 0/1-hour algorithm and safety of discharge after rule-out of myocardial infarction.

Stoyanov KM, Hund H, Biener M, Gandowitz J, ... Katus HA, Giannitsis E
Background
Although the value of fast diagnostic protocols in suspected acute coronary syndrome has been validated, there is insufficient real world evidence including patients with lower pre-test probability, atypical symptoms and confounding comorbidities. The feasibility, efficacy and safety of European Society of Cardiology (ESC) 0/1 and 0/3-hour algorithms using high-sensitivity troponin T were evaluated in a consecutive cohort with suspected acute coronary syndrome.
Methods
During 12 months, 2525 eligible patients were enrolled. In a pre-implementation period of 6 months, the prevalence of protocols, disposition, lengths of emergency department stay and treatments were registered. Implementation of the 0/1-hour protocol was monitored for another 6 months. Primary endpoints comprised the change of diagnostic protocols and 30-day mortality after direct discharge from the emergency department.
Results
Use of the ESC 0/1-hour algorithm increased by 270% at the cost of the standard 0/3-hour protocol. After rule-out (1588 patients), 1309 patients (76.1%) were discharged directly from the emergency department, with an all-cause mortality of 0.08% at 30 days (one death due to lung cancer). Median lengths of stay were 2.9 (1.9-3.8) and 3.2 (2.7-4.4) hours using a single high-sensitivity troponin T below the limit of detection (5 ng/L) at presentation and the ESC 0/1-hour algorithm, respectively, as compared to 5.3 (4.7-6.5) hours using the ESC 0/3-hour rule-out protocol (<0.001). Discharge rates increased from 53.9% to 62.8% (<0.001), without excessive use of diagnostic resources within 30 days.
Conclusion
Implementation of the ESC 0/1-hour algorithm is feasible and safe, is associated with shorter emergency department stay than the ESC 0/3-hour protocol, and an increase in discharge rates.
Trial registration
ClinicalTrials.gov , Unique identifier: NCT03111862.



Eur Heart J Acute Cardiovasc Care: 11 Jul 2019:2048872619861911; epub ahead of print
Stoyanov KM, Hund H, Biener M, Gandowitz J, ... Katus HA, Giannitsis E
Eur Heart J Acute Cardiovasc Care: 11 Jul 2019:2048872619861911; epub ahead of print | PMID: 31298551
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Impact:
Abstract

Predictors of permanent pacemaker requirement after cardiac surgery for infective endocarditis.

Hill TE, Kiehl EL, Shrestha NK, Gordon SM, ... Menon V, Tarakji KG
Background
Infectious endocarditis is often complicated by conduction abnormalities at the time of presentation. Cardiac surgery is the treatment of choice for many infectious endocarditis patients, but carries an additional risk of persistent postoperative conduction abnormality. We sought to define the incidence and clinical predictors of significant postoperative conduction abnormalities necessitating permanent pacemaker implantation after cardiac surgery for infectious endocarditis.
Methods
All consecutive patients with infectious endocarditis who were surgically treated at Cleveland Clinic from 2007 to 2013 were identified using the Cleveland Clinic Infective Endocarditis Registry and the Cardiovascular Information Registry. Patients with a pre-existing cardiac implantable electronic device were excluded. The primary outcome was the need for permanent pacemaker placement postoperatively for atrioventricular block. Regression analysis was performed to identify risk factors for permanent pacemaker requirement.
Results
Among 444 infectious endocarditis patients who underwent cardiac surgery for infectious endocarditis, 57 (13%) required postoperative permanent pacemaker for atrioventricular block. Multivariable analysis identified that prolongation in preoperative PR and QRS intervals,as the infectious endocarditis organism, the presence of intracardiac abscess, tricuspid valve involvement, and prior valvular surgery independently predicted postoperative permanent pacemaker placement. The developed model exhibited excellent predictive ability (c-statistic 0.88) and calibration.
Conclusion
Infectious endocarditis cardiac surgery patients often require a postoperative permanent pacemaker. Preoperative conduction abnormality,infection, abscess, tricuspid valve involvement, and prior valvular surgery are strong predictors of postoperative permanent pacemaker placement.



Eur Heart J Acute Cardiovasc Care: 03 Jul 2019:2048872619848661; epub ahead of print
Hill TE, Kiehl EL, Shrestha NK, Gordon SM, ... Menon V, Tarakji KG
Eur Heart J Acute Cardiovasc Care: 03 Jul 2019:2048872619848661; epub ahead of print | PMID: 31271038
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Impact:
Abstract

Current perspectives on location of monitoring and length of stay following PPCI for ST elevation myocardial infarction.

Sharkawi MA, McMahon S, Al Jabri D, Thompson PD
Importance
There is marked variability in location of care and hospital length of stay after primary percutaneous coronary intervention for ST elevation myocardial infarction (STEMI).
Observations
We performed a literature review on non-critical care monitoring and early discharge following primary percutaneous coronary intervention and describe a framework for implementation in the real world. The medical literature was searched from 1 January 1988 to 31 April 2019 using PubMed and Cochrane Central Register of Controlled Trials. Randomized clinical trials, observational studies and guideline statements were included. Available data suggest that carefully selected low-risk STEMI patients identified using Zwolle or CADILLAC risk stratification scores after primary percutaneous coronary intervention may be considered for discharge after 48 hours of hospital care. There was no increase in major adverse cardiac events, medication non-compliance or hospital readmission with this treatment strategy. There are limited data on non-critical monitoring of uncomplicated STEMI patients; however, given the low adverse events rate, this strategy is likely to be safe in selected patients and may facilitate reduced length of stay and reduce resource utilization.
Conclusions and relevance
Available evidence supports the safety of early discharge after 48 hours of care and omission of critical care monitoring in carefully selected patients following primary percutaneous coronary intervention. Early risk stratification and structured discharge planning are imperative. Adoption of this treatment strategy could reduce hospital costs, resource utilization and enhance patient satisfaction without affecting outcomes.



Eur Heart J Acute Cardiovasc Care: 01 Jul 2019:2048872619860217; epub ahead of print
Sharkawi MA, McMahon S, Al Jabri D, Thompson PD
Eur Heart J Acute Cardiovasc Care: 01 Jul 2019:2048872619860217; epub ahead of print | PMID: 31264471
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Impact:
Abstract

Arterial blood pressure during targeted temperature management after out-of-hospital cardiac arrest and association with brain injury and long-term cognitive function.

Grand J, Lilja G, Kjaergaard J, Bro-Jeppesen J, ... Nielsen N, Hassager C
Objectives
During targeted temperature management after out-of-hospital cardiac arrest infusion of vasoactive drugs is often needed to ensure cerebral perfusion pressure. This study investigated mean arterial pressure after out-of-hospital cardiac arrest and the association with brain injury and long-term cognitive function.
Methods
Post-hoc analysis of patients surviving at least 48 hours in the biobank substudy of the targeted temperature management trial with available blood pressure data. Patients were stratified in three groups according to mean arterial pressure during targeted temperature management (4-28 hours after admission; <70 mmHg, 70-80 mmHg, >80 mmHg). A biomarker of brain injury, neuron-specific enolase, was measured and impaired cognitive function was defined as a mini-mental state examination score below 27 in 6-month survivors.
Results
Of the 657 patients included in the present analysis, 154 (23%) had mean arterial pressure less than 70 mmHg, 288 (44%) had mean arterial pressure between 70 and 80 mmHg and 215 (33%) had mean arterial pressure greater than 80 mmHg. There were no statistically significant differences in survival (=0.35) or neuron-specific enolase levels (=0.12) between the groups. The level of target temperature did not statistically significantly interact with mean arterial pressure regarding neuron-specific enolase (=0.58). In the subgroup of survivors with impaired cognitive function (=132) (35%) mean arterial pressure during targeted temperature management was significantly higher (=0.03).
Conclusions
In a large cohort of comatose out-of-hospital cardiac arrest patients, low mean arterial pressure during targeted temperature management was not associated with higher neuron-specific enolase regardless of the level of target temperature (33°C or 36°C for 24 hours). In survivors with impaired cognitive function, mean arterial pressure during targeted temperature management was significantly higher.



Eur Heart J Acute Cardiovasc Care: 26 Jun 2019:2048872619860804; epub ahead of print
Grand J, Lilja G, Kjaergaard J, Bro-Jeppesen J, ... Nielsen N, Hassager C
Eur Heart J Acute Cardiovasc Care: 26 Jun 2019:2048872619860804; epub ahead of print | PMID: 31246109
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Impact:
Abstract

Impact of microaxillar mechanical left ventricular support on renal resistive index in patients with cardiogenic shock after myocardial infarction: a pilot trial to predict renal organ dysfunction in cardiogenic shock.

Markus B, Patsalis N, Chatzis G, Luesebrink U, ... Schieffer B, Karatolios K
Objectives
To evaluate the effects of left ventricular support with the microaxial left ventricular pump using the Impella device on the renal resistive index assessed by Doppler ultrasonography in haemodynamically stable patients with cardiogenic shock following myocardial infarction.
Methods
A non-randomised interventional single-centre study. Consecutive patients with cardiogenic shock supported with an Impella were included during May 2018 and October 2018. The renal resistive index determined as a quotient of (peak systolic velocity - end diastolic velocity)/ peak systolic velocity was obtained using Doppler ultrasound; invasive blood pressure was determined in radial artery simultaneously for safety reasons.
Results
A total of 15 patients were measured. The renal resistive index was determined in both kidneys in 13 patients and for one kidney in two patients, respectively. The mean difference between right and left renal resistive index was 0.026 ± 0.023 (=0.72). When increasing the Impella microaxillar mechanical support by a mean of 0.44 L/min (±0.2 L/min), the renal resistive index decreased significantly from 0.66 ± 0.08 to 0.62 ± 0.06 (<0.001) consistently in all patients, whereas systolic or diastolic blood pressure remained unchanged.
Conclusions
Microaxillar mechanical support by the Impella device in haemodynamically stable patients with cardiogenic shock led to a significant reduction of the renal resistive index without affecting systolic or diastolic blood pressure. This observation is consistent with the notion that Impella support may promote renal organ protection by enhancing renal perfusion.



Eur Heart J Acute Cardiovasc Care: 26 Jun 2019:2048872619860218; epub ahead of print
Markus B, Patsalis N, Chatzis G, Luesebrink U, ... Schieffer B, Karatolios K
Eur Heart J Acute Cardiovasc Care: 26 Jun 2019:2048872619860218; epub ahead of print | PMID: 31246097
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Impact:
Abstract

Risk prediction tools in cardiovascular disease prevention: A report from the ESC Prevention of CVD Programme led by the European Association of Preventive Cardiology (EAPC) in collaboration with the Acute Cardiovascular Care Association (ACCA) and the Association of Cardiovascular Nursing and Allied Professions (ACNAP).

Rossello X, Dorresteijn JA, Janssen A, Lambrinou E, ... Visseren FL, Dendale P

Risk assessment and risk prediction have become essential in the prevention of cardiovascular disease. Even though risk prediction tools are recommended in the European guidelines, they are not adequately implemented in clinical practice. Risk prediction tools are meant to estimate prognosis in an unbiased and reliable way and to provide objective information on outcome probabilities. They support informed treatment decisions about the initiation or adjustment of preventive medication. Risk prediction tools facilitate risk communication to the patient and their family, and this may increase commitment and motivation to improve their health. Over the years many risk algorithms have been developed to predict 10-year cardiovascular mortality or lifetime risk in different populations, such as in healthy individuals, patients with established cardiovascular disease and patients with diabetes mellitus. Each risk algorithm has its own limitations, so different algorithms should be used in different patient populations. Risk algorithms are made available for use in clinical practice by means of - usually interactive and online available - tools. To help the clinician to choose the right tool for the right patient, a summary of available tools is provided. When choosing a tool, physicians should consider medical history, geographical region, clinical guidelines and additional risk measures among other things. Currently, the U-prevent.com website is the only risk prediction tool providing prediction algorithms for all patient categories, and its implementation in clinical practice is suggested/advised by the European Association of Preventive Cardiology.



Eur Heart J Acute Cardiovasc Care: 24 Jun 2019:2048872619858285; epub ahead of print
Rossello X, Dorresteijn JA, Janssen A, Lambrinou E, ... Visseren FL, Dendale P
Eur Heart J Acute Cardiovasc Care: 24 Jun 2019:2048872619858285; epub ahead of print | PMID: 31303009
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Impact:
Abstract

Role of coronary angiography in patients with a non-diagnostic electrocardiogram following out of hospital cardiac arrest: Rationale and design of the multicentre randomized controlled COUPE trial.

Viana-Tejedor A, Ariza-Solé A, Martínez-Sellés M, Mena MJ, ... Ortiz AF, Macaya C
Background
Coronary artery disease (CAD) is a major cause of out-of-hospital cardiac arrest (OHCA). The role of emergency coronary angiography (CAG) and percutaneous coronary intervention (PCI) following cardiac arrest in patients without ST-segment elevation myocardial infarction (STEMI) remains unclear.
Aims
We aim to assess whether emergency CAG and PCI, when indicated, will improve survival with good neurological outcome in post-OHCA patients without STEMI who remain comatose.
Methods
COUPE is a prospective, multicentre and randomized controlled clinical trial. A total of 166 survivors of OHCA without STEMI will be included. Potentially non-cardiac aetiology of the cardiac arrest will be ruled out prior to randomization. Randomization will be 1:1 for emergency (within 2 h) or deferred (performed before discharge) CAG. Both groups will receive routine care in the intensive cardiac care unit, including therapeutic hypothermia. The primary efficacy endpoint is a composite of in-hospital survival free of severe dependence, which will be evaluated using the Cerebral Performance Category Scale. The safety endpoint will be a composite of major adverse cardiac events including death, reinfarction, bleeding and ventricular arrhythmias.
Conclusions
This study will assess the efficacy of an emergency CAG versus a deferred one in OHCA patients without STEMI in terms of survival and neurological impairment.



Eur Heart J Acute Cardiovasc Care: 24 Jun 2019:2048872618813843; epub ahead of print
Viana-Tejedor A, Ariza-Solé A, Martínez-Sellés M, Mena MJ, ... Ortiz AF, Macaya C
Eur Heart J Acute Cardiovasc Care: 24 Jun 2019:2048872618813843; epub ahead of print | PMID: 31237435
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Impact:
Abstract

Radial versus femoral access in patients with acute coronary syndrome undergoing invasive management: A prespecified subgroup analysis from VALIDATE-SWEDEHEART.

Völz S, Angerås O, Koul S, Haraldsson I, ... Erlinge D, Omerovic E
Aims
In the Bivalirudin versus Heparin in ST-Segment and Non-ST-Segment Elevation Myocardial Infarction in Patients on Modern Antiplatelet Therapy in the Swedish Web System for Enhancement and Development of Evidence-based Care in Heart Disease Evaluated according to Recommended Therapies Registry Trial (VALIDATE-SWEDEHEART), bivalirudin was not superior to unfractionated heparin in patients with acute coronary syndrome undergoing invasive management. We assessed whether the access site had an impact on the primary endpoint of death, myocardial infarction or major bleeding at 180 days and whether it interacted with bivalirudin/unfractionated heparin.
Methods and results
A total of 6006 patients with acute coronary syndrome planned for percutaneous coronary intervention were randomised to either bivalirudin or unfractionated heparin. Arterial access was left to the operator discretion. Overall, 90.5% of patients underwent transradial access and 9.5% transfemoral access. Baseline risk was higher in transfemoral access. The unadjusted hazard ratio for the primary outcome was lower with transradial access (hazard ratio 0.53, 95% confidence interval 0.43-0.67, <0.001) and remained lower after multivariable adjustment (hazard ratio 0.56, 95% confidence interval 0.52-0.84, <0.001). Transradial access was associated with lower risk of death (hazard ratio 0.41, 95% confidence interval 0.28-0.60, <0.001) and major bleeding (hazard ratio 0.57, 95% confidence interval 0.44-0.75, <0.001). There was no interaction between treatment with bivalirudin and access site for the primary endpoint (=0.976) or major bleeding (=0.801).
Conclusions
Transradial access was associated with lower risk of death, myocardial infarction or major bleeding at 180 days. Bivalirudin was not associated with less bleeding, irrespective of access site.



Eur Heart J Acute Cardiovasc Care: 24 Jun 2019:2048872618817217; epub ahead of print
Völz S, Angerås O, Koul S, Haraldsson I, ... Erlinge D, Omerovic E
Eur Heart J Acute Cardiovasc Care: 24 Jun 2019:2048872618817217; epub ahead of print | PMID: 31237158
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Impact:
Abstract

Treatment strategies for post-infarction left ventricular free-wall rupture.

Matteucci M, Fina D, Jiritano F, Meani P, ... Maessen J, Lorusso R

Left ventricular free-wall rupture is one of the most fatal complications after acute myocardial infarction. Surgical treatment of post-infarction left ventricular free-wall rupture has evolved over time. Direct closure of the ventricular wall defect (linear closure) and resection of the infarcted myocardium (infarctectomy), with subsequent closure of the created defect with a prosthetic patch, represented the original techniques. Recently, less aggressive approaches, either with the use of surgical glues or the application of collagen sponge patches on the infarct area to cover the tear and achieve haemostasis, have been proposed. Despite such modifications in the therapeutic strategy and surgical treatment, however, postoperative in-hospital mortality may be as high as 35%. In extremely high-risk or inoperable patients, a non-surgical approach has been reported.



Eur Heart J Acute Cardiovasc Care: 30 May 2019; 8:379-387
Matteucci M, Fina D, Jiritano F, Meani P, ... Maessen J, Lorusso R
Eur Heart J Acute Cardiovasc Care: 30 May 2019; 8:379-387 | PMID: 30932689
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Impact:
Abstract

Survival after refractory cardiogenic shock is comparable in patients with Impella and veno-arterial extracorporeal membrane oxygenation when adjusted for SAVE score.

Schiller P, Hellgren L, Vikholm P
Objectives
Survival after different short-term mechanical circulatory support is difficult to compare because various systems are used and patient disease severity is most often not adjusted for. This study compares the outcome after the use of Impella and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in refractory cardiogenic shock, adjusted for disease severity through the survival after the VA-ECMO (SAVE) score.
Methods
Patients with refractory shock treated with either VA-ECMO or Impella between January 2003 and August 2015 were included. Data were analysed to assess short and long-term survival and complications. The SAVE score was calculated for the two groups and outcome was compared adjusted for the SAVE score.
Results
There was no difference between VA-ECMO patients (=46) and Impella patients (=48) in mean age or renal failure. ECMO patients were more often intubated and had lower diastolic blood pressure at device implantation. ECMO patients had a lower SAVE score (-0.4 (6.5)) compared to Impella patients (4.1 (5.4)). There was no difference in intensive care unit survival between ECMO patients 65% (52-80) or Impella patients 63% (55-79), or long-term survival between groups. When stratified into worse (III-IV) or better SAVE class (I-II) there was no difference in survival between the groups.
Conclusions
Short and long-term survival is not measurably different among patients treated with Impella or VA-ECMO due to refractory cardiogenic shock, after adjustment for disease severity through the SAVE score.



Eur Heart J Acute Cardiovasc Care: 30 May 2019; 8:329-337
Schiller P, Hellgren L, Vikholm P
Eur Heart J Acute Cardiovasc Care: 30 May 2019; 8:329-337 | PMID: 30406678
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Impact:
Abstract

Real-life use of left ventricular circulatory support with Impella in cardiogenic shock after acute myocardial infarction: 12 years AMC experience.

Ouweneel DM, de Brabander J, Karami M, Sjauw KD, ... Tijssen JG, Henriques JP
Aims
Mortality in cardiogenic shock patients remains high. Short-term mechanical circulatory support with Impella can be used to support the circulation in these patients, but data from randomised controlled studies and \'real-world\' data are sparse. The aim is to describe real-life data on outcomes and complications of our 12 years of clinical experience with Impella in patients with cardiogenic shock after acute myocardial infarction and to identify predictors of 6-month mortality.
Methods
We describe a single-centre registry from October 2004 to December 2016 including all patients treated with Impella for cardiogenic shock after acute myocardial infarction. We report outcomes and complications and identify predictors of 6-month mortality.
Results
Our overall clinical experience consists of 250 patients treated with Impella 2.5, Impella CP or Impella 5.0. A total of 172 patients received Impella therapy for cardiogenic shock, of which 112 patients had cardiogenic shock after acute myocardial infarction. The mean age was 60.1±10.6 years, mean arterial pressure was 67 (56-77) mmHg, lactate was 6.2 (3.6-9.7) mmol/L, 87.5% were mechanically ventilated and 59.6% had a cardiac arrest before Impella placement. Overall 30-day mortality was 56.2% and 6-month mortality was 60.7%. Complications consisted of device-related vascular complications (17.0%), non-device-related bleeding (12.5%), haemolysis (7.1%) and stroke (3.6%). In a multivariate analysis, pH before Impella placement is a predictor of 6-month mortality.
Conclusions
Our registry shows that Impella treatment in cardiogenic shock after acute myocardial infarction is feasible, although mortality rates remain high and complications occur.



Eur Heart J Acute Cardiovasc Care: 30 May 2019; 8:338-349
Ouweneel DM, de Brabander J, Karami M, Sjauw KD, ... Tijssen JG, Henriques JP
Eur Heart J Acute Cardiovasc Care: 30 May 2019; 8:338-349 | PMID: 30403366
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Impact:
Abstract

Importance of elevated heart rate in the very early phase of ST-segment elevation myocardial infarction: Results from the DANAMI-3 trial.

Nepper-Christensen L, Lønborg J, Ahtarovski KA, Høfsten DE, ... Holmvang L, Engstrøm T
Background
Elevated heart rate is associated with poor clinical outcome in patients with acute myocardial infarction. However, in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention the importance of elevated heart rate in the very early phase remains unknown. We evaluated the impact of elevated heart rate in the very early pre-hospital phase of ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention on cardiovascular magnetic resonance markers of reperfusion success and clinical outcome.
Methods
In this DANAMI-3 substudy, 1560 ST-segment elevation myocardial infarction patients in sinus rhythm without cardiogenic shock were included in the analyses of clinical outcome and 796 patients underwent cardiovascular magnetic resonance to evaluate area at risk, infarct size and left ventricular ejection fraction. Heart rate was assessed on the first electrocardiogram with ST-elevation (time of diagnosis).
Results
Despite equal area at risk (33%±11 versus 36%±16, =0.174) patients with a pre-hospital heart rate ⩾100 beats per minute developed larger infarcts (19% (interquartile range, 9-17) versus 11% (interquartile range, 10-28), =0.001) and a lower left ventricular ejection fraction (54%±12 versus 58%±9, =0.047). Pre-hospital heart rate ⩾100 beats per minute was independently associated with an increased risk of all-cause mortality and heart failure (hazard ratio 2.39 (95% confidence interval 1.58-3.62), <0.001).
Conclusions
Very early heart rate ⩾100 beats per minute in ST-segment elevation myocardial infarction was independently associated with larger infarct size, reduced left ventricular ejection fraction and an increased risk of all-cause mortality and heart failure, and thus serves as an easily obtainable and powerful tool to identify ST-segment elevation myocardial infarction patients at high risk.



Eur Heart J Acute Cardiovasc Care: 30 May 2019; 8:318-328
Nepper-Christensen L, Lønborg J, Ahtarovski KA, Høfsten DE, ... Holmvang L, Engstrøm T
Eur Heart J Acute Cardiovasc Care: 30 May 2019; 8:318-328 | PMID: 30136597
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Impact:
Abstract

Development and validation of a prognostic model for survival in patients treated with venoarterial extracorporeal membrane oxygenation: the PREDICT VA-ECMO score.

Wengenmayer T, Duerschmied D, Graf E, Chiabudini M, ... Bode C, Staudacher DL
Aims
Several scoring systems have been introduced for prognostication after initiating venoarterial extracorporeal membrane oxygenation (VA-ECMO) therapy. However, static scores offer limited guidance once VA-ECMO is implanted, although continued allocation of healthcare resources is critical. Patients requiring continued VA-ECMO support are extremely unstable, with minimal heart function and multi-organ failure in most cases. The aim of the present study was to develop and validate a dynamic prognostic model for patients treated with VA-ECMO.
Methods and results
A derivation cohort included 205 all-comers undergoing VA-ECMO implantation at a tertiary referral hospital (51% received VA-ECMO during resuscitation and 43% had severe shock). Two prediction models based on point-of-care biomarkers were developed using penalised logistic regression in an elastic net approach. A validation cohort was recruited from an independent tertiary referral hospital. Comparators for the prediction of hospital survival were the SAVE score (area under the receiver operation characteristic curve (AUC) of 0.686), the SAPS score (AUC 0.679), the APACHE score (AUC 0.662) and the SOFA score (AUC 0.732) in 6-hour survivors. The 6-hour PREDICT VA-ECMO score (based on lactate, pH and standard bicarbonate concentration) outperformed the comparator scores with an AUC of 0.823. The 12-hour PREDICT VA-ECMO integrated lactate, pH and standard bicarbonate concentration at 1 hour, 6 hours and 12 hours after ECMO insertion allowed even better prognostication (AUC 0.839). Performance of the scores in the external validation cohort was good (AUCs 0.718 for the 6-hour score and 0.735 for the 12-hour score, respectively).
Conclusion
In patients requiring VA-ECMO therapy, a dynamic score using three point-of-care biomarkers predicts hospital mortality with high reliability. Furthermore, the PREDICT scores are the first scores for extracorporeal cardiopulmonary resuscitation patients.



Eur Heart J Acute Cardiovasc Care: 30 May 2019; 8:350-359
Wengenmayer T, Duerschmied D, Graf E, Chiabudini M, ... Bode C, Staudacher DL
Eur Heart J Acute Cardiovasc Care: 30 May 2019; 8:350-359 | PMID: 30003795
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Impact:
Abstract

Gender difference with the use of percutaneous left ventricular assist device in patients undergoing complex high-risk percutaneous coronary intervention: From pVAD Working Group.

Doshi R, Singh A, Jauhar R, Meraj PM
Background
The interventional treatment of complex high-risk indicated patients is technically difficult and can result in poor outcomes. Thus, percutaneous left ventricular assist devices are being increasingly used to provide hemodynamic support. No data is available comparing male and female for Complex High-risk Indicated Patients treated with percutaneous left ventricular assist devices. Our goal was to evaluate in-hospital as well as short term outcomes comparing males and females.
Methods
There were 160 complex high-risk indicated patients with percutaneous left ventricular assist device use who were not in cardiogenic shock. A total of 132 male and 28 female patients were included. Ejection fraction below 35% with one additional criterion such as use of atherectomy device or treatment on unprotected left main disease or multi-vessel disease were our inclusion criteria. An Impella 2.5 or Impella CP (Abiomed Inc.) device was used as a left ventricular support device.
Results
There was no difference in in-hospital mortality between the genders after performing a propensity score matched analysis (8.3% . 12.5%, =0.54). Secondary outcomes of myocardial infarction, cardiogenic shock, congestive heart failure, dysrhythmia, major adverse cardiac events and composite of all complications were higher in males. Furthermore, 30-day survival was similar in males and females (88.9% . 87.5%, =0.31). In addition, worse complications rates and survival were noted in patients with incomplete revascularization compared with those patients with complete revascularization in both gender.
Conclusion
This study demonstrated no gender difference in clinical outcomes when using percutaneous left ventricular assist device support for the treatment of complex high-risk indicated patients. Overall, males had higher secondary outcomes compared with females with no difference in in-hospital mortality or 30-day survival rates.



Eur Heart J Acute Cardiovasc Care: 30 May 2019; 8:369-378
Doshi R, Singh A, Jauhar R, Meraj PM
Eur Heart J Acute Cardiovasc Care: 30 May 2019; 8:369-378 | PMID: 29308660
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Impact:
Abstract

Predictive value of routine point-of-care cardiac troponin T measurement for prehospital diagnosis and risk-stratification in patients with suspected acute myocardial infarction.

Rasmussen MB, Stengaard C, Sørensen JT, Riddervold IS, ... Bøtker HE, Terkelsen CJ
Objective
The purpose of this study was to determine the predictive value of routine prehospital point-of-care cardiac troponin T measurement for diagnosis and risk stratification of patients with suspected acute myocardial infarction.
Methods and results
All prehospital emergency medical service vehicles in the Central Denmark Region were equipped with a point-of-care cardiac troponin T device (Roche Cobas h232) for routine use in all patients with a suspected acute myocardial infarction. During the study period, 1 June 2012-30 November 2015, prehospital point-of-care cardiac troponin T measurements were performed in a total of 19,615 cases seen by the emergency medical service and 18,712 point-of-care cardiac troponin T measurements in 15,781 individuals were matched with an admission. A final diagnosis of acute myocardial infarction was confirmed in 2187 cases and a total of 2150 point-of-care cardiac troponin T measurements (11.0%) had a value ≥50 ng/l, including 966 with acute myocardial infarction (sensitivity: 44.2%, specificity: 92.8%). Patients presenting with a prehospital point-of-care cardiac troponin T value ≥50 ng/l had a one-year mortality of 24% compared with 4.8% in those with values <50 ng/l, log-rank: <0.001. The following variables showed the strongest association with mortality in multivariable analysis: point-of-care cardiac troponin T≥50 ng/l (hazard ratio 2.10, 95% confidence interval: 1.90-2.33), congestive heart failure (hazard ratio 1.93, 95% confidence interval: 1.74-2.14), diabetes mellitus (hazard ratio 1.42, 95% confidence interval: 1.27-1.59) and age, one-year increase (hazard ratio 1.08, 95% confidence interval: 1.08-1.09).
Conclusions
Patients with suspected acute myocardial infarction and a prehospital point-of-care cardiac troponin T ≥50 ng/l have a poor prognosis irrespective of the final diagnosis. Routine troponin measurement in the prehospital setting has a high predictive value and can be used to identify high-risk patients even before hospital arrival so that they may be re-routed directly for advanced care at an invasive centre.



Eur Heart J Acute Cardiovasc Care: 30 May 2019; 8:299-308
Rasmussen MB, Stengaard C, Sørensen JT, Riddervold IS, ... Bøtker HE, Terkelsen CJ
Eur Heart J Acute Cardiovasc Care: 30 May 2019; 8:299-308 | PMID: 29199427
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Impact:
Abstract

Comparison of peri and post-procedural complications in patients undergoing revascularisation of coronary artery multivessel disease by coronary artery bypass grafting or protected percutaneous coronary intervention with the Impella 2.5 device.

Becher T, Baumann S, Eder F, Perschka S, ... Borggrefe M, Akin I
Background
While coronary artery bypass grafting remains the standard treatment of complex multivessel coronary artery disease, the advent of peripheral ventricular assist devices has enhanced the safety of percutaneous coronary intervention. We therefore evaluated the safety in terms of inhospital outcome comparing protected high-risk percutaneous coronary intervention with the Impella 2.5 device and coronary artery bypass grafting in patients with complex multivessel coronary artery disease.
Methods
This retrospective study included patients with complex multivessel coronary artery disease (SYNTAX score >22) undergoing either coronary artery bypass grafting before the implementation of a protected percutaneous coronary intervention programme with a peripheral ventricular assist device or protected percutaneous coronary intervention with the Impella 2.5 device following the start of the programme. The primary endpoint consisted of inhospital major adverse cardiac and cerebrovascular events. The combined secondary endpoint included peri and post-procedural adverse events.
Results
A total of 54 patients (mean age 70.1±9.9 years, 92.6% men) were enrolled in the study with a mean SYNTAX score of 34.5±9.8. Twenty-six (48.1%) patients underwent protected percutaneous coronary intervention while 28 (51.9%) patients received coronary artery bypass grafting. The major adverse cardiac and cerebrovascular event rate was numerically higher in the coronary artery bypass grafting group (17.9 vs. 7.7%; =0.43) but was not statistically significant. The combined secondary endpoint was not different between the groups; however, patients undergoing coronary artery bypass grafting experienced significantly more peri-procedural adverse events (28.6 vs. 3.8%; <0.05).
Conclusion
Patients with complex multivessel coronary artery disease undergoing protected percutaneous coronary intervention with the Impella 2.5 device experience similar intrahospital major adverse cardiac and cerebrovascular event rates when compared to coronary artery bypass grafting. Protected percutaneous coronary intervention represents a safe alternative to coronary artery bypass grafting in terms of inhospital adverse events.



Eur Heart J Acute Cardiovasc Care: 30 May 2019; 8:360-368
Becher T, Baumann S, Eder F, Perschka S, ... Borggrefe M, Akin I
Eur Heart J Acute Cardiovasc Care: 30 May 2019; 8:360-368 | PMID: 28660768
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Impact:
Abstract

Pulse pressure in acute coronary syndromes: Comparative prognostic significance with systolic blood pressure.

Tan NS, Sarak B, Fox KA, Brieger D, ... Yan AT,
Background
Pulse pressure is a readily available vital sign that has been shown to independently predict outcomes in several cardiovascular disease states. We investigated the prognostic significance of pulse pressure (PP) and systolic blood pressure (SBP) among patients with acute coronary syndromes (ACS).
Methods
A total of 14,514 patients with ACS in the prospective, multicentre Global Registry of Acute Coronary Events (GRACE), expanded GRACE (GRACE-2) and Canadian Registry of Acute Coronary Events (CANRACE) were stratified by initial PP on presentation. Patient characteristics and in-hospital outcomes were compared by PP quartiles and the independent prognostic significance of PP for in-hospital mortality was quantified. We compared the discriminative ability (c-statistic) of models incorporating either PP or SBP.
Results
Patients with higher PPs were older, more frequently female and had higher prevalence rates of conventional cardiovascular risk factors (all  < 0.01). Lower PP was associated with ST-segment elevation myocardial infarction presentation, higher GRACE risk scores and higher rates of adverse in-hospital outcomes ( < 0.001). PP was strongly correlated with SBP (Pearson\'s correlation coefficient = 0.79,  < 0.001). After adjustment for other GRACE risk model predictors, lower PP was independently associated with in-hospital mortality (first vs. fourth quartile [reference]: adjusted odds ratio 2.57, 95% confidence interval 1.80-3.67). The c-statistic was slightly higher for the multivariable model incorporating SBP as compared to the model with PP (0.868 vs. 0.864, respectively,  = 0.028) for in-hospital mortality.
Conclusion
Higher presenting PP is associated with increased age and more prevalent cardiovascular risk factors, whereas patients with lower PP present with worse clinical characteristics and in-hospital outcomes. Lower PP is an independent adverse prognosticator in ACS. However, PP did not improve the discriminatory performance of the GRACE risk score compared with SBP.



Eur Heart J Acute Cardiovasc Care: 30 May 2019; 8:309-317
Tan NS, Sarak B, Fox KA, Brieger D, ... Yan AT,
Eur Heart J Acute Cardiovasc Care: 30 May 2019; 8:309-317 | PMID: 28357882
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Impact:
Abstract

Family history of coronary artery disease is associated with acute coronary syndrome in 28,188 chest pain patients.

Wahrenberg A, Magnusson PK, Discacciati A, Ljung L, ... Linder R, Svensson P
Background
The value of family history of coronary artery disease (CAD) in diagnosing acute coronary syndrome (ACS) in chest pain patients is uncertain, especially in relation to high-sensitivity assays for cardiac troponin T (hs-cTnT), which have improved ACS diagnostics. Our objective was to investigate the association between verified family history of CAD and ACS in chest pain patients, overall and in different strata of initial hs-cTnT.
Methods
Data on chest pain patients visiting four emergency departments in Sweden during 2013-2016 were cross-referenced with national registers of kinship, diseases and prescriptions. Family history of early CAD was defined as the occurrence of myocardial infarction or coronary revascularization before the age of 55 years in male and 65 years in female first-degree relatives. The outcome was combined including ACS and cardiovascular death within 30 days of presentation.
Results
Of 28,188 patients, 4.7% of patients had ACS. In total, 8.2% and 32.4% had a family history of early and ever-occurring CAD, respectively. Family history of CAD was positively associated with the outcome, independently of age, gender, cardiovascular risk factors and electrocardiogram findings. The strongest association was observed for family history of early CAD (odds ratio 1.62, 95% confidence interval 1.35-1.94). Stronger associations were observed in young patients (e.g. <65 years) and in patients with non-elevated initial hs-cTnT levels ( p-value for interaction = 0.004 and 0.001, respectively).
Conclusions
Family history of CAD is associated with ACS in chest pain patients, especially in patients of young age or with non-elevated initial hs-cTnT levels.



Eur Heart J Acute Cardiovasc Care: 23 May 2019:2048872619853521; epub ahead of print
Wahrenberg A, Magnusson PK, Discacciati A, Ljung L, ... Linder R, Svensson P
Eur Heart J Acute Cardiovasc Care: 23 May 2019:2048872619853521; epub ahead of print | PMID: 31124704
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Impact:
Abstract

Impact of elevated HbA1c on long-term mortality in patients presenting with acute myocardial infarction in daily clinical practice: insights from a \'real world\' prospective registry of the Zwolle Myocardial Infarction Study Group.

Hermanides RS, Kennedy MW, Kedhi E, van Dijk PR, ... Bilo HJ, van \'t Hof AW
Background
Long-term clinical outcome is less well known in up to presentation persons unknown with diabetes mellitus who present with acute myocardial infarction and elevated glycosylated haemoglobin (HbA1c) levels on admission. We aimed to study the prognostic impact of deranged HbA1c at presentation on long-term mortality in patients not known with diabetes, presenting with acute myocardial infarction.
Methods
A single-centre, large, prospective observational study in patients with and without known diabetes admitted to our hospital for ST-segment elevation myocardial infarction (STEMI) and non-STEMI. Newly diagnosed diabetes mellitus was defined as HbA1c of 48 mmol/l or greater and pre-diabetes mellitus was defined as HbA1c between 39 and 47 mmol/l. The primary endpoint was all-cause mortality at short (30 days) and long-term (median 52 months) follow-up.
Results
Out of 7900 acute myocardial infarction patients studied, 1314 patients (17%) were known diabetes patients. Of the 6586 patients without known diabetes, 3977 (60%) had no diabetes, 2259 (34%) had pre-diabetes and 350 (5%) had newly diagnosed diabetes based on HbA1c on admission. Both short-term (3.9% vs. 7.4% vs. 6.0%, p<0.001) and long-term mortality (19% vs. 26% vs. 35%, p<0.001) for both pre-diabetes patients as well as newly diagnosed diabetes patients was poor and comparable to known diabetes patients. After multivariate analysis, newly diagnosed diabetes was independently associated with long-term mortality (hazard ratio 1.72, 95% confidence interval 1.27-2.34, P=0.001).
Conclusions
In the largest study to date, newly diagnosed or pre-diabetes was present in 33% of acute myocardial infarction patients and was associated with poor long-term clinical outcome. Newly diagnosed diabetes (HbA1c ⩾48 mmol/mol) is an independent predictor of long-term mortality. More attention to early detection of diabetic status and initiation of blood glucose-lowering treatment is necessary.



Eur Heart J Acute Cardiovasc Care: 23 May 2019:2048872619849921; epub ahead of print
Hermanides RS, Kennedy MW, Kedhi E, van Dijk PR, ... Bilo HJ, van 't Hof AW
Eur Heart J Acute Cardiovasc Care: 23 May 2019:2048872619849921; epub ahead of print | PMID: 31124695
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Impact:
Abstract

The prognostic effect of known and newly detected type 2 diabetes in patients with acute coronary syndrome.

Bjarnason TA, Hafthorsson SO, Kristinsdottir LB, Oskarsdottir ES, Johnsen A, Andersen K
Background
Dysglycemia is a well-established risk factor of coronary artery disease. Less is known of the prognostic effect of dysglycemia in acute coronary syndromes (ACSs). The aim of this study was to evaluate the long-term outcome of patients with ACSs according to glucometabolic categories.
Methods
Patients with ACSs were consecutively included in the study. Among those with no previous history of type 2 diabetes (T2DM) glucose metabolism was evaluated with fasting glucose in plasma, glycated hemoglobin and a standard 2-h oral glucose tolerance test. Patients were classified having normal glucose metabolism, prediabetes, newly detected T2DM (nT2DM) and previously known T2DM (kT2DM). The clinical outcome parameters were death or myocardial infarction and other major adverse cardiac events (MACEs).
Results
A total of 372 ACS patients (male 75.8%, 65.1 years (SD: 11.8)) constituted the study population. The proportion diagnosed with normal glucose metabolism, prediabetes, nT2DM and kT2DM was 20.7%, 46.5%, 6.2% and 26.6%, respectively. The mean follow-up period was 2.9 years. Patients with prediabetes, nT2DM and kT2DM had a hazard ratio of 5.8 (95% confidence interval (CI) 0.8-44.6), 10.9 (95% CI 1.2-98.3) and 14.9 (95% CI 2.0-113.7), respectively, for death/myocardial infarction and 1.4 (95% CI 0.6-3.1), 2.9 (95% CI 1.1-8.0) and 3.3 (95% CI 1.5-7.6), respectively, for a composite of MACEs.
Conclusion
Patients with ACS and nT2DM or kT2DM were at increased risk of death/myocardial infarction and MACE compared with patients with normal glucose metabolism after approximately three years of follow-up.



Eur Heart J Acute Cardiovasc Care: 19 May 2019:2048872619849925; epub ahead of print
Bjarnason TA, Hafthorsson SO, Kristinsdottir LB, Oskarsdottir ES, Johnsen A, Andersen K
Eur Heart J Acute Cardiovasc Care: 19 May 2019:2048872619849925; epub ahead of print | PMID: 31107107
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Impact:
Abstract

Revascularisation in older adult patients with non-ST-segment elevation acute coronary syndrome: effect and impact on 6-month mortality.

Bardaji A, Barrabés JA, Ribera A, Bueno H, ... Oristrell G, Ferreira-González I

Although revascularisation in non-ST-segment elevation acute coronary syndrome (NSTEACS) is associated with better outcomes, its impact in older adult patients is unclear. This is a retrospective analyses of three national NSTEACS registries conducted during the past decade in Spain. Patients aged 75 years and older were included: DESCARTES (DES; year 2002; n=534), MASCARA (MAS; 2005; n=1736) and DIOCLES (DIO; 2012; n=593). The adjusted association between revascularisation and total (inhospital and 6-month) mortality was estimated by two-stage meta-analysis (pooled effect across the three registries with inverse-variability weights) and one-stage meta-analysis (multilevel model with random effects across studies). The impact of revascularisation was assessed comparing the observed and the expected mortality based on a logistic regression model in the pooled database. Although revascularisation was associated with a lower risk of mortality in meta-analyses (two-stage: odds ratio 0.44, 95% confidence interval 0.29-0.67; one-stage: odds ratio 0.54, 95% confidence interval 0.36-0.81) and the revascularisation rate increased steadily from 2002 (DES 14.2%) to 2012 (DIO 43.7%), its impact was not patent across registries, probably because this increase was concentrated in low and medium-risk GRACE strata (tertile 1, 2 and 3: MAS 59%, 20% and 6%; DIO 64%, 39% and 19%, respectively). In conclusion, a consistent increase of revascularisation in NSTEACS in older adults was not followed by a decrease in mortality at 6 months, probably because the impact of this strategy is limited to the higher risk population, the stratum with the lowest revascularisation rate in real life.



Eur Heart J Acute Cardiovasc Care: 13 May 2019:2048872619849922; epub ahead of print
Bardaji A, Barrabés JA, Ribera A, Bueno H, ... Oristrell G, Ferreira-González I
Eur Heart J Acute Cardiovasc Care: 13 May 2019:2048872619849922; epub ahead of print | PMID: 31084380
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Impact:
Abstract

Serum potassium level on hospital arrival and survival after out-of-hospital cardiac arrest: The CRITICAL study in Osaka, Japan.

Shida H, Matsuyama T, Iwami T, Okabayashi S, ... Kitamura T, Kawamura T
Background
Little is known about the association between serum potassium level on hospital arrival and neurological outcome after out-of-hospital cardiac arrest (OHCA). We investigated whether the serum potassium level on hospital arrival had prognostic indications for patients with OHCA.
Methods
This prospective, multicenter observational study conducted in Osaka, Japan (CRITICAL study) enrolled consecutive patients with OHCA transported to 14 participating institutions from 2012 to 2016. We included adult patients aged ⩾18 years with OHCA of cardiac origin who achieved return of spontaneous circulation and whose serum potassium level on hospital arrival was available. Based on the serum potassium level, patients were divided into four quartiles: Q1 (K ⩽3.8 mEq/L), Q2 (3.8< K⩽4.5 mEq/L), Q3 (4.5< K⩽5.6 mEq/L) and Q4 (K >5.6 mEq/L). The primary outcome was one-month survival with favorable neurological outcome, defined as cerebral performance category scale 1 or 2.
Results
A total of 9822 patients were registered, and 1516 of these were eligible for analyses. The highest proportion of favorable neurological outcome was 44.8% (189/422) in Q1 group, followed by 30.3% (103/340), 11.7% (44/375) and 4.5% (17/379) in the Q2, Q3 and Q4 groups, respectively ( p<0.001). In the multivariable analysis, the proportion of favorable neurological outcome decreased as the serum potassium level increased ( p<0.001).
Conclusions
High serum potassium level was significantly and dose-dependently associated with poor neurological outcome. Serum potassium on hospital arrival would be one of the effective prognostic indications for OHCA achieving return of spontaneous circulation.



Eur Heart J Acute Cardiovasc Care: 12 May 2019:2048872619848883; epub ahead of print
Shida H, Matsuyama T, Iwami T, Okabayashi S, ... Kitamura T, Kawamura T
Eur Heart J Acute Cardiovasc Care: 12 May 2019:2048872619848883; epub ahead of print | PMID: 31081678
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Impact:
Abstract

Oxygen therapy in suspected acute myocardial infarction and concurrent normoxemic chronic obstructive pulmonary disease: a prespecified subgroup analysis from the DETO2X-AMI trial.

Andell P, James S, Östlund O, Yndigegn T, ... Erlinge D, Hofmann R
Background
The DETermination of the role of Oxygen in suspected Acute Myocardial Infarction (DETO2X-AMI) trial did not find any benefit of oxygen therapy compared to ambient air in normoxemic patients with suspected acute myocardial infarction. Patients with chronic obstructive pulmonary disease may both benefit and be harmed by supplemental oxygen. Thus we evaluated the effect of routine oxygen therapy compared to ambient air in normoxemic chronic obstructive pulmonary disease patients with suspected acute myocardial infarction.
Methods and results
A total of 6629 patients with suspected acute myocardial infarction were randomly assigned in the DETO2X-AMI trial to oxygen or ambient air. In the oxygen group ( n=3311) and the ambient air group ( n=3318), 155 and 141 patients, respectively, had chronic obstructive pulmonary disease (prevalence of 4.5%). Patients with chronic obstructive pulmonary disease were older, had more comorbid conditions and experienced a twofold higher risk of death at one year (chronic obstructive pulmonary disease: 32/296 (10.8%) vs. non-chronic obstructive pulmonary disease: 302/6333 (4.8%)). Oxygen therapy compared to ambient air was not associated with improved outcomes at 365 days (chronic obstructive pulmonary disease: all-cause mortality hazard ratio (HR) 0.99, 95% confidence interval (CI) 0.50-1.99, P=0.96); cardiovascular death HR 0.80, 95% CI 0.32-2.04, P=0.59); rehospitalisation with acute myocardial infarction or death HR 1.27, 95% CI 0.71-2.28, P=0.46); hospitalisation for heart failure or death HR 1.08, 95% CI 0.61-1.91, P=0.77]); there were no significant treatment-by-chronic obstructive pulmonary disease interactions.
Conclusions
Although chronic obstructive pulmonary disease patients had twice the mortality rate compared to non-chronic obstructive pulmonary disease patients, this prespecified subgroup analysis from the DETO2X-AMI trial on oxygen therapy versus ambient air in normoxemic chronic obstructive pulmonary disease patients with suspected acute myocardial infarction revealed no evidence for benefit of routine oxygen therapy consistent with the main trial\'s findings.
Clinical trials registration
NCT02290080.



Eur Heart J Acute Cardiovasc Care: 12 May 2019:2048872619848978; epub ahead of print
Andell P, James S, Östlund O, Yndigegn T, ... Erlinge D, Hofmann R
Eur Heart J Acute Cardiovasc Care: 12 May 2019:2048872619848978; epub ahead of print | PMID: 31081342
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Impact:
Abstract

Incidence, predictors and prognostic impact of intracranial bleeding within the first year after an acute coronary syndrome in patients treated with percutaneous coronary intervention.

Raposeiras-Roubín S, Abu-Assi E, Caneiro Queija B, Cobas Paz R, ... Kedev S, Íñiguez-Romo A
Background
The rate of intracranial haemorrhage after an acute coronary syndrome has been studied in detail in the era of thrombolysis; however, in the contemporary era of percutaneous coronary intervention, most of the data have been derived from clinical trials. With this background, we aim to analyse the incidence, timing, predictors and prognostic impact of post-discharge intracranial haemorrhage in patients with acute coronary syndrome undergoing percutaneous coronary intervention.
Methods
We analysed data from the BleeMACS registry (patients discharged for acute coronary syndrome and undergoing percutaneous coronary intervention from Europe, Asia and America, 2003-2014). Analyses were conducted using a competing risk framework. Uni and multivariate predictors of intracranial haemorrhage were assessed using the Fine-Gray proportional hazards regression analysis. The endpoint was 1-year post-discharge intracranial haemorrhage.
Results
Of 11,136 patients, 30 presented with intracranial haemorrhage during the first year (0.27%). The median time to intracranial haemorrhage was 150 days (interquartile range 55.7-319.5). The fatality rate of intracranial haemorrhage was very high (30%). After multivariate analysis, only age (subhazard ratio 1.05, 95% confidence interval 1.01-1.07) and prior stroke/transient ischaemic attack (hazard ratio 3.29, 95% confidence interval 1.36-8.00) were independently associated with a higher risk of intracranial haemorrhage. Hypertension showed a trend to associate with higher intracranial haemorrhage rate. The combination of older age (⩾75 years), prior stroke/transient ischaemic attack, and/or hypertension allowed us to identify most of the patients with intracranial haemorrhage (86.7%). The annual rate of intracranial haemorrhage was 0.1% in patients with no risk factors, 0.2% in those with one factor, 0.6% in those with two factors and 1.3% in those with three factors.
Conclusion
The incidence of intracranial haemorrhage in the first year after an acute coronary syndrome treated with percutaneous coronary intervention is low. Advanced age, previous stroke/transient ischaemic attack, and hypertension are the main predictors of increased intracranial haemorrhage risk.



Eur Heart J Acute Cardiovasc Care: 30 Apr 2019:2048872619827471; epub ahead of print
Raposeiras-Roubín S, Abu-Assi E, Caneiro Queija B, Cobas Paz R, ... Kedev S, Íñiguez-Romo A
Eur Heart J Acute Cardiovasc Care: 30 Apr 2019:2048872619827471; epub ahead of print | PMID: 31042052
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Impact:
Abstract

Fibrinolysis in left-sided mechanical prosthetic valve thrombosis with high INR.

Nishanth KR, Shankar M, Srinivasa KH, Manjunath CN, Ravindranath KS
Background
A significant number of patients with prosthetic valve thrombosis have a prothrombin time international normalised ratio in the therapeutic range at presentation. Surgery may not be possible in many patients and traditionally a high international normalised ratio is considered a relative contraindication for fibrinolysis.
Methods
We conducted an observational study in patients with left-sided obstructive prosthetic valve thrombosis with international normalised ratio at or above the therapeutic range at presentation who received fibrinolysis. The fibrinolytic regimens, timing of initiation, success of fibrinolysis, risk of major and minor bleeding and ischaemic stroke were evaluated in the study.
Results
Of 30 patients included in the study 70% received immediate fibrinolysis and in 30% it was delayed. The majority of patients (90%) presented with New York Heart Association class III/IV symptoms. The mean international normalised ratio at fibrinolysis was 3.04 ± 0.70 in the immediate group and 2.42 ± 0.89 in the delayed group. Haemodynamically stable patients who had delayed initiation of fibrinolysis had a trend towards less bleeding without an increase in mortality. The rates of intracranial haemorrhage (0% vs. 7.7%), minor bleeding (12.5% vs. 25.1%) and ischaemic stroke (0% vs. 30.7%) were lower in patients who received low dose infusion compared to a conventional dose.
Conclusions
Fibrinolysis can be considered in patients with prosthetic valve thrombosis with high international normalised ratio at presentation. For haemodynamically stable patients, delayed initiation of fibrinolysis is associated with a marginally lower bleeding risk without an increase in mortality. Low dose infusion may be considered over a conventional dose as it is associated with a lower incidence of ischaemic stroke and a good rate of valve function restoration with a trend towards less bleeding.



Eur Heart J Acute Cardiovasc Care: 25 Apr 2019:2048872619846329; epub ahead of print
Nishanth KR, Shankar M, Srinivasa KH, Manjunath CN, Ravindranath KS
Eur Heart J Acute Cardiovasc Care: 25 Apr 2019:2048872619846329; epub ahead of print | PMID: 31025873
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Impact:
Abstract

Riociguat, sildenafil and inhaled nitric oxide reduces pulmonary vascular resistance and improves right ventricular function in a porcine model of acute pulmonary embolism.

Schultz J, Andersen A, Gade IL, Kjaergaard B, Nielsen-Kudsk JE
Background
Pulmonary vasodilators as add-on to current treatment strategies in acute pulmonary embolism may improve right ventricular unloading and hence improve patient outcome. We aimed to investigate whether stimulation of the nitric oxide (NO)-soluble guanylate cyclase (sGC)-cyclic guanosine monophosphate (cGMP) pathway with riociguat, sildenafil or inhaled NO causes pulmonary vasodilation and improves right ventricular function in a porcine model of acute intermediate risk pulmonary embolism.
Methods
Two large autologous blood clots were administered to the pulmonary circulation of 28 pigs (60 kg). Animals were randomized to four increasing, clinically equivalent doses of riociguat ( n=6), sildenafil ( n=6), inhaled NO ( n=6) or vehicle ( n=6). Sham animals ( n=4) did not receive pulmonary embolism or treatment. Haemodynamic responses were evaluated at baseline, after pulmonary embolism and after each dose using invasive pressure measurements, transoesophageal echocardiography, respiratory parameters and blood analysis.
Results
Pulmonary embolism caused a three-fold increase in pulmonary vascular resistance compared with baseline (pulmonary embolism: 352±29 vs. baseline: 107±6 dynes, p<0.0001). All treatments lowered pulmonary vascular resistance compared with vehicle (riociguat: -158±35, sildenafil: -224±35, inhaled NO: -156±35 dynes, p<0.0001). Sildenafil, but neither inhaled NO nor riociguat, caused a decrease in systemic vascular resistance (sildenafil 678±41 vs. vehicle 1081±93 dynes, p=0.02) and increased cardiac output (sildenafil 8.8±0.8 vs. vehicle: 5.9±0.2 L/min, p<0.001). Systemic blood pressure was unaltered in all treatment groups.
Conclusion
Stimulation of the NO-sGC-cGMP pathway by riociguat, sildenafil and inhaled NO reduces pulmonary vascular resistance in a porcine model of acute pulmonary embolism without lowering systemic blood pressure.



Eur Heart J Acute Cardiovasc Care: 25 Apr 2019:2048872619840772; epub ahead of print
Schultz J, Andersen A, Gade IL, Kjaergaard B, Nielsen-Kudsk JE
Eur Heart J Acute Cardiovasc Care: 25 Apr 2019:2048872619840772; epub ahead of print | PMID: 31025569
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Impact:
Abstract

Risk stratification in normotensive acute pulmonary embolism patients: focus on the intermediate-high risk subgroup.

Santos AR, Freitas P, Ferreira J, Oliveira A, ... Campos L, Mendes M
Background
Patients with acute pulmonary embolism are at intermediate-high risk in the presence of imaging signs of right ventricular dysfunction plus one or more elevated cardiac biomarker. We hypothesised that intermediate-high risk patients with two elevated cardiac biomarkers and imaging signs of right ventricular dysfunction have a worse prognosis than those with one cardiac biomarker and imaging signs of right ventricular dysfunction.
Methods
We analysed the cumulative presence of cardiac biomarkers and imaging signs of right ventricular dysfunction in 525 patients with intermediate risk pulmonary embolism (intermediate-high risk = 237) presenting at the emergency department in two centres. Studied endpoints were composites of all-cause mortality and/or rescue thrombolysis at 30 days (primary endpoint; n=58) and pulmonary embolism-related mortality and/or rescue thrombolysis at 30 days (secondary endpoint; n=40).
Results
Patients who experienced the primary endpoint showed a higher proportion of elevated troponin (47% vs. 76%, P<0.001), elevated N-terminal pro-brain natriuretic peptide (67% vs. 93%, P<0.001) and imaging signs of right ventricular dysfunction (47% vs. 80%, P<0.001). Multivariate analysis revealed N-terminal pro-brain natriuretic peptide (hazard ratio (HR) 3.6, 95% confidence interval (CI) 1.3-10.3; P=0.015) and imaging signs of right ventricular dysfunction (HR 2.8, 95% CI 1.5-5.2; P=0.001) as independent predictors of events. In the intermediate-high risk group, patients with two cardiac biomarkers performed worse than those with one cardiac biomarker (HR 3.3, 95% CI 1.8-6.2; P=0.003).
Conclusions
Risk stratification in normotensive pulmonary embolism should consider the cumulative presence of cardiac biomarkers and imaging signs of right ventricular dysfunction, especially in the intermediate-high risk subgroup.



Eur Heart J Acute Cardiovasc Care: 23 Apr 2019:2048872619846506; epub ahead of print
Santos AR, Freitas P, Ferreira J, Oliveira A, ... Campos L, Mendes M
Eur Heart J Acute Cardiovasc Care: 23 Apr 2019:2048872619846506; epub ahead of print | PMID: 31017472
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Impact:
Abstract

Pentraxin-3 vs C-reactive protein and other prognostic biomarkers in acute coronary syndrome: A substudy of the Platelet Inhibition and Patients Outcomes (PLATO) trial.

Kontny F, Andersen T, Ueland T, Åkerblom A, ... Wallentin L,
Aims
We investigated the dynamics, associations with patient characteristics, other biomarkers, and clinical outcomes of pentraxin 3 in acute coronary syndrome.
Methods and results
In multivariate analyses, pentraxin 3 measured in 5154 patients randomised in the Platelet Inhibition and Patients Outcomes (PLATO) trial (NCT00391872) was compared with leukocytes, high-sensitivity C-reactive protein, interleukin-6, cystatin C, N-terminal prohormone brain natriuretic peptide, high-sensitivity troponin T and growth differentiation factor 15 concerning prediction of clinical outcome. Pentraxin 3 peaked earlier than high-sensitivity C-reactive protein and was more strongly correlated with N-terminal prohormone brain natriuretic peptide and high-sensitivity troponin T than with high-sensitivity C-reactive protein. The frequency of cardiovascular death, spontaneous myocardial infarction or stroke by quartiles of pentraxin 3 at admission was 6.1%, 7.3%, 9.7% and 10.7%, respectively ( p<0.0001). The hazard ratio per 50% increase of pentraxin 3 was 1.13 (95% confidence interval: 1.07-1.19), p<0.0001. This association remained significant after stepwise adjustments for leukocytes/high-sensitivity C-reactive protein (1.09 (1.02-1.15)), p=0.009, interleukin-6 (1.07 (1.01-1.14)), p=0.026, and cystatin C (1.07 (1.00-1.13)), p=0.044, but not after adjustment for N-terminal prohormone brain natriuretic peptide, high-sensitivity troponin T and growth differentiation factor 15. Admission pentraxin 3 was also associated with several of the individual endpoint components (cardiovascular death/spontaneous myocardial infarction; p=0.008, cardiovascular death; p=0.026, and spontaneous myocardial infarction; p=0.017), but not with stroke. Pentraxin 3 measured in the chronic phase (i.e. at one month) was still predictive of the composite endpoint in univariate analysis (1.12 (1.04-1.20) per 50% increase) p=0.0024, but not after adjustment for the other biomarkers.
Conclusion
Admission level of pentraxin 3 is a modestly stronger predictor than high-sensitivity C-reactive protein and interleukin-6, but not than N-terminal prohormone brain natriuretic peptide or high-sensitivity troponin T, concerning cardiovascular outcome in acute coronary syndrome. Pentraxin 3 is more strongly correlated with N-terminal prohormone brain natriuretic peptide and high-sensitivity troponin T than with high-sensitivity C-reactive protein.



Eur Heart J Acute Cardiovasc Care: 23 Apr 2019:2048872619846334; epub ahead of print
Kontny F, Andersen T, Ueland T, Åkerblom A, ... Wallentin L,
Eur Heart J Acute Cardiovasc Care: 23 Apr 2019:2048872619846334; epub ahead of print | PMID: 31017470
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Impact:
Abstract

Incremental value of high-frequency QRS analysis for diagnosis and prognosis in suspected exercise-induced myocardial ischaemia.

Schaerli N, Abächerli R, Walter J, Honegger U, ... Mueller C, Reichlin T
Aim
Exercise stress testing is used to detect myocardial ischaemia, but is limited by low sensitivity and specificity. The authors investigated the value of the analysis of high-frequency QRS components as a marker of abnormal depolarization in addition to standard ST-deviations as a marker of abnormal repolarization to improve the diagnostic accuracy.
Methods and results
Consecutive patients undergoing bicycle exercise stress nuclear myocardial perfusion imaging were prospectively enrolled. Presence of myocardial ischaemia, the primary diagnostic endpoint, was adjudicated using MPI and coronary angiography. Automated high-frequency QRS analysis was performed in a blinded fashion. The prognostic endpoint was major adverse cardiac events (MACEs) during two years of follow-up. Exercise-induced ischaemia was detected in 147/662 patients (22%). The sensitivity of high-frequency QRS was similar to ST-deviations (46% vs. 43%, p=0.59), while the specificity was lower (75% vs. 87%, p<0.001). The combined use of high-frequency QRS and ST-deviations classified 59% of patients as \'rule-out\' (both negative), 9% as \'rule-in\' (both positive) and 32% in an intermediate zone (one test positive). The sensitivity for \'rule-out\' and the specificity for \'rule-in\' improved to 63% and 97% compared with ST-deviation analysis alone (both p<0.001). MACE-free survival was 90%, 80% and 42% in patients in the \'rule-out\', intermediate and \'rule-in\' groups ( p<0.001). After adjustment for age, gender, ST-deviations and clinical post-test probability of ischaemia, high-frequency QRS remained an independent predictor for the occurrence of MACEs.
Conclusion
The use of high-frequency QRS analysis in addition to ST-deviation analysis improves the diagnostic accuracy during exercise stress testing and adds independent prognostic information.



Eur Heart J Acute Cardiovasc Care: 21 Apr 2019:2048872619842988; epub ahead of print
Schaerli N, Abächerli R, Walter J, Honegger U, ... Mueller C, Reichlin T
Eur Heart J Acute Cardiovasc Care: 21 Apr 2019:2048872619842988; epub ahead of print | PMID: 31008655
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Impact:
Abstract

Proposal for a standardized discharge letter after hospital stay for acute myocardial infarction.

Schiele F, Lemesle G, Angoulvant D, Krempf M, ... Belle L, Ferrières J

In patients admitted for acute myocardial infarction, the communication and transition from specialists to primary care physicians is often delayed, and the information imparted to subsequent healthcare providers (HCPs) may be sub-optimal. A French group of cardiologists, lipidologists and diabetologists decided to establish a consensus to optimize the discharge letter after hospitalization for acute myocardial infarction. The aim is to improve both the timeframe and the quality of the content transmitted to subsequent HCPs, including information regarding baseline assessment, procedures during hospitalization, residual risk, discharge treatments, therapeutic targets and follow-up recommendations in compliance with European Society of Cardiology guidelines. A consensus was obtained regarding a template discharge letter, to be released within two days after patient\'s discharge, and containing the description of the patient\'s history, risk factors, acute management, risk assessment, discharge treatments and follow-up pathway. Specifically for post acute MI patients, tailored details are necessary regarding the antithrombotic regimen, lipid-lowering and anti-diabetic treatments, including therapeutic targets. Lastly, the follow-up pathway needs to be precisely mentioned in the discharge letter. Additional information such as technical descriptions, imaging, and quality indicators may be provided separately. A template for a standardized discharge letter based on 8 major headings could be useful for implementation in routine practice and help to improve the quality and timing of information transmission between HCPs after acute MI.



Eur Heart J Acute Cardiovasc Care: 15 Apr 2019:2048872619844444; epub ahead of print
Schiele F, Lemesle G, Angoulvant D, Krempf M, ... Belle L, Ferrières J
Eur Heart J Acute Cardiovasc Care: 15 Apr 2019:2048872619844444; epub ahead of print | PMID: 30990337
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Impact:
Abstract

Outcomes of decreasing versus increasing cardiac troponin in patients admitted with non-ST-segment elevation myocardial infarction: the Atherosclerosis Risk in Communities Surveillance Study.

Arora S, Cavender MA, Chang PP, Qamar A, ... Kaul P, Caughey MC
Background
The fourth universal definition of myocardial infarction requires an increase or decrease in cardiac troponin for the classification of non-ST-segment elevation myocardial infarction. We sought to determine whether the characteristics, management, and outcomes of patients admitted with non-ST-segment elevation myocardial infarction differ by the initial biomarker pattern.
Methods
We identified patients in the Atherosclerosis Risk in Communities Surveillance Study admitted with chest pain and an initially elevated cardiac troponin I, who presented within 12 hours of symptom onset and were classified with non-ST-segment elevation myocardial infarction. A change in cardiac troponin I required an absolute difference of at least 0.02 ng/mL on the first day of hospitalization, prior to invasive cardiac procedures.
Results
A total of 1926 hospitalizations met the inclusion criteria, with increasing cardiac troponin I more commonly observed (78%). Patients with decreasing cardiac troponin I were more often black (45% vs. 35%) and women (54% vs. 40%), and were less likely to receive non-aspirin antiplatelets (44% vs. 63%), lipid-lowering agents (62% vs. 80%), and invasive angiography (38% vs. 64%). Inhospital mortality was 3%, irrespective of the cardiac troponin I pattern. However, patients with decreasing cardiac troponin I had twice the 28-day mortality (12% vs. 5%; P=0.01). Fatalities within 28 days were more often attributable to non-cardiovascular causes in those with decreasing versus increasing cardiac troponin I (75% vs. 38%; P=0.01).
Conclusion
Patients presenting with chest pain and an initially elevated cardiac troponin I which subsequently decreases are less often managed by evidence-based therapies and have greater mortality, primarily driven by non-cardiovascular causes. Whether associations are attributable to type 2 myocardial infarction or a subacute presentation merits further investigation.



Eur Heart J Acute Cardiovasc Care: 07 Apr 2019:2048872619842983; epub ahead of print
Arora S, Cavender MA, Chang PP, Qamar A, ... Kaul P, Caughey MC
Eur Heart J Acute Cardiovasc Care: 07 Apr 2019:2048872619842983; epub ahead of print | PMID: 30958029
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Impact:
Abstract

Prognostic value of automated pupillometry: an unselected cohort from a cardiac intensive care unit.

Obling L, Hassager C, Illum C, Grand J, ... Kondziella D, Kjaergaard J
Background:
Patients admitted to a cardiac intensive care unit are often unconscious with uncertain prognosis. Automated infrared pupillometry for neurological assessment in the intensive care unit may provide early prognostic information. This study aimed to determine the prognostic value of automated pupillometry in different subgroups of patients in a cardiac intensive care unit with 30-day mortality as the primary endpoint and neurological outcome as the secondary endpoint.
Methods:
A total of 221 comatose patients were divided into three groups: out-of-hospital cardiac arrest, in-hospital cardiac arrest and others (i.e. patients with cardiac diagnoses other than cardiac arrest). Automated pupillometry was serially performed until discharge or death and pupil measurements were analysed using the neurological pupil index algorithm. We applied receiver operating characteristic curves in univariable and multivariable logistic regression models and a calculated Youden index identified neurological pupil index cut-off values at different specificities.
Results:
In out-of-hospital cardiac arrest patients higher neurological pupil index values were independently associated with lower 30-day mortality. The univariable model for 30-day mortality had an area under the curve of 0.87 and the multivariable model achieved an area under the curve of 0.94. The Youden index identified a neurological pupil index cut-off in out-of-hospital cardiac arrest patients of 2.40 for a specificity of 100%. For patients with in-hospital cardiac arrest and other cardiac diagnoses, we found no association between neurological pupil index values and 30-day mortality, and the univariable models showed poor predictive values.
Conclusion:
Automated infrared pupillometry has promising predictive value after out-of-hospital cardiac arrest, but poor predictive value in patients with in-hospital cardiac arrest or cardiac diagnoses unrelated to cardiac arrest. Our data suggest a possible neurological pupil index cut-off of 2.40 for poor outcome in out-of-hospital cardiac arrest patients.



Eur Heart J Acute Cardiovasc Care: 04 Apr 2019:2048872619842004; epub ahead of print
Obling L, Hassager C, Illum C, Grand J, ... Kondziella D, Kjaergaard J
Eur Heart J Acute Cardiovasc Care: 04 Apr 2019:2048872619842004; epub ahead of print | PMID: 30950641
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Impact:
Abstract

Gender differences in patient and system delay for primary percutaneous coronary intervention: current trends in a Swiss ST-segment elevation myocardial infarction population.

Meyer MR, Bernheim AM, Kurz DJ, O\'Sullivan CJ, ... Rosemann T, Eberli FR
Background
Women with ST-segment elevation myocardial infarction (STEMI) experience greater delays for percutaneous coronary intervention-facilitated reperfusion than men. Whether women and men benefit equally from current strategies to reduce ischaemic time and whether there are gender differences in factors determining delays is unclear.
Methods
Patient delay (symptom onset to first medical contact) and system delay (first medical contact to percutaneous coronary intervention-facilitated reperfusion) were compared between women ( n=967) and men ( n=3393) in a Swiss STEMI treatment network. Trends from 2000 to 2016 were analysed, with additional comparisons between three time periods (2000-2005, 2006-2011 and 2012-2016). Factors predicting delays and hospital mortality were determined by multivariate regression modelling.
Results
Female gender was independently associated with greater patient delay ( P=0.02 vs. men), accounting for a 12% greater total ischaemic time among women in 2012-2016 (median 215 vs. 192 minutes, P<0.001 vs. men). From 2000-2005 to 2012-2016, median system delay was reduced by 18 and 25 minutes in women and men, respectively ( P<0.0001 for trend, P=n.s. for gender difference). Total occlusion of the culprit artery, stent thrombosis, a Killip class of 3 or greater, and presentation during off-hours predicted delays in men, but not in women. A Killip class of 3 or greater and age, but not gender or delays, were independently associated with hospital mortality.
Conclusions
STEMI-related ischaemic time in women remains greater than in men due to persistently greater patient delays. In contrast to men, clinical signs of ongoing chest discomfort do not predict delays in women, suggesting that female STEMI patients are less likely to attribute symptoms to a condition requiring urgent treatment.



Eur Heart J Acute Cardiovasc Care: 30 Mar 2019; 8:283-290
Meyer MR, Bernheim AM, Kurz DJ, O'Sullivan CJ, ... Rosemann T, Eberli FR
Eur Heart J Acute Cardiovasc Care: 30 Mar 2019; 8:283-290 | PMID: 30406673
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Impact:
Abstract

Sex differences in health outcomes at one year following acute myocardial infarction: A report from the China Patient-Centered Evaluative Assessment of Cardiac Events prospective acute myocardial infarction study.

Dreyer RP, Zheng X, Xu X, Liu S, ... Krumholz HM, Jiang L
Background
We examined sex differences in long-term health outcomes following acute myocardial infarction in China, including mortality, major adverse cardiac events and health status (symptoms, functioning, quality of life).
Methods
A total of 3415 acute myocardial infarction patients (23.2% women) aged ⩾18 years were enrolled across 10 geographic regions in China (2012-2014) in the China Patient-Centered Evaluative Assessment of Cardiac Events (PEACE) study. Clinical data was abstracted from medical records. Generic (Euro-Quality of Life Scale) and disease-specific (Seattle Angina Questionnaire) health status was obtained through interviews at baseline and one year.
Results
At one year, women with acute myocardial infarction had a higher risk of death from all causes ( p<0.001), but had similar rates of major adverse cardiac events ( p=0.2). Women had lower mean generic (Euro-Quality of Life Scale utility index score: 0.90±0.13 vs 0.94±0.11) and disease specific health scores indicating poorer functioning (Seattle Angina Questionnaire summary score: 75.3±11.4 vs 78.4±9.7) and higher rates of daily/weekly angina (Seattle Angina Questionnaire angina frequency score ⩽60 vs >60: 9.1% vs 4.7%; all p<0.001). In multivariable analysis, there was a significant association between female sex and mortality (β=0.45, standard error=0.21, p=0.03) but not for major adverse cardiac events (β=-0.02, standard error=0.14, p=0.89). The association between female sex and worse generic health status persisted (β=-0.02, standard error=0.01, p=0.003), but was no longer significant between sexes for disease-specific health status (β=-0.82, standard error=0.58, p=0.154) or daily/weekly angina (odds ratio=1.39; 95% confidence interval 0.88-2.21).
Conclusion
Women in China have higher crude rates of all-cause/cardiovascular death versus men, as well as worse generic/disease specific health status at one-year post-acute myocardial infarction. The association between female sex and worse generic health status persisted following adjustment.



Eur Heart J Acute Cardiovasc Care: 30 Mar 2019; 8:273-282
Dreyer RP, Zheng X, Xu X, Liu S, ... Krumholz HM, Jiang L
Eur Heart J Acute Cardiovasc Care: 30 Mar 2019; 8:273-282 | PMID: 30270637
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Impact:
Abstract

Editor\'s Choice- Impact of insulin-treated diabetes on cardiovascular outcomes following high-risk myocardial infarction.

Rossello X, Ferreira JP, McMurray JJ, Aguilar D, ... Zannad F,
Background
Diabetes is associated with poor cardiovascular outcomes, and insulin-treated patients usually have a worse prognosis than non-insulin-treated subjects. The relationship between insulin treatment and outcomes in high-risk myocardial infarction patients has not been described in a large dataset.
Methods
To investigate the association between insulin-treated diabetes and long-term cardiovascular outcomes in patients with high-risk myocardial infarction, we used adjusted Cox models to compare cardiovascular mortality and hospitalisation among 28,771 patients grouped by diabetes status and insulin treatment from four randomised clinical trials (VALIANT, EPHESUS, OPTIMAAL, CAPRICORN) of acute myocardial infarction complicated by heart failure and/or left ventricular systolic dysfunction.
Results
After an approximately 2-year follow-up, patients with no diabetes (21,386 subjects, 74.3%), non-insulin-treated diabetes (4977 patients, 17.3%) and insulin-treated diabetes (2409 subjects, 8.4%) had an incremental yearly mortality risk (15.8%, 21.3% and 28.1%, respectively). Insulin-treated diabetes patients presented with a higher cardiovascular burden and comorbidities. After adjustment for 18 baseline covariates, patients with non-insulin-treated and insulin-treated diabetes were at higher risk of cardiovascular death (hazard ratio (HR) 1.25, 95% confidence interval (CI) 1.13-1.38 and HR 1.49, 95% CI 1.31-1.69, respectively; P for comparison of non-insulin-treated vs. insulin-treated diabetes =0.016) and cardiovascular hospitalisation (HR 1.33, 95% CI 1.25-1.41 and HR 1.16, 95% CI 1.11-1.22, respectively) compared to patients without diabetes. These results remained consistent after further adjustment for medications and left ventricular ejection fraction.
Conclusions
Insulin-treated diabetes patients had higher event rates than diabetes patients taking oral treatments and patients without diabetes. However, insulin-treated diabetes patients had more comorbidities and atherosclerotic disease, precluding any causality suggestion between insulin treatment and outcomes. This high-risk population may require specific and/or more intense cardiovascular protective therapies.



Eur Heart J Acute Cardiovasc Care: 30 Mar 2019; 8:231-241
Rossello X, Ferreira JP, McMurray JJ, Aguilar D, ... Zannad F,
Eur Heart J Acute Cardiovasc Care: 30 Mar 2019; 8:231-241 | PMID: 30259764
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Impact:
Abstract

Octogenarian women with acute coronary syndrome present frailty and readmissions more frequently than men.

Vicent L, Ariza-Solé A, Alegre O, Sanchís J, ... Abu-Assi E, Martínez-Sellés M
Background
A worse prognosis has been reported among women with acute coronary syndrome compared to men. Our aim was to address the role of frailty and sex in the management and prognosis of elderly patients with non-ST-segment elevation acute coronary syndrome.
Methods
A prospective registry in 44 Spanish hospitals including patients aged 80 years and older with non-ST-segment elevation acute coronary syndrome. Frailty assessment was performed using the FRAIL scale.
Results
Of a total of 535 patients, 207 (38.7%) were women. Mean age was 84.8±4.0 years, similar in men and women. A prior history of coronary artery disease was more common in men (146, 44.9%) than in women (46, 22.2%), P<0.001. Frailty was less frequent in men (65, 20.2%) than in women (77, 37.8%), P<0.001. Female sex was an independent predictor of death/hospitalisation (hazard ratio (HR) 1.7, 95% confidence interval (CI) 1.1-2.4) and of hospitalisation at 6 months (HR 1.6, 95% CI 1.04-2.4). In men, compared to non-frail patients, both a prefrail status (HR 3.47, 95% CI 1.22-9.89) and frailty (HR 3.19, 95% CI 1.08-9.43) were independently associated with higher mortality. In women only frailty was independently associated with higher mortality (HR 5.68, 95% CI 1.91-16.18, compared to prefrailty or robustness). Frailty was associated with readmissions in men (HR 3.34, 95% CI 1.79-6.22) but not in women.
Conclusions
In octogenarians with acute coronary syndrome female sex was independently associated with death/hospitalisation at 6 months. Frailty was more common in women and was a predictor of poor prognosis. In men prefrailty also predicted a poor prognosis.



Eur Heart J Acute Cardiovasc Care: 30 Mar 2019; 8:252-263
Vicent L, Ariza-Solé A, Alegre O, Sanchís J, ... Abu-Assi E, Martínez-Sellés M
Eur Heart J Acute Cardiovasc Care: 30 Mar 2019; 8:252-263 | PMID: 30168725
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Impact:
Abstract

Differences in symptoms, first medical contact and pre-hospital delay times between patients with ST- and non-ST-elevation myocardial infarction.

Ängerud KH, Sederholm Lawesson S, Isaksson RM, Thylén I, Swahn E
Aim
In ST-elevation myocardial infarction, time to reperfusion is crucial for the prognosis. Symptom presentation in myocardial infarction influences pre-hospital delay times but studies about differences in symptoms between patients with ST-elevation myocardial infarction and non-ST-elevation myocardial infarction are sparse and inconclusive. The aim was to compare symptoms, first medical contact and pre-hospital delay times in patients with ST-elevation myocardial infarction and non-ST-elevation myocardial infarction.
Methods and results
This multicentre, observational study included 694 myocardial infarction patients from five hospitals. The patients filled in a questionnaire about their pre-hospital experiences within 24 h of hospital admittance. Chest pain was the most common symptom in ST-elevation myocardial infarction and non-ST-elevation myocardial infarction (88.7 vs 87.0%, p=0.56). Patients with cold sweat (odds ratio 3.61, 95% confidence interval 2.29-5.70), jaw pain (odds ratio 2.41, 95% confidence interval 1.04-5.58), and nausea (odds ratio 1.70, 95% confidence interval 1.01-2.87) were more likely to present with ST-elevation myocardial infarction, whereas the opposite was true for symptoms that come and go (odds ratio 0.58, 95% confidence interval 0.38-0.90) or anxiety (odds ratio 0.52, 95% confidence interval 0.29-0.92). Use of emergency medical services was higher among patients admitted with ST-elevation myocardial infarction. The pre-hospital delay time from symptom onset to first medical contact was significantly longer in non-ST-elevation myocardial infarction (2:05 h vs 1:10 h, p=0.001).
Conclusion
Patients with ST-elevation myocardial infarction differed from those with non-ST-elevation myocardial infarction regarding symptom presentation, ambulance utilisation and pre-hospital delay times. This knowledge is important to be aware of for all healthcare personnel and the general public especially in order to recognise symptoms suggestive of ST-elevation myocardial infarction and when to decide if there is a need for an ambulance.



Eur Heart J Acute Cardiovasc Care: 30 Mar 2019; 8:201-207
Ängerud KH, Sederholm Lawesson S, Isaksson RM, Thylén I, Swahn E
Eur Heart J Acute Cardiovasc Care: 30 Mar 2019; 8:201-207 | PMID: 29111768
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Impact:
Abstract

Clinical outcomes following primary percutaneous coronary intervention for ST-elevation myocardial infarction according to sex and race.

Krishnamurthy A, Keeble C, Burton-Wood N, Somers K, ... Wheatcroft SB, Greenwood JP
Background
Female sex and South Asian race have been associated with poor clinical outcomes following primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) but remain understudied in large real-world series. We therefore investigated the association of sex and race with clinical outcomes following PPCI.
Methods
We conducted a prospective study of all patients undergoing PPCI for STEMI between January 2009 and December 2011 at a large UK cardiac centre. Clinical characteristics and outcomes were compared according to sex and race using Chi-square test, independent samples Student\'s t-test and Mann-Whitney U-test. Primary and secondary outcomes were 12-month major adverse cardiovascular events (MACEs) - defined as all-cause mortality, myocardial infarction and unplanned revascularization, analysed using Cox proportional hazard models adjusting for cardiovascular risk factors.
Results
Three thousand and forty-nine patients were included. Women ( n=826) were older than men ( n=2223) (median age 69 vs. 60 years, p <0.01). Mortality (hazard ratio 1.48 (1.15-1.90)) and MACE (hazard ratio 1.40 (1.14-1.72)) were higher in women in univariable analysis. However, there were no significant sex-differences in mortality or MACE after age-stratification alone. Multivariable analysis also showed no significant differences in outcomes between sexes. South Asians ( n=297) were younger but had a higher prevalence of most risk factors than White patients ( n=2570). Mortality and MACE did not differ significantly between South Asian and White patients in univariable or multivariable analysis.
Conclusion
MACE and mortality was not greater in women, or in South Asian patients following PPCI after adjustment for cardiovascular risk factors including age, which was most strongly associated with both outcomes.



Eur Heart J Acute Cardiovasc Care: 30 Mar 2019; 8:264-272
Krishnamurthy A, Keeble C, Burton-Wood N, Somers K, ... Wheatcroft SB, Greenwood JP
Eur Heart J Acute Cardiovasc Care: 30 Mar 2019; 8:264-272 | PMID: 28980483
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Impact:
Abstract

Clinical impact and predictors of complete ST segment resolution after primary percutaneous coronary intervention: A subanalysis of the ATLANTIC Trial.

Fabris E, van \'t Hof A, Hamm CW, Lapostolle F, ... Vicaut E, Montalescot G
Background
In the ATLANTIC (Administration of Ticagrelor in the catheterization laboratory or in the Ambulance for New ST elevation myocardial Infarction to open the Coronary artery) trial the early use of aspirin, anticoagulation, and ticagrelor coupled with very short medical contact-to-balloon times represent good indicators of optimal treatment of ST-elevation myocardial infarction and an ideal setting to explore which factors may influence coronary reperfusion beyond a well-established pre-hospital system.
Methods
This study sought to evaluate predictors of complete ST-segment resolution after percutaneous coronary intervention in ST-elevation myocardial infarction patients enrolled in the ATLANTIC trial. ST-segment analysis was performed on electrocardiograms recorded at the time of inclusion (pre-hospital electrocardiogram), and one hour after percutaneous coronary intervention (post-percutaneous coronary intervention electrocardiogram) by an independent core laboratory. Complete ST-segment resolution was defined as ≥70% ST-segment resolution.
Results
Complete ST-segment resolution occurred post-percutaneous coronary intervention in 54.9% ( n=800/1456) of patients and predicted lower 30-day composite major adverse cardiovascular and cerebrovascular events (odds ratio 0.35, 95% confidence interval 0.19-0.65; p<0.01), definite stent thrombosis (odds ratio 0.18, 95% confidence interval 0.02-0.88; p=0.03), and total mortality (odds ratio 0.43, 95% confidence interval 0.19-0.97; p=0.04). In multivariate analysis, independent negative predictors of complete ST-segment resolution were the time from symptoms to pre-hospital electrocardiogram (odds ratio 0.91, 95% confidence interval 0.85-0.98; p<0.01) and diabetes mellitus (odds ratio 0.6, 95% confidence interval 0.44-0.83; p<0.01); pre-hospital ticagrelor treatment showed a favorable trend for complete ST-segment resolution (odds ratio 1.22, 95% confidence interval 0.99-1.51; p=0.06).
Conclusions
This study confirmed that post-percutaneous coronary intervention complete ST-segment resolution is a valid surrogate marker for cardiovascular clinical outcomes. In the current era of ST-elevation myocardial infarction reperfusion, patients\' delay and diabetes mellitus are independent predictors of poor reperfusion and need specific attention in the future.



Eur Heart J Acute Cardiovasc Care: 30 Mar 2019; 8:208-217
Fabris E, van 't Hof A, Hamm CW, Lapostolle F, ... Vicaut E, Montalescot G
Eur Heart J Acute Cardiovasc Care: 30 Mar 2019; 8:208-217 | PMID: 28841028
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Abstract

Management of myocardial infarction in the elderly. Insights from Spanish Minimum Basic Data Set.

Ariza-Solé A, Alegre O, Elola FJ, Fernández C, ... Lorente V, Cequier A
Background
We aimed to assess the impact of implementation of reperfusion networks, the type of hospital and specialty of the treating physician on the management and outcomes of ST segment elevation myocardial infarction in patients aged ⩾75 years.
Methods
We analysed data from the Minimum Basic Data Set of the Spanish public health system, assessing hospital discharges between 2004 and 2013. Discharges were distributed in three groups depending on the clinical management: percutaneous coronary intervention, thrombolysis or no reperfusion. Primary outcome measure was all cause in-hospital mortality. For risk adjustment, patient comorbidities were identified for each index hospitalization.
Results
We identified 299,929 discharges, of whom 107,890 (36%) were in-patients aged ⩾75 years. Older patients had higher prevalence of comorbidities, were less often treated in high complexity hospitals and were less frequently managed by cardiologists ( p<0.001). Both percutaneous coronary intervention and fibrinolysis were less often performed in elderly patients ( p<0.001). A progressive increase in the rate of percutaneous coronary intervention was observed in the elderly across the study period (from 17% in 2004 to 45% in 2013, p<0.001), with a progressive reduction of crude mortality (from 23% in 2004 to 19% in 2013, p<0.001). Adjusted analysis showed an association between being treated in high complexity hospitals, being treated by cardiologists and lower in-hospital mortality ( p <0.001).
Conclusions
Elderly patients with ST segment elevation myocardial infarction are less often managed in high complexity hospitals and less often treated by cardiologists. Both factors are associated with higher in-hospital mortality.



Eur Heart J Acute Cardiovasc Care: 30 Mar 2019; 8:242-251
Ariza-Solé A, Alegre O, Elola FJ, Fernández C, ... Lorente V, Cequier A
Eur Heart J Acute Cardiovasc Care: 30 Mar 2019; 8:242-251 | PMID: 28714314
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Impact:
Abstract

Increased mortality risk in diabetic patients discharged from hospital with insulin therapy after an acute myocardial infarction: Data from the FAST-MI 2005 registry.

Bataille V, Ferrières J, Danchin N, Puymirat E, ... Simon T, Carrié D
Background
Merits of insulin use for diabetes treatment in patients with advanced atherosclerosis are debated. This observational study conducted in diabetic patients after an acute myocardial infarction aimed to assess whether insulin prescription at discharge (IPD) was related to all-cause mortality during follow-up.
Methods
Subjects were diabetic patients admitted in intensive- or coronary-care units for acute myocardial infarction (consecutively recruited in 223 centres in France) and discharged alive from the hospital, with or without an IPD. Vital status after five years was obtained and the relationship between insulin prescription at discharge and survival was studied.
Results
Overall, 1221 diabetic patients were discharged alive and 38% had an IPD. Factors independently related to IPD were female gender, hospitalization in a public hospital, duration of diabetes, HbA1c level, smoking, peripheral artery disease, history of coronary heart disease and Killip class. After adjustment, IPD was independently related to all-cause mortality after five years of follow-up (adjusted hazard ratio = 1.72 (1.42-2.09), p<0.001). This increased mortality in subjects with IPD was also observed in propensity matched analyses, when subjects actually treated or actually not treated with insulin at discharge were compared in two groups matched on their computed probability of having had insulin prescribed.
Conclusions
Insulin was preferably prescribed in seriously affected patients, regarding diabetes and cardiovascular risk. However, insulin prescription at discharge was associated with increased all-cause mortality after extensive adjustments for confounders. These results suggest possible intrinsic harmful effects of insulin in high-risk diabetic patients after myocardial infarction.



Eur Heart J Acute Cardiovasc Care: 30 Mar 2019; 8:218-230
Bataille V, Ferrières J, Danchin N, Puymirat E, ... Simon T, Carrié D
Eur Heart J Acute Cardiovasc Care: 30 Mar 2019; 8:218-230 | PMID: 28691497
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Impact:
Abstract

Mitochondrial dysfunction in adults after out-of-hospital cardiac arrest.

Wiberg S, Stride N, Bro-Jeppesen J, Holmberg MJ, ... Hassager C, Dela F
Background:
While preclinical studies suggest that mitochondria play a pivotal role in ischaemia-reperfusion injury, the knowledge of mitochondrial function in human out-of-hospital cardiac arrest remains scarce. The present study sought to compare oxidative phosphorylation capacity in skeletal muscle biopsies from out-of-hospital cardiac arrest patients to healthy controls.
Methods:
This was a substudy of a randomised trial comparing targeted temperature management at 33°C versus 36°C for out-of-hospital cardiac arrest patients. Skeletal muscle biopsies were obtained from adult resuscitated comatose out-of-hospital cardiac arrest patients 28 hours after initiation of targeted temperature management, i.e. at target temperature prior to rewarming, and from age-matched healthy controls. Mitochondrial function was analysed by high-resolution respirometry. Maximal sustained respiration through complex I, maximal coupled respiration through complex I and complex II and maximal electron transport system capacity was compared.
Results:
A total of 20 out-of-hospital cardiac arrest patients and 21 controls were included in the analysis. We found no difference in mitochondrial function between temperature allocations. We found no difference in complex I sustained respiration between out-of-hospital cardiac arrest and controls (23 (18-26) vs. 22 (19-26) pmol O/mg/s, P=0.76), whereas coupled complex I and complex II respiration was significantly lower in out-of-hospital cardiac arrest patients versus controls (53 (42-59) vs. 64 (54-68) pmol O/mg/s, P=0.01). Furthermore, electron transport system capacity was lower in out-of-hospital cardiac arrest versus controls (63 (51-69) vs. 73 (66-78) pmol O/mg/s, P=0.005).
Conclusions:
Mitochondrial oxidative phosphorylation capacity in skeletal muscle biopsies was reduced in out-of-hospital cardiac arrest patients undergoing targeted temperature management compared to age-matched, healthy controls. The role of mitochondria as risk markers and potential targets for post-resuscitation care remains unknown.



Eur Heart J Acute Cardiovasc Care: 10 Mar 2019:2048872618814700; epub ahead of print
Wiberg S, Stride N, Bro-Jeppesen J, Holmberg MJ, ... Hassager C, Dela F
Eur Heart J Acute Cardiovasc Care: 10 Mar 2019:2048872618814700; epub ahead of print | PMID: 30854867
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Impact:
Abstract

Editor\'s Choice- Reperfusion cardiac arrhythmias and their relation to reperfusion-induced cell death.

van der Weg K, Prinzen FW, Gorgels AP

Reperfusion does not only salvage ischaemic myocardium but can also cause additional cell death which is called lethal reperfusion injury. The time of reperfusion is often accompanied by ventricular arrhythmias, i.e. reperfusion arrhythmias. While both conditions are seen as separate processes, recent research has shown that reperfusion arrhythmias are related to larger infarct size. The pathophysiology of fatal reperfusion injury revolves around intracellular calcium overload and reactive oxidative species inducing apoptosis by opening of the mitochondrial protein transition pore. The pathophysiological basis for reperfusion arrhythmias is the same intracellular calcium overload as that causing fatal reperfusion injury. Therefore both conditions should not be seen as separate entities but as one and the same process resulting in two different visible effects. Reperfusion arrhythmias could therefore be seen as a potential marker for fatal reperfusion injury.



Eur Heart J Acute Cardiovasc Care: 27 Feb 2019; 8:142-152
van der Weg K, Prinzen FW, Gorgels AP
Eur Heart J Acute Cardiovasc Care: 27 Feb 2019; 8:142-152 | PMID: 30421619
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Abstract

Atrial fibrillation detected initially during acute medical illness: A systematic review.

McIntyre WF, Um KJ, Cheung CC, Belley-Côté EP, ... Seifer CM, Healey JS
Objective:
There is uncertainty about the incidence of and prognosis associated with atrial fibrillation that is documented for the first time in the setting of an acute stressor, such as surgery or medical illness. Our objective was to perform a systematic review of the incidence and long-term recurrence rates for atrial fibrillation occurring transiently with stress in the setting of acute medical illness.
Data sources:
Medline, Embase and Cochrane Central to September 2017.
Study selection:
We included retrospective and prospective observational studies, and randomised controlled trials. The population of interest included patients hospitalised for medical (i.e. non-surgical) illness who developed newly diagnosed atrial fibrillation. Studies were included if they included data on either the incidence of atrial fibrillation or the rate of atrial fibrillation recurrence in atrial fibrillation occurring transiently with stress patients following hospital discharge.
Data extraction:
Two reviewers collected data independently and in duplicate. We characterised each study\'s methodology for ascertainment of prior atrial fibrillation history, atrial fibrillation during hospitalisation and atrial fibrillation recurrence after hospital discharge.
Data synthesis:
Thirty-six studies reported the incidence of atrial fibrillation. Ten used a prospective design and included a period of continuous electrocardiographic (ECG) monitoring. Atrial fibrillation incidence ranged from 1% to 44%, which was too heterogeneous to justify meta-analysis ( I=99%). In post-hoc meta-regression models, the use of continuous ECG monitoring explained 13% of the variance in atrial fibrillation incidence, while care in an intensive care unit explained none. Two studies reported the long-term rate of atrial fibrillation recurrence following atrial fibrillation occurring transiently with stress. Neither of these studies used prospective, systematic monitoring. Recurrence rates at 5 years ranged from 42% to 68%.
Conclusions:
The incidence of atrial fibrillation with medical illness may be as high as 44%, with higher estimates in reports using continuous ECG monitoring. Within 5 years following hospital discharge, atrial fibrillation recurrence is documented in approximately half of patients; however, the true rate may be higher.
Protocol registration
PROSPERO CRD42016043240.



Eur Heart J Acute Cardiovasc Care: 27 Feb 2019; 8:130-141
McIntyre WF, Um KJ, Cheung CC, Belley-Côté EP, ... Seifer CM, Healey JS
Eur Heart J Acute Cardiovasc Care: 27 Feb 2019; 8:130-141 | PMID: 30403364
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Impact:
Abstract

Right bundle branch block in patients with suspected myocardial infarction.

Neumann JT, Sörensen NA, Rübsamen N, Ojeda F, ... Clemmensen P, Westermann D
Aims:
The new European Society of Cardiology guideline for ST-segment elevation myocardial infarction recommends that left and right bundle branch block should be considered equal for recommending urgent angiography in patients with suspected myocardial infarction. We aimed to evaluate this novel recommendation in two prospective studies of patients with suspected myocardial infarction.
Methods and results:
We included 4067 patients presenting to the emergency department with suspected myocardial infarction. All patients had an ECG recorded immediately upon admission. Patients were classified as having right bundle branch block (RBBB), left bundle branch block (LBBB), bifascicular block (BFB) or no bundle branch block. All patients were followed for up to two years to assess mortality. In the overall population 125 (3.1%) patients had RBBB, 281 (6.9%) LBBB and 60 (1.5%) BFB. The final diagnosis of myocardial infarction was adjudicated in 20.8% (RBBB), 28.5% (LBBB), 23.3% (BFB) and 21.6% (no complete block) of patients. The mortality rate after one year was 10.7% (RBBB), 7% (LBBB), 17.5% (BFB) and 3.2% (no complete block). The adjusted hazard ratios were 1.29 (95% confidence interval (CI) 0.71-2.34; P=0.40) for RBBB, 1.71 (95% CI 1.17-2.50; P=0.006) for LBBB and 2.27 (95% CI 1.28-4.05; P=0.005) for BFB.
Conclusion:
Our results support the new European Society of Cardiology ST-segment elevation myocardial infarction guideline describing RBBB as a high risk for mortality in patients with suspected myocardial infarction. However, the data challenge the concept of RBBB as a trigger of acute angiography because the likelihood of myocardial infarction in a chest pain unit setting is equally frequent in patients without bundle branch block.



Eur Heart J Acute Cardiovasc Care: 27 Feb 2019; 8:161-166
Neumann JT, Sörensen NA, Rübsamen N, Ojeda F, ... Clemmensen P, Westermann D
Eur Heart J Acute Cardiovasc Care: 27 Feb 2019; 8:161-166 | PMID: 30362813
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Impact:
Abstract

Edoxaban in atrial fibrillation patients with established coronary artery disease: Insights from ENGAGE AF-TIMI 48.

Zelniker TA, Ruff CT, Wiviott SD, Blanc JJ, ... Braunwald E, Giugliano RP
Background:
The relative efficacy and safety profile of the oral Factor Xa inhibitor edoxaban compared with warfarin in patients with atrial fibrillation and established coronary artery disease (CAD) has not been analyzed.
Materials and methods:
In the ENGAGE AF-TIMI 48 trial, two edoxaban regimens were compared with warfarin in 21,105 patients with atrial fibrillation and CHADS ⩾2. We analyzed the primary trial endpoints (efficacy: stroke or systemic embolic event, safety: International Society on Thrombosis and Haemostasis major bleeding) in patients with versus without CAD, and used interaction testing to assess for treatment effect modification.
Results:
The 4510 patients (21.4%) with known CAD were older, more likely male, on aspirin, with lower creatinine clearance and higher CHADS and HAS-BLED scores ( p <0.001 for each). Treatment with the higher-dose edoxaban regimen (versus warfarin) in patients with known CAD tended to have a greater reduction in stroke/systemic embolic event compared with patients without CAD (CAD: hazard ratio 0.65 (0.46-0.92) versus no CAD: hazard ratio 0.94 (0.79-1.12), p-INT 0.062) and also in myocardial infarction (CAD: hazard ratio 0.69 (0.49-0.98) versus no CAD: hazard ratio 1.24 (0.89-1.72), p-INT 0.017), while there was a similar reduction in bleeding irrespective of CAD status (hazard ratio 0.81 and 0.80, p-INT 0.97). Presence or absence of CAD did not modify the efficacy or safety profile of the lower-dose edoxaban regimen (versus warfarin).
Conclusion:
The reduction in ischemic events with the higher-dose edoxaban regimen versus warfarin was greater in patients with CAD, while bleeding was significantly reduced with edoxaban regardless of CAD status. The efficacy and safety profile of the lower-dose edoxaban regimen relative to warfarin was unaffected by CAD status.



Eur Heart J Acute Cardiovasc Care: 27 Feb 2019; 8:176-185
Zelniker TA, Ruff CT, Wiviott SD, Blanc JJ, ... Braunwald E, Giugliano RP
Eur Heart J Acute Cardiovasc Care: 27 Feb 2019; 8:176-185 | PMID: 30039978
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Impact:
Abstract

Cardiac arrest as an age-dependent prognosticator for long-term mortality after acute myocardial infarction: the potential impact of infarction size.

Sulzgruber P, Schnaubelt S, Koller L, Goliasch G, ... Wojta J, Niessner A
Background:
The development of cardiac arrhythmias resulting in cardiac arrest represents a severe complication in patients with acute myocardial infarction. While the worsening of the prognosis in this vulnerable patient collective is well known, less attention has been paid to its age-specific relevance from a long-term perspective.
Methods:
Based on a clinical acute myocardial infarction registry we analysed 832 patients with acute myocardial infarction within the current analysis. Patients were stratified into equal groups ( n=208 per group) according to age in less than 45 years, 45-64 years, 65-84 years and 85 years and older via propensity score matching. Multivariate Cox regression analysis was used to assess the age-dependent influence of cardiac arrest on mortality.
Results:
The total number of cardiac arrests differed significantly between age groups, demonstrating the highest incidence in the youngest population with 18.8% ( n=39), and a significantly lower incidence by increasing age (-11.6%; P=0.01). After a mean follow-up time of 8 years, a total of 264 patients (31.7%) died due to cardiovascular causes. While cardiac arrest was a strong and independent predictor for mortality within the total study population with an adjusted hazard ratio of 3.21 (95% confidence interval 2.23-4.61; P<0.001), there was no significant association with mortality independently in very young patients (<45 years; adjusted hazard ratio of 1.73, 95% confidence interval 0.55-5.53; P=0.35).
Conclusion:
We found that arrhythmias resulting in cardiac arrest are more common in very young acute myocardial infarction patients (<45 years) compared to their older counterparts, and were able to demonstrate that the prognostic value of cardiac arrest on long-term mortality in patients with acute myocardial infarction is clearly age dependent.



Eur Heart J Acute Cardiovasc Care: 27 Feb 2019; 8:153-160
Sulzgruber P, Schnaubelt S, Koller L, Goliasch G, ... Wojta J, Niessner A
Eur Heart J Acute Cardiovasc Care: 27 Feb 2019; 8:153-160 | PMID: 29856229
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Abstract

Impact of known or new-onset atrial fibrillation on 2-year cardiovascular event rate in patients with acute coronary syndromes: results from the prospective EPICOR Registry.

Zeymer U, Annemans L, Danchin N, Pocock S, ... Medina J, Bueno H
Background:
Atrial fibrillation (AF) is associated with increased morbidity in acute coronary syndrome patients, but impact on outcomes beyond 1 year is unclear.
Methods:
This was a post-hoc analysis from the long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients (EPICOR) registry (NCT01171404), a prospective, observational study conducted in Europe and Latin America, which enrolled acute coronary syndrome survivors at discharge. Antithrombotic management patterns, mortality, a composite endpoint of death/new non-fatal myocardial infarction/stroke and bleeding events were assessed after 2 years of follow-up in patients with or without AF.
Results:
Of 10,568 patients enrolled, 397 (4.7%) had prior AF and 382 (3.6%) new-onset AF during index hospitalisation. Fewer patients with AF underwent percutaneous coronary intervention (52.1% vs. 66.6%; P<0.0001). At discharge, fewer AF patients received dual antiplatelet therapy (71.6% vs. 89.5%; P<0.0001); oral anticoagulant use was higher in AF patients but was still infrequent (35.0% vs. 2.5%; P<0.0001). Use of dual antiplatelet therapy and oral anticoagulants declined over follow-up with over 50% of all AF/no AF patients remaining on dual antiplatelet therapy (55.6% vs. 60.6%), and 23.3% (new-onset AF) to 42.1% (prior AF) on oral anticoagulants at 2 years. At 2 years, mortality, composite endpoint and bleeding rates were higher in AF patients (all P<0.0001) compared to patients without AF. On multivariable analysis, the risk of mortality or the composite endpoint was significant for prior AF ( P=0.003, P=0.001) but not new-onset AF ( P=0.88, P=0.92).
Conclusions:
Acute coronary syndrome patients with AF represent a high-risk group with increased event rates during long-term follow-up. Prior AF is an independent predictor of mortality and/or ischaemic events at 2 years. Use of anticoagulants in AF after acute coronary syndrome is still suboptimal.



Eur Heart J Acute Cardiovasc Care: 27 Feb 2019; 8:121-129
Zeymer U, Annemans L, Danchin N, Pocock S, ... Medina J, Bueno H
Eur Heart J Acute Cardiovasc Care: 27 Feb 2019; 8:121-129 | PMID: 29611427
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Abstract

Editor\'s Choice- Sedation in the coronary intensive care unit: An adapted algorithm for critically ill cardiovascular patient.

Schenone AL, Chen K, Andress K, Militello M, Cho L

In the current era, cardiovascular intensive care units care for more complex patients who are far sicker than historical post-myocardial infarction patients, and sedation has become a common intervention in these units. Current sedation best practices derive mainly from non-cardiac units which limits their generalization to the critically ill cardiac patient. Thus, a great variability in sedation protocols, especially the selection of sedative agents, is commonly seen in daily practice across cardiac units. We present an updated review on sedation in cardiovascular critical care medicine with emphasis on the hemodynamic impact. The goal of this review is to generate a general sedation algorithm specific for the cardiac patient.



Eur Heart J Acute Cardiovasc Care: 27 Feb 2019; 8:167-175
Schenone AL, Chen K, Andress K, Militello M, Cho L
Eur Heart J Acute Cardiovasc Care: 27 Feb 2019; 8:167-175 | PMID: 29392967
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Abstract

Safety and efficacy of rivaroxaban for the secondary prevention following acute coronary syndromes among biomarker-positive patients: Insights from the ATLAS ACS 2-TIMI 51 trial.

Korjian S, Braunwald E, Daaboul Y, Verheugt F, ... Burton P, Gibson CM
Background:
Despite dual antiplatelet therapy, persistent thrombin generation and thrombin-mediated platelet activation account in part for the residual risk of atherothrombotic disease among patients with prior acute coronary syndrome (ACS). Inhibition of thrombin generation among high-risk ACS patients (biomarker-positive ACS) with the factor Xa inhibitor rivaroxaban may limit ongoing thrombus formation and myocardial necrosis and thereby improve clinical outcomes.
Objectives and methods:
ATLAS ACS 2-TIMI 51 was a double-blind, placebo-controlled clinical trial that randomized ACS patients to either rivaroxaban 2.5 mg b.i.d., rivaroxaban 5 mg b.i.d., or placebo plus standard-of-care antiplatelet therapy for a mean of 13.1 months and up to 31 months ( N=15,526). This post-hoc analysis evaluates the safety and efficacy of rivaroxaban among biomarker-positive ACS patients with and without a history of prior stroke of transient ischemic attack in the ATLAS ACS 2-TIMI 51 trial.
Results:
A total of 12,626 biomarker-positive ACS patients were included in this analysis. Among biomarker-positive patients without a prior history of stroke or transient ischemic attack, rivaroxaban 2.5 b.i.d. was associated with a reduction in the primary efficacy endpoint (composite of cardiovascular death, myocardial infarction, or stroke) as compared with placebo (hazard ratio=0.80, 95% confidence interval (0.68-0.94), p=0.007) at the expense of an increase in non-coronary-artery-bypass-graft-related Thrombolysis in Myocardial Infarction major bleeding (1.9% vs. 0.7%, p<0.0001), but not a significant increase in either intracranial hemorrhage (0.4% vs. 0.2%, p=0.11) or fatal bleeding (0.1% vs. 0.3%, p=0.16).
Conclusion:
Rivaroxaban 2.5 mg b.i.d. was associated with a significant reduction in the composite of cardiovascular death, myocardial infarction, or stroke with no increase in fatal bleeding. Biomarker-positive patients with no prior history of stroke or transient ischemic attack may be a optimal target population to receive \"dual pathway\" therapy with rivaroxaban plus dual antiplatelet therapy for secondary prevention following ACS.



Eur Heart J Acute Cardiovasc Care: 27 Feb 2019; 8:186-193
Korjian S, Braunwald E, Daaboul Y, Verheugt F, ... Burton P, Gibson CM
Eur Heart J Acute Cardiovasc Care: 27 Feb 2019; 8:186-193 | PMID: 29249166
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Abstract

Intravenous vernakalant in comparison with intravenous flecainide in the cardioversion of recent-onset atrial fibrillation.

Pohjantähti-Maaroos H, Hyppölä H, Lekkala M, Sinisalo E, Heikkola A, Hartikainen J
Background:
Pharmacological cardioversion of atrial fibrillation is a reasonable alternative for electrical cardioversion in acute atrial fibrillation. We compared the efficacy and safety of intravenous vernakalant and intravenous flecainide in patients with recent-onset (< 48 h) atrial fibrillation.
Methods:
A total of 200 consecutive patients, 100 patients undergoing cardioversion with intravenous vernakalant and 100 patients undergoing cardioversion with intravenous flecainide, were included in this single centre non-randomized retrospective study. The primary endpoint was conversion to sinus rhythm within 120 minutes from the drug administration.
Results:
Cardioversion was successful in 67% of patients treated with vernakalant and in 46% of patients treated with flecainide ( p=0.003). Vernakalant (odds ratio 1.99, 95% confidence interval 1.08-3.69, p=0.029) and female gender (odds ratio 2.48, 95% confidence interval 1.22-15.05, p=0.012) were significant predictors of successful cardioversion. The success rate of cardioversion was lowest among men treated with flecainide (36.9%). Patients treated with vernakalant were discharged earlier from the emergency department compared with those treated with flecainide (8.2 ± 4.7 h vs. 12.0 ± 6.0 h, p < 0.001). There was no difference in the complication rate between the groups. Vernakalant treated patients were older (59.3 ± 12.5 vs. 55.4 ± 13.0 years, p=0.03), had higher CHADS-VASc score (1.4 ± 1.3 vs. 0.9 ± 1.2, p = 0.002) and were more often on beta-blocker medication (59% vs. 42%, p= 0.016) than flecainide treated patients.
Conclusion:
Vernakalant was safe, more effective and faster than flecainide in the cardioversion of recent-onset atrial fibrillation. The difference in efficacy was especially apparent among men.



Eur Heart J Acute Cardiovasc Care: 27 Feb 2019; 8:114-120
Pohjantähti-Maaroos H, Hyppölä H, Lekkala M, Sinisalo E, Heikkola A, Hartikainen J
Eur Heart J Acute Cardiovasc Care: 27 Feb 2019; 8:114-120 | PMID: 28849946
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Abstract

Echocardiography is useful to predict postoperative atrial fibrillation in patients undergoing isolated coronary bypass surgery: A prospective study.

Magne J, Salerno B, Mohty D, Serena C, ... Le Guyader A, Aboyans V
Objective:
Postoperative atrial fibrillation is a major complication following coronary artery bypass graft. We hypothesized that, beyond clinical and electrocardiogram (ECG) data, transthoracic echocardiography could improve the prediction of postoperative atrial fibrillation.
Methods:
We prospectively studied 169 patients in sinus rhythm who underwent isolated coronary artery bypass graft in our institution. Clinical, biological, ECG and transthoracic echocardiography data were collected within 24 h before surgery. The patients were continuously monitored during the first five days, and then had daily 12-lead ECG afterwards until discharge. Postoperative atrial fibrillation was defined by any episode >10 min.
Results:
Postoperative atrial fibrillation was found in 65 patients (38%). Compared with those without, patients with postoperative atrial fibrillation were significantly older ( p=0.008), had more frequently a history of hypertension ( p=0.009), history of atrial fibrillation ( p<0.001) and New York Heart Association class ⩾III ( p=0.004). They also had longer PR interval ( p=0.005), higher preoperative NT-pro brain natriuretic peptide level ( p=0.006), left ventricle end-diastolic volume ( p=0.002), indexed left ventricle mass ( p<0.0001), indexed maximal left atrial volume ( p<0.0001), maximal right atrial area ( p<0.001) and lower left ventricle ejection fraction ( p=0.04). In multivariate analysis, history of atrial fibrillation (odds ratio =6.1, 95% confidence interval: 1.4-26.0, p=0.02) and indexed maximal left atrial volume (odds ratio =1.13, 95% confidence interval: 1.1-1.2, p=0.001) were the only two independent predictive factors of postoperative atrial fibrillation. The addition of echocardiographic parameters improved the predictive value (χ) of the model, from 34 to 57.
Conclusion:
A history of atrial fibrillation and indexed left atrial maximal volume are the best predictors of the occurrence of postoperative atrial fibrillation following coronary artery bypass graft. The identification of high risk population of postoperative atrial fibrillation using these two factors could lead to the development of targeted strategies to limit this frequent complication in these patients.



Eur Heart J Acute Cardiovasc Care: 27 Feb 2019; 8:104-113
Magne J, Salerno B, Mohty D, Serena C, ... Le Guyader A, Aboyans V
Eur Heart J Acute Cardiovasc Care: 27 Feb 2019; 8:104-113 | PMID: 28059577
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Impact:

This program is still in alpha version.