Journal: Eur Heart J Acute Cardiovasc Care

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Abstract

Reperfusion therapy for ST-elevation myocardial infarction complicated by cardiogenic shock: the European Society of Cardiology EurObservational programme acute cardiovascular care-European association of PCI ST-elevation myocardial infarction registry.

Zeymer U, Ludman P, Danchin N, Kala P, ... Bartus S, Weidinger F
Aims
To determine the current state of the use of reperfusion and adjunctive therapies and in-hospital outcomes in European Society of Cardiology (ESC) member and affiliated countries for patients with ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS).
Methods and results
ESC EurObservational Research Programme prospective international cohort study of admissions with STEMI within 24 h of symptom onset (196 centres; 26 ESC member and 3 affiliated countries). Of 11 462 patients enrolled, 448 (3.9%) had CS. Patients with compared to patients without CS, less frequently received primary percutaneous coronary intervention (PCI) (65.5% vs. 72.2%) and fibrinolysis (15.9% vs. 19.0), and more often had no reperfusion therapy (19.0% vs. 8.5%). Mechanical support devices (intraaortic ballon pump 11.2%, extracoporeal membrane oxygenation 0.7%, other 1.1%) were used infrequently in CS. Bleeding definition academic research consortium 2-5 bleeding complications (10.1% vs. 3.0%, P < 0.01) and stroke (4.2% vs. 0.9%, P < 0.01) occurred more frequently in patients with CS. In-hospital mortality was 10-fold higher (35.5% vs. 3.1%) in patients with CS. Mortality in patients with CS in the groups with PCI, fibrinolysis, and no reperfusion therapy were 27.4%, 36.6%, and 62.4%, respectively.
Conclusion
In this multi-national registry, patients with STEMI complicated by CS less frequently receive reperfusion therapy than patients with STEMI without CS. Early mortality in patients with CS not treated with primary PCI is very high. Therefore, strategies to improve clinical outcome in STEMI with CS are needed.

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

Eur Heart J Acute Cardiovasc Care: 20 May 2022; epub ahead of print
Zeymer U, Ludman P, Danchin N, Kala P, ... Bartus S, Weidinger F
Eur Heart J Acute Cardiovasc Care: 20 May 2022; epub ahead of print | PMID: 35593654
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Abstract

Targeted temperature management after out of hospital cardiac arrest: quo vadis?

Krychtiuk KA, Fordyce CB, Hansen CM, Hassager C, ... van Diepen S, Granger CB
Targeted temperature management (TTM) has become a cornerstone in the treatment of comatose post-cardiac arrest patients over the last two decades. Belief in the efficacy of this intervention for improving neurologically intact survival was based on two trials from 2002, one truly randomized-controlled and one small quasi-randomized trial, without clear confirmation of that finding. Subsequent large randomized trials reported no difference in outcomes between TTM at 33 vs. 36°C and no benefit of TTM at 33°C as compared with fever control alone. Given that these results may help shape post-cardiac arrest patient care, we sought to review the history and rationale as well as trial evidence for TTM, critically review the TTM2 trial, and highlight gaps in knowledge and research needs for the future. Finally, we provide contemporary guidance for the use of TTM in daily clinical practice.

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

Eur Heart J Acute Cardiovasc Care: 17 May 2022; epub ahead of print
Krychtiuk KA, Fordyce CB, Hansen CM, Hassager C, ... van Diepen S, Granger CB
Eur Heart J Acute Cardiovasc Care: 17 May 2022; epub ahead of print | PMID: 35579006
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Abstract

Eligibility of extracorporeal cardiopulmonary resuscitation on in-hospital cardiac arrests in Sweden: a national registry study.

Ölander CH, Vikholm P, Schiller P, Hellgren L
Aims
Extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest (CA) is used in selected cases. The incidence of ECPR-eligible patients is not known. The aim of this study was to identify the ECPR-eligible patients among in-hospital CAs (IHCA) in Sweden and to estimate the potential gain in survival and neurological outcome, if ECPR was to be used.
Methods and results
Data between 1 January 2015 and 30 August 2019 were extracted from the Swedish Cardiac Arrest Register (SCAR). Two arbitrary groups were defined, based on restrictive or liberal inclusion criteria. In both groups, logistic regression was used to determine survival and cerebral performance category (CPC) for conventional cardiopulmonary resuscitation (cCPR). When ECPR was assumed to be possible, it was considered equivalent to return of spontaneous circulation, and the previous logistic regression model was applied to define outcome for comparison of conventional CPR and ECPR. The assumption in the model was a minimum of 15 min of refractory CA and 5 min of cannulation. A total of 9209 witnessed IHCA was extracted from SCAR. Depending on strictness of inclusion, an average of 32-64 patients/year remains in refractory after 20 min of cCPR, theoretically eligible for ECPR. If optimal conditions for ECPR are assumed and potential negative side effects disregarded of, the estimated potential benefit of survival of ECPR in Sweden would be 10-19 (0.09-0.19/100 000) patients/year, when a 30% success rate is expected. The benefit of ECPR on survival and CPC scoring was found to be detrimental over time and minimal at 60 min of cCPR.
Conclusion
The number of ECPR-eligible patients among IHCA in Sweden is dependent on selection criteria and predicted to be low. There is an estimated potential benefit of ECPR, on survival and neurological outcome if initiated within 60 min of the IHCA.

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

Eur Heart J Acute Cardiovasc Care: 11 May 2022; epub ahead of print
Ölander CH, Vikholm P, Schiller P, Hellgren L
Eur Heart J Acute Cardiovasc Care: 11 May 2022; epub ahead of print | PMID: 35543269
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Abstract

Response to acute vasodilator challenge and haemodynamic modifications after MitraClip in patients with functional mitral regurgitation and pulmonary hypertension.

Mandurino-Mirizzi A, Munafò A, Raineri C, Magrini G, ... Oltrona-Visconti L, Crimi G
The effectiveness of transcatheter edge-to-edge repair (TEER) in patients with functional mitral regurgitation (FMR) and pulmonary hypertension (PH) is still debated and pre-procedural predictors of haemodynamic improvement after TEER in this setting are currently unknown. We investigated whether normalization of pulmonary artery wedge pressure (PAWP) in response to sodium nitroprusside (SNP) during baseline right heart catheterization might be predictive of a favourable haemodynamic response to MitraClip in patients with FMR and PH. Among 22 patients enrolled, 13 had a positive response to SNP (responders), nine were non-responders. At 6-months follow-up, responders showed a 33% reduction in PAWP and a 25% reduction in mean pulmonary artery pressure (PAP) (P = 0.002 and 0.004, respectively); no significant change occurred in non-responders. In patients with FMR and PH, pre-procedural vasodilator challenge with SNP may help define patients who may have haemodynamic improvement after TEER.

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

Eur Heart J Acute Cardiovasc Care: 07 May 2022; epub ahead of print
Mandurino-Mirizzi A, Munafò A, Raineri C, Magrini G, ... Oltrona-Visconti L, Crimi G
Eur Heart J Acute Cardiovasc Care: 07 May 2022; epub ahead of print | PMID: 35524735
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Abstract

Utility of plasma CA125 as a proxy of intra-abdominal pressure in patients with acute heart failure.

Rubio-Gracia J, Crespo-Aznarez S, De la Espriella R, Nuñez G, ... Pérez-Calvo JI, Nuñez J
Aims
Increased intra-abdominal pressure (IAP) is now considered a potential contributor to organ damage and disease progression in acute heart failure (AHF). In this work, we aimed to determine if antigen carbohydrate 125 (CA125) is associated with IAP and to identify a cutpoint of CA125 useful for ruling out intra-abdominal hypertension (defined as IAP ≥ 12 mmHg).
Methods and results
We prospectively evaluated a cohort of 53 patients admitted with AHF in which IAP was measured within the first 24-h of admission. The mean age was 80 ± 8 years, 31 (58.5%) were female, and 31 (58.5%) had left ventricular ejection fraction ≥50%. The median plasma levels of NT-proBNP and CA125 were 3830 pg/mL (2417-8929) and 45.8 U/mL (29.8-114.0), respectively. The median of IAP was 15 mmHg (11-17), and 39 (73%) patients had an IAP ≥ 12 mmHg. The diagnostic performance of CA125 for identifying an IAP ≥ 12 mmHg was tested using the receiving operating characteristic (ROC) curve. The cut-off for CA125 of 17.1 U/mL showed a sensitivity of 92%, a specificity of 50%, and an area under the ROC curve of 0.71. After multivariate adjustment, CA125 remained non-linearly and positively associated with higher IAP (P-value = 0.003), explaining almost 28% of the model\'s variability (R2: 27.6%).
Conclusions
Patients with AHF and intra-abdominal hypertension had higher CA125 plasma levels. A baseline concentration of CA125 below 17.1 U/mL will increase the odds of identifying a subset of patients with normal IAP.

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

Eur Heart J Acute Cardiovasc Care: 05 May 2022; epub ahead of print
Rubio-Gracia J, Crespo-Aznarez S, De la Espriella R, Nuñez G, ... Pérez-Calvo JI, Nuñez J
Eur Heart J Acute Cardiovasc Care: 05 May 2022; epub ahead of print | PMID: 35512321
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Abstract

Incidence and predictors of mortality after an electrical storm in the ICU.

Ninni S, Layec J, Brigadeau F, Behal H, ... Klug D, Lacroix D
Aims
For assessing predictors of early mortality following hospitalization for electrical storm (ES), only limited data are available. The purpose of this study was to assess the incidence and predictors of early mortality following hospitalization in the intensive care unit (ICU) for ES in a large retrospective study.
Methods and results
In this retrospective study, we included all patients who were hospitalized for ES from July 2015 to May 2020 in our tertiary centre. A total of 253 patients were included. The median age was 66 [56; 73], and 64% had ischemic cardiomyopathy. A total of 37% of patients presented hemodynamic instability requiring catecholamine at admission. A total of 17% of patients presented an acute reversible cause for ES. The one-year mortality was 34% (95% CI, 30-43%), mostly driven by heart failure (HF). The multivariable Cox\'s regression model identified age, left ventricular ejection fraction, right ventricle dysfunction, haemoglobin level as independent predictors of one-year mortality. The use of catecholamine at admission was identified as the only variable related to the initial management of ES associated with an increased 30-day mortality risk (HR: 7.95 (95%CI, 3.18-19.85).
Conclusion
In patients admitted for ES in ICU, the one-year mortality remains high and mostly driven by HF. The use of catecholamine at admission is associated with a seven-fold risk for mortality within 30 days. In such patients, the potential use of VT ablation can be questioned and a careful action plan regarding invasive HF-related therapy could be considered.

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

Eur Heart J Acute Cardiovasc Care: 04 May 2022; epub ahead of print
Ninni S, Layec J, Brigadeau F, Behal H, ... Klug D, Lacroix D
Eur Heart J Acute Cardiovasc Care: 04 May 2022; epub ahead of print | PMID: 35512138
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Abstract

Myocardial bridging is significantly associated to myocardial infarction with non-obstructive coronary arteries.

Matta A, Nader V, Canitrot R, Delmas C, ... Galinier M, Roncalli J
Background
Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a common disorder characterized by the presence of clinical criteria for acute myocardial infarction in the absence of obstructive coronary artery disease on angiography. We aim to investigate the relationship between myocardial bridging (MB) and MINOCA.
Methods and results
An observational retrospective study was conducted on 15 036 patients who had been referred for coronary angiography and who fulfilled the Fourth Universal Definition of Myocardial Infarction. The study population was divided into ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) patients, from which we defined two main groups: the MINOCA group and the coronary artery disease (CAD) group. Statistical analyses were carried out by using SPSS, version 20. The prevalence of angiographic MB among the groups was significantly greater in the MINOCA group (2.9% vs. 0.8%). MINOCA accounted for 14.5% of spontaneous myocardial infarction, and the clinical presentation was more frequently NSTEMI rather than STEMI (84.3% vs. 15.7%). After adjusting for confounders, multivariate analyses showed a positive association between MB and MINOCA [odds ratio = 3.28, 95% CI (2.34; 4.61) P < 0.001]. Cardiovascular risk factors were less common in the MINOCA population, which was younger and more often female.
Conclusion
MB is a risk factor for MINOCA. Because MB prevalence differed significantly between the controls (CAD group) and cases (MINOCA group), which were positively associated to MB, it seems likely that MB would be a potential cause of MINOCA. Investigations for MB in MINOCA cases and especially in NSTEMI patients seem necessary.

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

Eur Heart J Acute Cardiovasc Care: 03 May 2022; epub ahead of print
Matta A, Nader V, Canitrot R, Delmas C, ... Galinier M, Roncalli J
Eur Heart J Acute Cardiovasc Care: 03 May 2022; epub ahead of print | PMID: 35511689
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Abstract

Association of peripheral venous pressure with adverse post-discharge outcomes in patients with acute heart failure: a prospective cohort study.

Nagao K, Maruichi-Kawakami S, Aida K, Matsuto K, ... Kimura T, Inada T
Aims
Congestion is the major cause of hospitalization for heart failure (HF). Traditional bedside assessment of congestion is limited by insufficient accuracy. Peripheral venous pressure (PVP) has recently been shown to accurately predict central venous congestion. We examined the association between PVP before discharge and post-discharge outcomes in hospitalized patients with acute HF.
Methods and results
Bedside PVP measurement at the forearm vein and traditional clinical examination were performed in 239 patients. The association with the primary composite endpoint of cardiovascular death or HF hospitalization and the incremental prognostic value beyond the established HF risk score was examined. The PVP correlated with peripheral oedema, jugular venous pressure, and inferior vena cava diameter, but not with brain-type natriuretic peptide. The 1-year incidence of the primary outcome measure in the first, second, and third tertiles of PVP was 21.4, 29.9, and 40.7%, respectively (log-rank P = 0.017). The adjusted hazard ratio of PVP per 1 mmHg increase for the 1-year outcome was 1.08 [95% confidence interval (1.03-1.14), P = 0.004]. When added onto the Meta-Analysis Global Group in Chronic HF risk score, PVP significantly increased the area under the receiver-operating characteristic curve for predicting the outcome [from 0.63 (0.56-0.71) to 0.70 (0.62-0.77), P = 0.02), while traditional assessments did not. The addition of PVP also yielded significant net reclassification improvement [0.46 (0.19-0.74), P < 0.001].
Conclusion
The PVP at discharge correlated with prognosis. The results warrant further investigation to evaluate the clinical application of PVP measurement in the care of HF.
Trial registration number
UMIN000034279.

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

Eur Heart J Acute Cardiovasc Care: 03 May 2022; epub ahead of print
Nagao K, Maruichi-Kawakami S, Aida K, Matsuto K, ... Kimura T, Inada T
Eur Heart J Acute Cardiovasc Care: 03 May 2022; epub ahead of print | PMID: 35511694
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Abstract

Association between β-blocker dose and quality of life after myocardial infarction: a real-world Swedish register-linked study.

Humphries S, Wallert J, Mars K, Held C, Hofmann R, Olsson EMG
Background
β-blockers are routinely administered to patients following myocardial infarction (MI), yet their potential effect on health-related quality of life (HRQoL) is not entirely understood. We investigated the relationship between two different doses of β-blockers with HRQoL following MI.
Methods and results
This nationwide observational study used Swedish national registries to collate sociodemographic, clinical, medication, and HRQoL {the latter operationalized using EuroQol [European Quality of Life Five Dimensions Questionnaire (EQ-5D)]}. Estimates at 6-10 weeks and 12-14 months post-MI follow-up from pooled linear and logistic models were calculated after multiple imputation. We identified 35 612 patients with first-time MI, discharged with β-blockers, and enrolled in cardiac rehabilitation between 2006 and 2015. Upon discharge, patients were either dispensed <50% [24 082 (67.6%)] or ≥50% [11 530 (32.4%)] of the target dosage, as defined in previous trials. After adjusting for pre-defined covariates, neither the EQ-5D Index nor the Emotional Distress items were statistically different between groups. The EQ-VAS score was significantly lower in patients treated with ≥50% target β-blocker dose than those treated with <50% of the target dose [-0.87 [-1.23, -0.46], P < .001]. Results were similar at the 12-month follow-up and across sub-groups separated by sex and age.
Conclusion
No difference in HRQoL was found among patients taking <50% vs. ≥50% of the target β-blocker dose, except for the EQ-VAS in which higher scores were reported in those taking a lower dose. The clinical meaningfulness of this statistical significance is likely low.

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

Eur Heart J Acute Cardiovasc Care: 02 May 2022; epub ahead of print
Humphries S, Wallert J, Mars K, Held C, Hofmann R, Olsson EMG
Eur Heart J Acute Cardiovasc Care: 02 May 2022; epub ahead of print | PMID: 35510962
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Abstract

Return to work after acute myocardial infarction with cardiogenic shock: a Danish nationwide cohort study.

Lauridsen MD, Rørth R, Butt JH, Schmidt M, ... Køber L, Fosbøl EL
Background
Physical and mental well-being after critical illness may be objectified by the ability to work. We examined return to work among patients with myocardial infarction (MI) by cardiogenic shock (CS) status.
Methods
Danish nationwide registries were used to identify patients with first-time MI by CS status between 2005 and 2015, aged 18-63 years, working before hospitalization and discharged alive. Multiple logistic regression models were used to compare groups.
Results
We identified 19 799 patients with MI of whom 653 had CS (3%). The median age was similar for patients with and without CS (53 years, interquartile range 47-58). One-year outcomes in patients with and without CS were as follows: 52% vs. 83% returned to work, 41% vs. 16% did not and 6% vs. 1% died. The adjusted odds ratio (OR) of returning to work was 0.53 [95% confidence limit (CI): 0.42-0.66]. In patients with CS, males and patients surviving OHCA were more likely to return to work (OR: 1.83, 95% CI: 1.15-2.92 and 1.55, 95% CI: 1.00-2.40, respectively), whereas prolonged hospitalization (OR: 0.38, 95% CI: 0.22-0.65) and anoxic brain damage (OR: 0.36, 95% CI: 0.18-0.72) were associated with lower likelihood of returning to work.
Conclusion
In patients with MI discharged alive, approximately 80% of those without CS returned to work at 1-year follow-up in contrast to 50% of those with CS. Among patients with CS, male sex and OHCA survivors were markers positively related to return to work, whereas prolonged hospitalization and anoxic brain damage were negatively related markers.

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

Eur Heart J Acute Cardiovasc Care: 15 Apr 2022; epub ahead of print
Lauridsen MD, Rørth R, Butt JH, Schmidt M, ... Køber L, Fosbøl EL
Eur Heart J Acute Cardiovasc Care: 15 Apr 2022; epub ahead of print | PMID: 35425972
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Abstract

Does age influence out-of-hospital cardiac arrest incidence and outcomes among women? Insights from the Paris SDEC.

Lavignasse D, Lemoine S, Karam N, Gaye B, ... Empana JP, Jouven X
Aims 
Age and sex disparities in out-of-hospital cardiac arrest (OHCA) have been described. Reproductive age may have a protected effect on females vs. males, although results are conflicting. We aimed to clarify this using the Paris Sudden Death Expertise Centre (SDEC) registry.
Methods and results
The Paris SDEC registry collects OHCAs occurring in the Greater Paris Area. We included all OHCAs of presumed cardiac causes occurring between 2013 and 2018. Patients were divided into age groups: 1-13, 13-50, 50-75, and >75 years. Sex and age disparities in OHCA incidence and outcomes were analysed using multivariable negative binomial and logistic regression models. There were 19 782 OHCAs meeting inclusion criteria: 0.37% aged 1-13 years, 12.4% aged 13-50 years, 40.4% aged 50-75 years, and 46.9% aged >75 years. Adjusted incidence rate ratios (IRRs) in females vs. males were for the youngest to the older age groups: 1.29 [95% confidence interval (CI) 0.78-2.13], 0.54 [0.49-0.59], 0.60 [0.56-0.64], and 0.75 [0.67-0.84]. At reproductive age, females were more likely than males to have a return of spontaneous circulation [adjusted odds ratio (OR) 1.60 (1.27-2.02)], to be alive at hospital admission [OR: 1.49 (1.18-1.89)]. In both sexes, patients aged 13-50 years were more likely to survive at hospital discharge than those aged 50-75 years [males: OR 1.81 (1.49-2.20), females: 2.24 (1.54-3.25)]. However, at reproductive age, no sex disparity was observed in survival at hospital discharge [OR: 1.16 (0.75-1.80)].
Conclusion 
Incidence rate ratios were similar between pre- and post-menopausal aged patients. At reproductive age, no sex disparity in survival at hospital discharge was observed, suggesting that menopausal status may not influence OHCA occurrence and prognosis.

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

Eur Heart J Acute Cardiovasc Care: 13 Apr 2022; epub ahead of print
Lavignasse D, Lemoine S, Karam N, Gaye B, ... Empana JP, Jouven X
Eur Heart J Acute Cardiovasc Care: 13 Apr 2022; epub ahead of print | PMID: 35415752
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Abstract

A prospective multi-centre study assessing the safety and effectiveness following the implementation of an accelerated chest pain pathway using point-of-care troponin for use in New Zealand rural hospital and primary care settings.

Miller R, Nixon G, Pickering JW, Stokes T, ... Du Toit S, Than M
Aims
Most rural hospitals and general practices in New Zealand (NZ) are reliant on point-of-care troponin. A rural accelerated chest pain pathway (RACPP), combining an electrocardiogram (ECG), a structured risk score (Emergency Department Assessment of Chest Pain Score), and serial point-of-care troponin, was designed for use in rural hospital and primary care settings across NZ. The aim of this study was to evaluate the safety and effectiveness of the RACPP.
Methods and results
A prospective multi-centre evaluation following implementation of the RACPP was undertaken from 1 July 2018 to 31 December 2020 in rural hospitals, rural and urban general practices, and urgent care clinics. The primary outcome measure was the presence of 30-day major adverse cardiac events (MACEs) in low-risk patients. The secondary outcome was the percentage of patients classified as low-risk that avoided transfer or were eligible for early discharge. There were 1205 patients enrolled in the study. 132 patients were excluded. Of the 1073 patients included in the primary analysis, 474 (44.0%) patients were identified as low-risk. There were no [95% confidence interval (CI): 0-0.3%] MACE within 30 days of the presentation among low-risk patients. Most of these patients (91.8%) were discharged without admission to hospital. Almost all patients who presented to general practice (99%) and urgent care clinics (97.6%) were discharged to home directly.
Conclusion
The RACPP is safe and effective at excluding MACEs in NZ rural hospital and primary care settings, where it can identify a group of low-risk patients who can be safely discharged home without transfer to hospital.

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

Eur Heart J Acute Cardiovasc Care: 04 Apr 2022; epub ahead of print
Miller R, Nixon G, Pickering JW, Stokes T, ... Du Toit S, Than M
Eur Heart J Acute Cardiovasc Care: 04 Apr 2022; epub ahead of print | PMID: 35373255
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Abstract

Integrating palliative care into the modern cardiac intensive care unit: a review.

Kim JM, Godfrey S, O\'Neill D, Sinha SS, ... Katz JN, Warraich HJ
The modern cardiac intensive care unit (CICU) specializes in the care of a broad range of critically ill patients with both cardiac and non-cardiac serious illnesses. Despite advances, most conditions that necessitate CICU admission such as cardiogenic shock, continue to have a high burden of morbidity and mortality. The CICU often serves as the final destination for patients with end-stage disease, with one study reporting that one in five patients in the USA die in an intensive care unit (ICU) or shortly after an ICU admission. Palliative care is a broad subspecialty of medicine with an interdisciplinary approach that focuses on optimizing patient and family quality of life (QoL), decision-making, and experience. Palliative care has been shown to improve the QoL and symptom burden in patients at various stages of illness, however, the integration of palliative care in the CICU has not been well-studied. In this review, we outline the fundamental principles of high-quality palliative care in the ICU, focused on timeliness, goal-concordant decision-making, and family-centred care. We differentiate between primary palliative care, which is delivered by the primary CICU team, and secondary palliative care, which is provided by the consulting palliative care team, and delineate their responsibilities and domains. We propose clinical triggers that might spur serious illness communication and reappraisal of patient preferences. More research is needed to test different models that integrate palliative care in the modern CICU.

© The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Cardiology 2022. This work is written by (a) US Government employee(s) and is in the public domain in the US.

Eur Heart J Acute Cardiovasc Care: 01 Apr 2022; epub ahead of print
Kim JM, Godfrey S, O'Neill D, Sinha SS, ... Katz JN, Warraich HJ
Eur Heart J Acute Cardiovasc Care: 01 Apr 2022; epub ahead of print | PMID: 35363258
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Abstract

CALL-K score: predicting the need for renal replacement therapy in cardiogenic shock.

Rodenas-Alesina E, Wang VN, Brahmbhatt DH, Scolari FL, ... Overgaard CB, Luk A
Aims
The clinical predictors and outcomes of patients with cardiogenic shock (CS) requiring renal replacement therapy (RRT) have not been studied previously. This study assesses the impact of RRT on mortality in patients with CS and aims to identify clinical factors that contribute to the need of RRT.
Methods and results
Consecutive patients presenting with CS were included from a prospective registry of cardiac intensive care unit admissions at a single institution between 2014 and 2020. Of the 1030 patients admitted with CS, 123 (11.9%) received RRT. RRT was associated with higher 1-year mortality [adjusted hazard ratio = 1.62, 95% confidence interval (CI) 1.02-2.14], and a higher in-hospital incidence of sepsis [risk ratio = 2.76, P < 0.001], and pneumonia (risk ratio = 2.9, P = 0.001). Those who received RRT were less likely to receive guideline-directed medical treatment at time of discharge, undergo heart transplantation (2.4% vs. 11.5%, P = 0.002) or receive a durable left ventricular assist device (0.0% vs. 11.6%, P < 0.001). Five variables at admission best predicted the need for RRT (age, lactate, haemoglobin, use of pre-admission loop diuretics, and admission estimated glomerular filtration rate) and were used to generate the CALL-K 9-point risk score, with better discrimination than creatinine alone (P = 0.008). The score was internally validated (area under the curve = 0.815, 95% CI 0.739-0.835) with good calibration (Hosmer-Lemeshow P = 0.827).
Conclusions
RRT is associated with worse outcomes, including a lower likelihood to receive advanced heart failure therapies in patients with CS. A risk score comprising five variables routinely collected at admission can accurately estimate the risk of needing RRT.

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

Eur Heart J Acute Cardiovasc Care: 18 Mar 2022; epub ahead of print
Rodenas-Alesina E, Wang VN, Brahmbhatt DH, Scolari FL, ... Overgaard CB, Luk A
Eur Heart J Acute Cardiovasc Care: 18 Mar 2022; epub ahead of print | PMID: 35303055
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Abstract

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

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

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Acute Cardiovasc Care: 16 Mar 2022; 11:224-229
Vicente-Miralles R, Martín-Langerwerf DA, Núñez-Martínez JM, Marco-Juan A, ... Gil-Guillén VF, Bertomeu-Gonzalez V
Eur Heart J Acute Cardiovasc Care: 16 Mar 2022; 11:224-229 | PMID: 34918044
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Impact:
Abstract

Delayed administration of epinephrine is associated with worse neurological outcomes in patients with out-of-hospital cardiac arrest and initial pulseless electrical activity: insight from the nationwide multicentre observational JAAM-OHCA (Japan Association for Acute Medicine) registry.

Enzan N, Hiasa KI, Ichimura K, Nishihara M, ... Kitazono T, Tsutsui H
Aims
The delayed administration of epinephrine has been proven to worsen the neurological outcomes of patients with out-of-hospital cardiac arrest (OHCA) and shockable rhythm or asystole. We aimed to investigate whether the delayed administration of epinephrine might also worsen the neurological outcomes of patients with witnessed OHCA and initial pulseless electrical activity (PEA).
Methods and results
The JAAM-OHCA Registry is a multicentre registry including OHCA patients between 2014 and 2017. Patients with emergency medical services (EMS)-treated OHCA and initial PEA rhythm were included. The primary exposure was the time from the EMS call to the administration of epinephrine. The secondary exposure was the time to epinephrine dichotomized as early (≤15 min) or delayed (>15 min). The primary outcome was the achievement of a favourable neurological outcome, defined as Cerebral Performance Categories Scale 1-2 at 30 days after OHCA. Out of 34 754 patients with OHCA, 3050 patients were included in the present study. After adjusting for potential confounders, the delayed administration of the epinephrine was associated with a lower likelihood of achieving a favourable neurological outcome [adjusted odds ratio (OR) 0.96; 95% confidence interval (CI) 0.93-0.99; P = 0.016]. The percentage of patients who achieved a favourable neurological outcome in the delayed epinephrine group was lower than that in the early epinephrine group (1.3% vs. 4.7%; adjusted OR 0.33; 95% CI 0.15-0.72; P = 0.005). A restricted cubic spline analysis demonstrated that delayed epinephrine administration could decrease the likelihood of achieving a favourable neurological outcome; this was significant within the first 10 min.
Conclusions
The delayed administration of epinephrine was associated with worse neurological outcomes in patients with witnessed OHCA patients with initial PEA.

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

Eur Heart J Acute Cardiovasc Care: 02 Mar 2022; epub ahead of print
Enzan N, Hiasa KI, Ichimura K, Nishihara M, ... Kitazono T, Tsutsui H
Eur Heart J Acute Cardiovasc Care: 02 Mar 2022; epub ahead of print | PMID: 35238895
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Impact:
Abstract

Basic mechanisms in cardiogenic shock: part 1-definition and pathophysiology.

Krychtiuk KA, Vrints C, Wojta J, Huber K, Speidl WS
Cardiogenic shock mortality rates remain high despite significant advances in cardiovascular medicine and the widespread uptake of mechanical circulatory support systems. Except for early invasive angiography and percutaneous coronary intervention of the infarct-related artery, the most widely used therapeutic measures are based on low-quality evidence. The grim prognosis and lack of high-quality data warrant further action. Part 1 of this two-part educational review defines cardiogenic shock and discusses current treatment strategies. In addition, we summarize current knowledge on basic mechanisms in the pathophysiology of cardiogenic shock, focusing on inflammation and microvascular disturbances, which may ultimately be translated into diagnostic or therapeutic approaches to improve the outcome of our patients.

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Eur Heart J Acute Cardiovasc Care: 25 Feb 2022; epub ahead of print
Krychtiuk KA, Vrints C, Wojta J, Huber K, Speidl WS
Eur Heart J Acute Cardiovasc Care: 25 Feb 2022; epub ahead of print | PMID: 35218350
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Impact:
Abstract

Basic mechanisms in cardiogenic shock: part 2 - biomarkers and treatment options.

Krychtiuk KA, Vrints C, Wojta J, Huber K, Speidl WS
Cardiogenic shock mortality rates remain high despite significant advances in cardiovascular medicine and the widespread uptake of mechanical circulatory support systems. Except for early invasive angiography and percutaneous coronary intervention of the infarct-related artery, all other widely used therapeutic measures are based on low-quality evidence. The grim prognosis and lack of high-quality data warrant further action. Within Part 2 of this two-part educational review on basic mechanisms in cardiogenic shock, we aimed to highlight the current status of translating our understanding of the pathophysiology of cardiogenic shock into clinical practice. We summarize the current status of biomarker research in risk stratification and therapy guidance. In addition, we summarized the current status of translating the findings from bench-, bedside, and biomarker studies into treatment options. Several large randomized controlled trials (RCTs) are underway, providing a huge opportunity to study contemporary cardiogenic shock patients. Finally, we call for translational, homogenous, biomarker-based, international RCTs testing novel treatment approaches to improve the outcome of our patients.

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Eur Heart J Acute Cardiovasc Care: 25 Feb 2022; epub ahead of print
Krychtiuk KA, Vrints C, Wojta J, Huber K, Speidl WS
Eur Heart J Acute Cardiovasc Care: 25 Feb 2022; epub ahead of print | PMID: 35218355
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Impact:
Abstract

Effects of early myocardial reperfusion and perfusion on myocardial necrosis/dysfunction and inflammation in patients with ST-segment and non-ST-segment elevation acute coronary syndrome: results from the PLATelet inhibition and patients Outcomes (PLATO) trial.

Batra G, Renlund H, Kunadian V, James SK, ... Siegbahn A, Wallentin L
Aims
Restoration of myocardial blood flow and perfusion during percutaneous coronary intervention (PCI) measured using Thrombolysis in Myocardial Infarction (TIMI) flow grade (TFG) and perfusion grade (TMPG) is associated with improved outcomes in acute coronary syndrome (ACS). Associations between TFG/TMPG and changes in biomarkers reflecting myocardial damage/dysfunction and inflammation is unknown.
Methods and results
Among 2606 patients included, TFG was evaluated in 2198 and TMPG in 1874 with ST-segment elevation myocardial infarction (STEMI) or non-ST-segment ACS (NSTE-ACS). Biomarkers reflecting myocardial necrosis [troponin T (TnT)], myocardial dysfunction [N-terminal prohormone brain natriuretic peptide (NT-proBNP)], inflammation [interleukin-6 (IL-6) and C-reactive protein (CRP)], and oxidative stress/ageing/inflammation [growth differentiation factor-15 (GDF-15)] were measured at baseline, discharge, and 1- and 6-month post-randomization. Associations between TFG/TMPG and changes in biomarker levels were evaluated using the Mann-Whitney-Wilcoxon signed test. In total, 1423 (54.6%) patients had STEMI and 1183 (45.4%) NSTE-ACS. Complete reperfusion after PCI with TFG = 3 was achieved in 1110 (85.3%) with STEMI and in 793 (88.5%) with NSTE-ACS. Normal myocardial perfusion with TMPG = 3 was achieved in 475 (41.6%) with STEMI and in 396 (54.0%) with NSTE-ACS. Levels of TnT, NT-proBNP, IL-6, CRP, and GDF-15 were substantially lower at discharge in patients with complete vs. incomplete TFG and STEMI (P < 0.01). This pattern was not observed for patients with NSTE-ACS. Patients with normal vs. abnormal TMPG and NSTE-ACS had lower levels of NT-proBNP at discharge (P = 0.01).
Conclusions
Successful restoration of epicardial blood flow in STEMI was associated with less myocardial necrosis/dysfunction and inflammation. Attainment of normal myocardial perfusion was associated with less myocardial dysfunction in NSTE-ACS.

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

Eur Heart J Acute Cardiovasc Care: 24 Feb 2022; epub ahead of print
Batra G, Renlund H, Kunadian V, James SK, ... Siegbahn A, Wallentin L
Eur Heart J Acute Cardiovasc Care: 24 Feb 2022; epub ahead of print | PMID: 35213721
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Impact:
Abstract

Intracranial haemorrhage in adult patients on venoarterial extracorporeal membrane oxygenation.

Lüsebrink E, Zimmer S, Schrage B, Dabboura S, ... Orban M, ICH-VA-ECMO Investigator Group
Aims 
Intracranial haemorrhage (ICH) is one of the most serious complications of adult patients treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) and is associated with increased morbidity and mortality. However, the prevalence and risk factors of ICH in this cohort are still insufficiently understood. We hypothesized that a considerable proportion of patients undergoing VA-ECMO support suffer from ICH and that specific risk factors are associated with the occurrence of ICH. Therefore, the purpose of this study was to further investigate the prevalence and associated mortality as well as to identify risk factors for ICH in VA-ECMO patients.
Methods and results 
We conducted a retrospective multicentre study including adult patients (≥18 years) treated with VA-ECMO in cardiac intensive care units (ICUs) at five German clinical sites between January 2016 and March 2020, excluding patients with ICH upon admission. Differences in baseline characteristics and clinical outcome between VA-ECMO patients with and without ICH were analysed and risk factors for ICH were identified. Among the 598 patients included, 70/598 (12%) developed ICH during VA-ECMO treatment. In-hospital mortality in patients with ICH was 57/70 (81%) and 1-month mortality 60/70 (86%), compared to 332/528 (63%) (P = 0.002) and 340/528 (64%) (P < 0.001), respectively, in patients without ICH. Intracranial haemorrhage was positively associated with diabetes mellitus [odds ratio (OR) 2, 95% confidence interval (CI) 1.11-3.56; P = 0.020] and lactate (per mmol/L) (OR 1.06, 95% CI 1.01-1.11; P = 0.020), and negatively associated with platelet count (per 100 G/L) (OR 0.32, 95% CI 0.15-0.59; P = 0.001) and fibrinogen (per 100 mg/dL) (OR 0.64, 95% CI 0.49-0.83; P < 0.001).
Conclusion 
Intracranial haemorrhage was associated with a significantly higher mortality rate. Diabetes mellitus and lactate were positively, platelet count, and fibrinogen level negatively associated with the occurrence of ICH. Thus, platelet count and fibrinogen level were revealed as potentially modifiable, independent risk factors for ICH. The findings address an area with limited data, provide information about risk factors and the epidemiology of ICH, and may be a starting point for further investigations to develop effective strategies to prevent and treat ICH.

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Eur Heart J Acute Cardiovasc Care: 24 Feb 2022; epub ahead of print
Lüsebrink E, Zimmer S, Schrage B, Dabboura S, ... Orban M, ICH-VA-ECMO Investigator Group
Eur Heart J Acute Cardiovasc Care: 24 Feb 2022; epub ahead of print | PMID: 35213724
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Impact:
Abstract

Hyperlactataemia and acid-base disturbances in normotensive patients with acute heart failure.

Bar O, Aronson D
Aims
Acute heart failure (AHF) may be associated with low-tissue perfusion and/or hypoxaemia leading to increased lactate levels and acid-base perturbations. Few data are available on the clinical significance of elevated lactate levels and primary acid-base disorders in the setting of AHF.
Methods and results
Arterial blood gas was obtained at admission in 4012 normotensive (systolic blood pressure ≥ 90 mmHg) patients with AHF. The association between lactate levels and acid-base status and in-hospital mortality was determined using multivariable logistic regression. Hyperlactataemia (>2 mmol/L) was present in 38.0% of patients and was strongly associated with markers of sympathetic activation, such as hyperglycaemia. Hyperlactataemia was present in 31.0%, 43.7%, and 42.0% of patients with normal pH, acidosis, and alkalosis, respectively. In-hospital mortality occurred in 16.4% and 11.1% of patients with and without hyperlactataemia [adjusted odds ratio (OR) 1.49; 95% confidence interval (CI) 1.22-1.82, P < 0.0001]. Compared with normal pH, the OR for in-hospital mortality was 2.48 (95% CI 1.95-3.16, P < 0.0001) in patients with acidosis and 1.77 (95% CI 1.32-2.26, P < 0.0001) in patients with alkalosis. The risk for in-hospital mortality was high with acidosis (18.1%) or alkalosis (10.4%) even with normal lactate. The most common primary acid-base disturbances included metabolic acidosis, respiratory acidosis, and metabolic alkalosis with respiratory acidosis having the highest risk for in-hospital mortality.
Conclusion
Hyperlactataemia was common in patients without hypotension and was associated with increased risk for in-hospital mortality. Hyperlactataemia is not associated with any specific acid-base disorder. Acute heart failure patients also present with diverse acid-base disorders portending increased in-hospital mortality.

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

Eur Heart J Acute Cardiovasc Care: 15 Feb 2022; epub ahead of print
Bar O, Aronson D
Eur Heart J Acute Cardiovasc Care: 15 Feb 2022; epub ahead of print | PMID: 35171237
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Impact:
Abstract

Comparison of chlorthalidone and spironolactone as additional diuretic therapy in patients with acute heart failure and preserved ejection fraction.

Llàcer P, Núñez J, García M, Ruiz R, ... Gomis A, Manzano L
Aims
Patients with acute heart failure (AHF) require intensification in the diuretic strategy. However, the optimal diuretic strategy remains unclear. In this work, we aimed to evaluate the effect of chlorthalidone compared with spironolactone on diuretic efficacy and safety profile in a cohort of patients with AHF and preserved ejection fraction (AHF-pEF).
Methods and results
It was a prospective observational study in a single centre in Spain, included 44 consecutive patients admitted between June 2020 and March 2021, with AHF-pEF in which an additional diuretic was prescribed. The primary endpoint was changes in urinary sodium at 24 and 72 h, and the secondary were urine output, and other security endpoints. Mixed linear regression models were used to analyse the endpoints. Estimates were reported as least squares mean with their respective 95% confidence intervals. The median age of the study population was 85 years (82.5-88.5), and 30 (68.2%) were women. After multivariate analysis, the linear mixed regression analysis confirmed a greater natriuretic response of chlorthalidone over spironolactone, especially at 24 h (P = 0.009). Multivariate analysis also showed a greater cumulative diuretic response in those treated with chlorthalidone (P = 0.001). We did not find significant differences in glomerular filtration rate, serum sodium, and serum potassium at 72 h, neither significant differences were found in 24 and 72 h in systolic blood pressure.
Conclusion
In patients with AHF and left ventricular ejection fraction ≥50% receiving intravenous loop diuretics, chlorthalidone administration was associated with a greater short-term natriuresis.

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Eur Heart J Acute Cardiovasc Care: 14 Feb 2022; epub ahead of print
Llàcer P, Núñez J, García M, Ruiz R, ... Gomis A, Manzano L
Eur Heart J Acute Cardiovasc Care: 14 Feb 2022; epub ahead of print | PMID: 35167653
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Impact:
Abstract

Predictive ability of the sequential organ failure assessment score for in-hospital mortality in patients with cardiac critical illnesses: a nationwide observational study.

Nishimoto Y, Ohbe H, Matsui H, Nakajima M, ... Sato Y, Yasunaga H
Aims
Several studies have reported a high predictive ability of the Sequential Organ Failure Assessment (SOFA) score for in-hospital mortality specifically for patients with cardiac critical illnesses, however, differences according to the admission classification (surgical or non-surgical) are unknown. The present study aimed to evaluate the predictive ability of the SOFA score in surgical and non-surgical patients with cardiac critical illnesses.
Methods and results
Using the Japanese nationwide Diagnosis Procedure Combination database, we identified patients with cardiac critical illnesses, defined as patients admitted to the intensive care unit (ICU) and treated by cardiologists or cardiovascular surgeons as their physicians in charge from April 2018 to March 2020. The discriminatory ability of the SOFA score for in-hospital mortality was assessed by calculating the area under the receiver operating characteristic curve (AUROC). Among 52 819 eligible patients with available data on their SOFA scores, 33 526 (64%) were postoperative cardiac surgeries. The median SOFA score on ICU admission was 5.0 (interquartile range, 2.0-8.0) and overall in-hospital mortality 6.8%. The AUROC of the SOFA score was 0.75 [95% confidence interval (CI), 0.75-0.76]. In the subgroup analyses, the AUROCs were 0.76 (95% CI, 0.74-0.77) in the surgical patients, 0.83 (95% CI, 0.83-0.84) in the non-surgical patients, and 0.88 (95% CI, 0.87-0.89) in the non-surgical acute coronary syndrome patients.
Conclusions
The predictive ability of the SOFA score on the day of ICU admission for in-hospital mortality was confirmed to be acceptable in the patients with cardiac critical illnesses and varied according to the admission classification and primary diagnoses.

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Eur Heart J Acute Cardiovasc Care: 13 Feb 2022; epub ahead of print
Nishimoto Y, Ohbe H, Matsui H, Nakajima M, ... Sato Y, Yasunaga H
Eur Heart J Acute Cardiovasc Care: 13 Feb 2022; epub ahead of print | PMID: 35156119
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Impact:
Abstract

A 0/1h-algorithm using cardiac myosin-binding protein C for early diagnosis of myocardial infarction.

Kaier TE, Twerenbold R, Lopez-Ayala P, Nestelberger T, ... Mueller C, APACE Investigators
Aims 
Cardiac myosin-binding protein C (cMyC) demonstrated high diagnostic accuracy for the early detection of non-ST-elevation myocardial infarction (NSTEMI). Its dynamic release kinetics may enable a 0/1h-decision algorithm that is even more effective than the ESC hs-cTnT/I 0/1 h rule-in/rule-out algorithm.
Methods and results 
In a prospective international diagnostic study enrolling patients presenting with suspected NSTEMI to the emergency department, cMyC was measured at presentation and after 1 h in a blinded fashion. Modelled on the ESC hs-cTnT/I 0/1h-algorithms, we derived a 0/1h-cMyC-algorithm. Final diagnosis of NSTEMI was centrally adjudicated according to the 4th Universal Definition of Myocardial Infarction. Among 1495 patients, the prevalence of NSTEMI was 17%. The optimal derived 0/1h-algorithm ruled-out NSTEMI with cMyC 0 h concentration below 10 ng/L (irrespective of chest pain onset) or 0 h cMyC concentrations below 18 ng/L and 0/1 h increase <4 ng/L. Rule-in occurred with 0 h cMyC concentrations of at least 140 ng/L or 0/1 h increase ≥15 ng/L. In the validation cohort (n = 663), the 0/1h-cMyC-algorithm classified 347 patients (52.3%) as \'rule-out\', 122 (18.4%) as \'rule-in\', and 194 (29.3%) as \'observe\'. Negative predictive value for NSTEMI was 99.6% [95% confidence interval (CI) 98.9-100%]; positive predictive value 71.1% (95% CI 63.1-79%). Direct comparison with the ESC hs-cTnT/I 0/1h-algorithms demonstrated comparable safety and even higher triage efficacy using the 0h-sample alone (48.1% vs. 21.2% for ESC hs-cTnT-0/1 h and 29.9% for ESC hs-cTnI-0/1 h; P < 0.001).
Conclusion 
The cMyC 0/1h-algorithm provided excellent safety and identified a greater proportion of patients suitable for direct rule-out or rule-in based on a single measurement than the ESC 0/1h-algorithm using hs-cTnT/I.
Trial registration
ClinicalTrials.gov number, NCT00470587.

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

Eur Heart J Acute Cardiovasc Care: 11 Feb 2022; epub ahead of print
Kaier TE, Twerenbold R, Lopez-Ayala P, Nestelberger T, ... Mueller C, APACE Investigators
Eur Heart J Acute Cardiovasc Care: 11 Feb 2022; epub ahead of print | PMID: 35149868
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Impact:
Abstract

The association between time to extracorporeal cardiopulmonary resuscitation and outcome in patients with out-of-hospital cardiac arrest.

Kawakami S, Tahara Y, Koga H, Noguchi T, Inoue S, Yasuda S
Aims
Extracorporeal cardiopulmonary resuscitation (ECPR) is considered for potentially reversible out-of-hospital cardiac arrest (OHCA). However, the association between time to ECPR and outcome has not been well established.
Methods and results
Between June 2014 and December 2017, we enrolled 34 754 OHCA patients in a multicentre, prospective fashion [Japanese Association for Acute Medicine (JAAM)-OHCA registry]. After the application of exclusion criteria, 695 OHCA patients who underwent ECPR for cardiac causes were eligible for this study. We investigated the association between the call-to-ECPR interval and favourable neurological outcome (cerebral performance category 1 or 2) at 30 days. Seventy-seven patients (11%) had a favourable neurological outcome at 30 days. The call-to-ECPR intervals in these patients were significantly shorter than in those with an unfavourable neurological outcome [49 (41-58) vs. 58 (48-68) min, respectively, P < 0.001]. A longer call-to-ECPR interval was associated with a smaller proportion of patients undergoing percutaneous coronary intervention (PCI) (P = 0.034) or target temperature management (TTM) (P < 0.001). Stepwise multivariable logistic regression analysis revealed that the call-to-ECPR interval was an independent predictor of favourable neurological outcome [odds ratio (OR) 0.96, 95% confidence interval (CI) 0.94-0.99, P = 0.001], as were age, male gender, initial shockable rhythm, transient return of spontaneous circulation in the prehospital setting, arterial pH at hospital arrival, PCI (OR 2.30, 95% CI 1.14-4.66, P = 0.019), and TTM (OR 2.28, 95% CI 1.13-4.62, P = 0.019).
Conclusion
A shorter call-to-ECPR interval and implementation of PCI and TTM predicted a favourable neurological outcome at 30 days in OHCA patients who underwent ECPR for cardiac causes.

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

Eur Heart J Acute Cardiovasc Care: 09 Feb 2022; epub ahead of print
Kawakami S, Tahara Y, Koga H, Noguchi T, Inoue S, Yasuda S
Eur Heart J Acute Cardiovasc Care: 09 Feb 2022; epub ahead of print | PMID: 35143634
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 07 Feb 2022; 11:102-110
Bansal A, Jaber WA, Cremer P, Wassif H, Mentias A, Menon V
Eur Heart J Acute Cardiovasc Care: 07 Feb 2022; 11:102-110 | PMID: 34871384
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Impact:
Abstract

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

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

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

Eur Heart J Acute Cardiovasc Care: 07 Feb 2022; 11:160-169
Tolsma RT, Fokkert MJ, van Dongen DN, Badings EA, ... Ottervanger JP, van 't Hof AWJ
Eur Heart J Acute Cardiovasc Care: 07 Feb 2022; 11:160-169 | PMID: 34849660
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 07 Feb 2022; 11:137-147
Prepoudis A, Koechlin L, Nestelberger T, Boeddinghaus J, ... Mueller C, APACE investigators
Eur Heart J Acute Cardiovasc Care: 07 Feb 2022; 11:137-147 | PMID: 34849666
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 07 Feb 2022; 11:113-123
Tiller C, Reindl M, Holzknecht M, Lechner I, ... Metzler B, Reinstadler SJ
Eur Heart J Acute Cardiovasc Care: 07 Feb 2022; 11:113-123 | PMID: 34849677
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 07 Feb 2022; 11:148-159
Martens P, Ferreira JP, Vincent J, Abreu P, ... Zannad F, Rossignol P
Eur Heart J Acute Cardiovasc Care: 07 Feb 2022; 11:148-159 | PMID: 35021200
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 07 Feb 2022; 11:173-185
Masip J, Frank Peacok W, Arrigo M, Rossello X, ... Miró Ò, Acute Heart Failure Study Group of the Association for Acute Cardiovascular Care (ACVC) of the European Society of Cardiology
Eur Heart J Acute Cardiovasc Care: 07 Feb 2022; 11:173-185 | PMID: 35040931
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Impact:
Abstract

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

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

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

Eur Heart J Acute Cardiovasc Care: 07 Feb 2022; 11:89-98
Ekerstad N, Javadzadeh D, Alexander KP, Bergström O, ... Yndigegn T, Alfredsson J
Eur Heart J Acute Cardiovasc Care: 07 Feb 2022; 11:89-98 | PMID: 34905049
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Impact:
Abstract

Diagnostic accuracy of a high-sensitivity troponin I assay and external validation of 0/3 h rule out strategies.

van den Berg P, Collinson P, Morris N, Body R
Aims 
The timely diagnosis and exclusion of acute coronary syndromes in the Emergency Department (ED) remains a challenge. This study aims to evaluate the diagnostic accuracy of a high-sensitivity cardiac troponin I assay (Siemens TNIH) on serial sampling for ED patients as standalone test and in rule-out algorithms as recommendations remain assay specific.
Methods and results 
This secondary analysis from a prospective diagnostic accuracy study at 14 centres included ED patients presenting with chest pain of suspected cardiac nature. Serum drawn on arrival and 3 h later was batchtested for TNIH. The target condition was an adjudicated diagnosis of acute myocardial infarction (AMI). We evaluated the diagnostic accuracy of absolute and relative delta criteria and four rule-out strategies. Of 802 included patients, 13.8% had AMI. Absolute delta criteria had superior accuracy to relative criteria (C-statistic 0.94 vs. 0.76, P < 0.001). However, no delta criteria achieved >95.5% sensitivity for AMI when used alone. Ruling out AMI with TNIH below the 99th percentile at 0 and 3 h had 88.3% (95% confidence interval 80.8-93.6%) sensitivity. The adapted European Society of Cardiology (ESC) 0/2 h algorithm had higher sensitivity (98.2%) than both High-STEACS (93.7%, P = 0.03) and the ESC 0/3 h algorithm (79.3%, P < 0.001). These pathways ruled out 63%, 74%, and 88% patients, respectively.
Conclusion 
With serial sampling over 3 h, the Siemens TNIH assay should be used with a validated algorithm incorporating bespoke cut-offs and absolute delta criteria. In our analysis, the adapted ESC 0/2 h algorithm had greatest sensitivity. \'Ruling out\' AMI using the 99th percentile of the assay cannot be recommended.

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Eur Heart J Acute Cardiovasc Care: 07 Feb 2022; 11:127-136
van den Berg P, Collinson P, Morris N, Body R
Eur Heart J Acute Cardiovasc Care: 07 Feb 2022; 11:127-136 | PMID: 35136994
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Impact:
Abstract

Acute ischaemic stroke and its challenges for the intensivist.

Robba C, van Dijk EJ, van der Jagt M
Acute ischaemic stroke (AIS) is responsible for almost 90% of all strokes and is one of the leading causes of death and disability. Acute ischaemic stroke is caused by a critical alteration in focal cerebral blood flow (ischaemia) from a variety of causes, resulting in infarction. The primary cerebral injury due to AIS occurs in the first hours, therefore early reperfusion importantly impacts on patient outcome (\'Time is brain\' concept). Secondary cerebral damage progressively evolves over the following hours and days due to cerebral oedema, haemorrhagic transformation, and cerebral inflammation. Systemic complications, such as pneumonia, sepsis, and deep venous thrombosis, could also affect outcome. The risk of a recurrent ischaemic stroke is in particular high in the first days, which necessitate particular attention. The role of intensive care unit physicians is therefore to avoid or reduce the risk of secondary damage, especially in the areas where the brain is functionally impaired and \'at risk\' of further injury. Therapeutic strategies therefore consist of restoration of blood flow and a bundle of medical, endovascular, and surgical strategies, which-when applied in a timely and consistent manner-can prevent secondary deterioration due to cerebral and systemic complications and recurrent stroke and improve short- and long-term outcomes. A multidisciplinary collaboration between neurosurgeons, interventional radiologists, neurologists, and intensivists is necessary to elaborate the best strategy for the treatment of these patients.

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Eur Heart J Acute Cardiovasc Care: 02 Feb 2022; epub ahead of print
Robba C, van Dijk EJ, van der Jagt M
Eur Heart J Acute Cardiovasc Care: 02 Feb 2022; epub ahead of print | PMID: 35134852
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Impact:
Abstract

A pragmatic lab-based tool for risk assessment in cardiac critical care: data from the Critical Care Cardiology Trials Network (CCCTN) Registry.

Patel SM, Jentzer JC, Alviar CL, Baird-Zars VM, ... Katz JN, Morrow DA
Aims
Contemporary cardiac intensive care unit (CICU) outcomes remain highly heterogeneous. As such, a risk-stratification tool using readily available lab data at time of CICU admission may help inform clinical decision-making.
Methods and results
The primary derivation cohort included 4352 consecutive CICU admissions across 25 tertiary care CICUs included in the Critical Care Cardiology Trials Network (CCCTN) Registry. Candidate lab indicators were assessed using multivariable logistic regression. An integer risk score incorporating the top independent lab indicators associated with in-hospital mortality was developed. External validation was performed in a separate CICU cohort of 9716 patients from the Mayo Clinic (Rochester, MN, USA). On multivariable analysis, lower pH [odds ratio (OR) 1.96, 95% confidence interval (CI) 1.72-2.24], higher lactate (OR 1.40, 95% CI 1.22-1.62), lower estimated glomerular filtration rate (OR 1.26, 95% CI 1.10-1.45), and lower platelets (OR 1.18, 95% CI 1.05-1.32) were the top four independent lab indicators associated with higher in-hospital mortality. Incorporated into the CCCTN Lab-Based Risk Score, these four lab indicators identified a 20-fold gradient in mortality risk with very good discrimination (C-index 0.82, 95% CI 0.80-0.84) in the derivation cohort. Validation of the risk score in a separate cohort of 3888 patients from the Registry demonstrated good performance (C-index of 0.82; 95% CI 0.80-0.84). Performance remained consistent in the external validation cohort (C-index 0.79, 95% CI 0.77-0.80). Calibration was very good in both validation cohorts (r = 0.99).
Conclusion
A simple integer risk score utilizing readily available lab indicators at time of CICU admission may accurately stratify in-hospital mortality risk.

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Eur Heart J Acute Cardiovasc Care: 02 Feb 2022; epub ahead of print
Patel SM, Jentzer JC, Alviar CL, Baird-Zars VM, ... Katz JN, Morrow DA
Eur Heart J Acute Cardiovasc Care: 02 Feb 2022; epub ahead of print | PMID: 35134860
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Impact:
Abstract

Epidemiology and outcomes of pulmonary hypertension in the cardiac intensive care unit.

Jentzer JC, Wiley BM, Reddy YNV, Barnett C, Borlaug BA, Solomon MA
Aims
Pulmonary hypertension (PH) has been consistently associated with adverse outcomes in hospitalized patients. Limited epidemiologic data exist regarding PH in the cardiac intensive care unit (CICU) population. Here, we describe the prevalence, aetiology, and outcomes of PH in the CICU.
Methods and results
Cardiac intensive care unit patients admitted from 2007 to 2018 who had right ventricular systolic pressure (RVSP) measured via transthoracic echocardiography near CICU admission were included. PH was defined as RVSP >35 mmHg, and moderate-to-severe PH as RVSP ≥50 mmHg. Predictors of in-hospital mortality were determined using multivariable logistic regression. Among 5042 patients (mean age 69.4 ± 14.8 years; 41% females), PH was present in 3085 (61%). The majority (68%) of patients with PH had left heart failure, and 29% had lung disease. In-hospital mortality occurred in 8.3% and was more frequent in patients with PH [10.9% vs. 4.2%, adjusted odds ratio (OR) 1.40, 95% confidence interval (CI) 1.03-1.92, P = 0.03], particularly patients with moderate-to-severe PH (14.4% vs. 6.2%, adjusted OR 1.65, 95% CI 1.27-2.14, P < 0.001). In-hospital mortality increased incrementally as a function of higher RVSP (adjusted 1.18 per 10 mmHg increase, 95% CI 1.09-1.28, P < 0.001). Patients with higher RVSP or moderate-to-severe PH had increased in-hospital mortality across admission diagnoses (all P < 0.05).
Conclusions
Pulmonary hypertension is very common in the CICU population and appears to be independently associated with a higher risk of death during hospitalization, although the strength of this association varies according to the underlying admission diagnosis. These data highlight the importance of PH in patients with cardiac critical illness.

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Eur Heart J Acute Cardiovasc Care: 21 Jan 2022; epub ahead of print
Jentzer JC, Wiley BM, Reddy YNV, Barnett C, Borlaug BA, Solomon MA
Eur Heart J Acute Cardiovasc Care: 21 Jan 2022; epub ahead of print | PMID: 35064269
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Impact:
Abstract

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

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

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

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

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

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

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

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

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

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

Critical care management of the patient with pulmonary hypertension.

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

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

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

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

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

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

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

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

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

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

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

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.

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

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

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

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.

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

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

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

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:1016-1026
Sawatani T, Shirakabe A, Okazaki H, Matsushita M, ... Shimizu W, Asai K
Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:1016-1026 | PMID: 34432003
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:978-987
Sun H, Li Z, Song X, Liu H, ... Yang Q, CCC-ACS Investigators
Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:978-987 | PMID: 34263300
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:967-975
Otani T, Ichiba T, Kashiwa K, Naito H
Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:967-975 | PMID: 34458899
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:1074-1083
Petersen LT, Riddersholm S, Andersen DC, Polcwiartek C, ... Rasmussen BS, Kragholm KH
Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:1074-1083 | PMID: 34648620
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:1056-1064
Andersen CF, Bang C, Lauridsen KG, Frederiksen CA, ... Hornung N, Løfgren B
Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:1056-1064 | PMID: 34423355
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:1027-1037
Ma I, Genet T, Clementy N, Bisson A, ... Ivanes F, Fauchier L
Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:1027-1037 | PMID: 34453835
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:999-1006
Ancona MB, Montorfano M, Masiero G, Burzotta F, ... Tarantini G, Chieffo A
Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:999-1006 | PMID: 34389852
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:1038-1047
Khan E, Lambrakis K, Blyth A, Seshadri A, ... Nelson AJ, Chew DP
Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:1038-1047 | PMID: 34195809
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:1086-1098
Dauw J, Dupont M, Martens P, Nijst P, Mullens W
Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:1086-1098 | PMID: 34697640
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:1065-1073
Chichareon P, Nilmoje T, Suriyaamorn W, Preechawettayakul I, Suwanugsorn S
Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:1065-1073 | PMID: 34448824
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:990-998
Milasinovic D, Mladenovic D, Zaharijev S, Mehmedbegovic Z, ... Vukcevic V, Stankovic G
Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:990-998 | PMID: 34151365
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Impact:
Abstract

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

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

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

Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:1009-1015
Karami M, Eriksen E, Ouweneel DM, Claessen BE, ... Lagrand WK, Henriques JPS
Eur Heart J Acute Cardiovasc Care: 06 Dec 2021; 10:1009-1015 | PMID: 34327527
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Impact:
Abstract

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

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

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:918-925
Galcerá-Jornet E, Consuegra-Sánchez L, Galcerá-Tomás J, Melgarejo-Moreno A, ... Vicente-Gilabert M, Padilla-Serrano A
Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:918-925 | PMID: 33993235
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:890-897
Freund A, Pöss J, de Waha-Thiele S, Meyer-Saraei R, ... Desch S, Thiele H
Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:890-897 | PMID: 34529043
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:829-839
Mohamed MO, Van Spall HGC, Kontopantelis E, Alkhouli M, ... Bhatt DL, Mamas MA
Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:829-839 | PMID: 33587752
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:947-959
Gevaert SA, Halvorsen S, Sinnaeve PR, Sambola A, ... Okines A, Asteggiano R
Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:947-959 | PMID: 34453829
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:940-946
Jentzer JC, Rossello X
Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:940-946 | PMID: 34453848
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:843-851
Miller PE, Mullan CW, Chouairi F, Sen S, ... Desai NR, Ahmad T
Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:843-851 | PMID: 34389855
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:855-865
Weichwald S, Candreva A, Burkholz R, Klingenberg R, ... Buhmann JM, Matter CM
Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:855-865 | PMID: 34015112
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:909-917
Johannessen Ø, Claggett B, Lewis EF, Groarke JD, ... Solomon SD, Platz E
Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:909-917 | PMID: 34160009
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:878-889
Rossello X, Massó-van Roessel A, Perelló-Bordoy A, Mas-Lladó C, ... Pons J, Peral V
Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:878-889 | PMID: 34151368
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:898-908
Otero-García O, Cid-Álvarez AB, Juskova M, Álvarez-Álvarez B, ... Trillo-Nouche R, González-Juanatey JR
Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:898-908 | PMID: 34327531
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:933-939
Sharkey SW, Alfadhel M, Thaler C, Lin D, ... Henry TD, Saw J
Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:933-939 | PMID: 33580787
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Impact:
Abstract

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

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

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Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:869-877
Chunawala ZS, Hall ME, Arora S, Dai X, ... Matsushita K, Caughey MC
Eur Heart J Acute Cardiovasc Care: 27 Oct 2021; 10:869-877 | PMID: 34263294
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Impact:
Abstract

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

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

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

Population-based incidence and outcomes of acute aortic dissection in Japan.

Yamaguchi T, Nakai M, Yano T, Matsuyama M, ... Ueda Y, Ogino H
Aims
The population-based incidence and outcomes of acute aortic dissection (AAD) are still unknown because some patients are already dead on arrival, and the accurate diagnosis of AAD is difficult due to the low autopsy rate. We performed a population-based review of all patients with AAD in a well-defined geographical area in Japan between 2016 and 2018.
Methods and results
Data of all patients with AAD at Miyazaki Prefectural Nobeoka Hospital (MPNH), which performs medical care for 120 000 residents, were collected retrospectively. The emergency medical service is dedicated to the transfer of all patients in this area to the MPNH. For all patients who were dead on arrival, the diagnosis of AAD was made by autopsy imaging (AI) using computed tomography. The age-adjusted incidence and mortality per 100 000 population were calculated using the Japanese population distribution model in 2015. The total incidence of AAD was 79 (type A: 64.5%, n = 51). Of those, 60.8% (31/51) of patients with type A and 21.4% (6/28) with type B were dead on arrival and diagnosed by AI. The 30-day mortality rates were 74.5% (38/51) in type A and 25.0% (7/28) in type B. The age-adjusted incidence and mortality of AAD per 100 000 inhabitants were 17.6 (type A: 11.3, type B: 6.2) and 9.9 (type A: 8.4, type B: 1.5), respectively.
Conclusions
The population-based survey of AAD showed that the age-adjusted incidence of AAD was two-fold higher than in previous reports, and the actual mortality rates were markedly higher due to the high incidence of dead-on-arrival.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Acute Cardiovasc Care: 01 Oct 2021; 10:701-709
Yamaguchi T, Nakai M, Yano T, Matsuyama M, ... Ueda Y, Ogino H
Eur Heart J Acute Cardiovasc Care: 01 Oct 2021; 10:701-709 | PMID: 34189568
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Abstract

The association between cardiac intensive care unit mechanical ventilation volumes and in-hospital mortality.

Nandiwada S, Islam S, Jentzer JC, Miller PE, ... Kaul P, van Diepen S
Aims
The incidence of respiratory failure and use of invasive or non-invasive mechanical ventilation (MV) in the cardiac intensive care units (CICUs) is increasing. While institutional MV volumes are associated with reduced mortality in medical and surgical ICUs, this volume-mortality relationship has not been characterized in the CICU.
Methods and results
National population-based data were used to identify patients admitted to CICUs (2005-2015) requiring MV in Canada. CICUs were categorized into low (≤100), intermediate (101-300), and high (>300) volume centres based on spline knots identified in the association between annual MV volume and mortality. Outcomes of interest included all-cause in-hospital mortality, the proportion of patients requiring prolonged MV (>96 h) and CICU length of stay (LOS). Among 47 173 CICU admissions requiring MV, 89.5% (42 200) required invasive MV. The median annual CICU MV volume was 43 (inter-hospital range 1-490). Compared to low-volume centres (35.9%), in-hospital mortality was lower in intermediate [29.2%, adjusted odds ratio (aOR) 0.84, 95% confidence interval (CI) 0.72-0.97, P = 0.019] and high-volume (18.2%; aOR 0.82, 95% CI 0.66-1.02, P = 0.076) centres. Prolonged MV was higher in low-volume (29.2%) compared to high-volume (14.8%, aOR 0.70, 95% CI 0.55-0.89, P = 0.003) and intermediate-volume (23.0%, aOR 0.85, 95% CI 0.68-1.06, P = 0.14] centres. Mortality and prolonged MV were lower in percutaneous coronary intervention (PCI)-capable and academic centres, but a shorter CICU LOS was observed only in subgroup of PCI-capable intermediate- and high-volume hospitals.
Conclusions
In a national dataset, we observed that higher CICU MV volumes were associated with lower incidence of in-hospital mortality, prolonged MV, and CICU LOS. Our data highlight the need for minimum MV volume benchmarks for CICUs caring for patients with respiratory failure.

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Eur Heart J Acute Cardiovasc Care: 01 Oct 2021; 10:797-805
Nandiwada S, Islam S, Jentzer JC, Miller PE, ... Kaul P, van Diepen S
Eur Heart J Acute Cardiovasc Care: 01 Oct 2021; 10:797-805 | PMID: 34318875
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Abstract

\'Ticagrelor alone vs. dual antiplatelet therapy from 1 month after drug-eluting coronary stenting among patients with STEMI\': a post hoc analysis of the randomized GLOBAL LEADERS trial.

Gamal AS, Hara H, Tomaniak M, Lunardi M, ... Onuma Y, Serruys PW
Aim
To evaluate the efficacy and safety of ticagrelor monotherapy beyond 1 month and up to 24 months vs. standard 12-month dual antiplatelet therapy (DAPT) with aspirin and ticagrelor followed by aspirin monotherapy among ST-elevation myocardial infarction (STEMI) patients undergoing percutaneous coronary intervention (PCI) in the GLOBAL LEADERS trial.
Methods and results
We performed a post hoc analysis of STEMI patients in the GLOBAL LEADERS trial comparing experimental ticagrelor monotherapy (1062 patients) with standard 12-month DAPT (1030 patients). We evaluated predefined primary and secondary endpoints in both treatment arms. Rates of net adverse clinical events (NACE), patient-oriented composite endpoints (POCE), and bleeding academic research consortium (BARC)-defined bleeding Type 3 or 5 were also evaluated. At 2 years, there were no significant differences in rates of primary endpoints in patients who had STEMI [0.89 (0.61-1.31)]. There were similar rates of NACE and POCE in both experimental and reference treatment groups at 2 years post-PCI [hazard ratio (HR) 0.96 (0.77-1.20) and 0.96 (0.77-1.21), respectively]. BARC 3 or 5 bleeding events were numerically less in experimental compared to reference treatment groups at 1 year [HR 0.55 (0.27-1.13)] and 2 years [0.61 (0.32-1.16)].
Conclusion
Presentation with STEMI has not influenced the incidence of GLOBAL LEADERS defined primary endpoints. There were no significant differences in rates of NACE, POCE, and BARC bleeding between the two treatment groups up to 2 years of follow-up. Although these findings should be viewed as exploratory, they expand the evidence on potential safety of aspirin-free antiplatelet strategies after PCI in STEMI.

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

Eur Heart J Acute Cardiovasc Care: 01 Oct 2021; 10:756-773
Gamal AS, Hara H, Tomaniak M, Lunardi M, ... Onuma Y, Serruys PW
Eur Heart J Acute Cardiovasc Care: 01 Oct 2021; 10:756-773 | PMID: 34212187
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Abstract

Predicting outcome in acute myocardial infarction: an analysis investigating 175 circulating biomarkers.

Eggers KM, Lindhagen L, Lindhagen L, Baron T, ... Spaak J, Lindahl B
Aims 
There is a paucity of studies comprehensively comparing the prognostic value of larger arrays of biomarkers indicative of different pathobiological axes in acute myocardial infarction (MI).
Methods and results 
In this explorative investigation, we simultaneously analysed 175 circulating biomarkers reflecting different inflammatory traits, coagulation activity, endothelial dysfunction, atherogenesis, myocardial dysfunction and damage, apoptosis, kidney function, glucose-, and lipid metabolism. Measurements were performed in samples from 1099 MI patients (SWEDEHEART registry) applying two newer multimarker panels [Proximity Extension Assay (Olink Bioscience), Multiple Reaction Monitoring mass spectrometry]. The prognostic value of biomarkers regarding all-cause mortality, recurrent MI, and heart failure hospitalizations (median follow-up ≤6.6 years) was studied using Lasso analysis, a penalized logistic regression model that considers all biomarkers simultaneously while minimizing the risk for spurious findings. Tumour necrosis factor-related apoptosis-inducing ligand receptor 2 (TRAIL-R2), ovarian cancer-related tumour marker CA 125 (CA-125), and fibroblast growth factor 23 (FGF-23) consistently predicted all-cause mortality in crude and age/sex-adjusted analyses. Growth-differentiation factor 15 (GDF-15) was strongly predictive in the crude model. TRAIL-R2 and B-type natriuretic peptide (BNP) consistently predicted heart failure hospitalizations. No biomarker predicted recurrent MI. The prognostic value of all biomarkers was abrogated following additional adjustment for clinical variables owing to our rigorous statistical approach.
Conclusion 
Apart from biomarkers with established prognostic value (i.e. BNP and to some extent GDF-15), several \'novel\' biomarkers (i.e. TRAIL-R2, CA-125, FGF-23) emerged as risk predictors in patients with MI. Our data warrant further investigation regarding the utility of these biomarkers for clinical decision-making in acute MI.

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Eur Heart J Acute Cardiovasc Care: 01 Oct 2021; 10:806-812
Eggers KM, Lindhagen L, Lindhagen L, Baron T, ... Spaak J, Lindahl B
Eur Heart J Acute Cardiovasc Care: 01 Oct 2021; 10:806-812 | PMID: 34100060
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Abstract

Prediction of right heart failure after left ventricular assist implantation: external validation of the EUROMACS right-sided heart failure risk score.

Rivas-Lasarte M, Kumar S, Derbala MH, Ferrall J, ... Smith SA, Sims DB
Aims
Prediction of right heart failure (RHF) after left ventricular assist device (LVAD) implant remains a challenge. The EUROMACS right-sided heart failure (EUROMACS-RHF) risk score was proposed as a prediction tool for post-LVAD RHF but lacks from large external validation. The aim of our study was to externally validate the score.
Methods and results
From January 2007 to December 2017, 878 continuous-flow LVADs were implanted at three tertiary centres. We calculated the EUROMACS-RHF score in 662 patients with complete data. We evaluated its predictive performance for early RHF defined as either (i) need for short- or long-term right-sided circulatory support, (ii) continuous inotropic support for ≥14 days, or (iii) nitric oxide for ≥48 h post-operatively. Right heart failure occurred in 211 patients (32%). When compared with non-RHF patients, pre-operatively they had higher creatinine, bilirubin, right atrial pressure, and lower INTERMACS class (P < 0.05); length of stay and in-hospital mortality were higher. Area under the ROC curve for RHF prediction of the EUROMACS-RHF score was 0.64 [95% confidence interval (CI) 0.60-0.68]. Reclassification of patients with RHF was significantly better when applying the EUROMACS-RHF risk score on top of previous published scores. Patients in the high-risk category had significantly higher in-hospital and 2-year mortality [hazard ratio: 1.64 (95% CI 1.16-2.32) P = 0.005].
Conclusion
In an external cohort, the EUROMACS-RHF had limited discrimination predicting RHF. The clinical utility of this score remains to be determined.

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Eur Heart J Acute Cardiovasc Care: 01 Oct 2021; 10:723-732
Rivas-Lasarte M, Kumar S, Derbala MH, Ferrall J, ... Smith SA, Sims DB
Eur Heart J Acute Cardiovasc Care: 01 Oct 2021; 10:723-732 | PMID: 34050652
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Abstract

Diagnostic pathways in myocardial infarction with non-obstructive coronary artery disease (MINOCA).

Occhipinti G, Bucciarelli-Ducci C, Capodanno D
When acute myocardial injury is found in a clinical setting suggestive of myocardial ischaemia, the event is labelled as acute myocardial infarction (AMI), and the absence of coronary stenosis angiographically 50% or greater leads to the working diagnosis of myocardial infarction with non-obstructive coronary arteries (MINOCA). The initial diagnosis of MINOCA can be confirmed or ruled out based on the results of subsequent investigations. This narrative review discusses the downstream diagnostic approaches to MINOCA, and appraises strengths and limitations of invasive and non-invasive investigations for this condition. The aim of this article is to increase the awareness that establishing the underlying cause of a MINOCA is possible in the vast majority cases. Determining the cause of MINOCA and excluding other possible causes for cardiac troponin elevation has notable implications for tailoring secondary prevention measures aimed at improving the overall prognosis of AMI.

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Eur Heart J Acute Cardiovasc Care: 01 Oct 2021; 10:813-822
Occhipinti G, Bucciarelli-Ducci C, Capodanno D
Eur Heart J Acute Cardiovasc Care: 01 Oct 2021; 10:813-822 | PMID: 34179954
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Abstract

Outcome of patients with different clinical presentations of high-risk pulmonary embolism.

Ebner M, Sentler C, Harjola VP, Bueno H, ... Konstantinides SV, Lankeit M
Aims
The 2019 European Society of Cardiology (ESC) guidelines provide a revised definition of high-risk pulmonary embolism (PE) encompassing three clinical presentations: Cardiac arrest, obstructive shock, and persistent hypotension. This study investigated the prognostic implications of this new definition.
Methods and results
Data from 784 consecutive PE patients prospectively enrolled in a single-centre registry were analysed. Study outcomes include an in-hospital adverse outcome (PE-related death or cardiopulmonary resuscitation) and in-hospital all-cause mortality. Overall, 86 patients (11.0%) presented with high-risk PE and more often had an adverse outcome (43.0%) compared to intermediate-high-risk patients (6.1%; P < 0.001). Patients with cardiac arrest had the highest rate of an in-hospital adverse outcome (78.4%) and mortality (59.5%; both P < 0.001 compared to intermediate-high-risk patients). Obstructive shock and persistent hypotension had similar rates of adverse outcomes (15.8% and 18.2%, respectively; P = 0.46), but the only obstructive shock was associated with an increased all-cause mortality risk. Use of an optimised venous lactate cut-off value (3.8 mmol/L) to diagnose obstructive shock allowed differentiation of adverse outcome risk between patients with shock (21.4%) and persistent hypotension (9.5%), resulting in a net reclassification improvement (0.24 ± 0.08; P = 0.002).
Conclusion
The revised ESC 2019 guidelines definition of high-risk PE stratifies subgroups at different risk of in-hospital adverse outcomes and all-cause mortality. Risk prediction can be improved by using an optimised venous lactate cut-off value to diagnose obstructive shock, which might help to better assess the risk-to-benefit ratio of systemic thrombolysis in different subgroups of high-risk patients.

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

Eur Heart J Acute Cardiovasc Care: 01 Oct 2021; 10:787-796
Ebner M, Sentler C, Harjola VP, Bueno H, ... Konstantinides SV, Lankeit M
Eur Heart J Acute Cardiovasc Care: 01 Oct 2021; 10:787-796 | PMID: 34125186
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Abstract

Clinical presentation of patients with prior coronary artery bypass grafting and suspected acute myocardial infarction.

Koechlin L, Boeddinghaus J, Nestelberger T, Miró Ò, ... Mueller C, APACE investigators
Aims
Diagnosis of acute myocardial infarction (AMI) can be challenging in patients with prior coronary artery bypass grafting (CABG).
Methods and results
Final diagnoses were adjudicated by two independent cardiologists using the universal definition of AMI among patients presenting to the emergency department (ED) with suspected AMI. Diagnostic accuracy of 34 chest pain characteristics (CPCs) and four electrocardiogram (ECG) signatures stratified according to the presence or absence of prior CABG were prospectively quantified. Among 4015 patients (no prior CABG: n = 3686; prior CABG: n = 329), prevalence of AMI and unstable angina were higher in patients with prior CABG (35% vs. 18%; 26% vs. 8%; both P < 0.001). Three CPCs (9%) and two electrocardiographic findings (50%) showed a different diagnostic performance (interaction P < 0.05) with loss of diagnostic value in patients with prior CABG. The diagnostic accuracy as quantified by the area under the curve (AUC) of the integrated clinical judgement was moderate to good in patients with prior CABG, and significantly lower compared to patients without prior CABG [AUC 0.80 (95% confidence interval (CI) 0.75-0.84) vs. AUC 0.87 (95% CI 0.86-0.89); P = 0.004]. Time to discharge from the ED was significantly longer in patients with prior CABG [359 (215-525) min vs. 300 (192-435) min; P < 0.001]. Key findings were confirmed in a large independent external validation cohort (n = 13 653).
Conclusions
Patients with prior CABG presenting with suspected AMI have a high prevalence of AMI and unstable angina and lower diagnostic accuracy of CPCs and the ECG, possibly justifying liberal use of early coronary angiography in these vulnerable patients.
Clinicaltrials.gov registry
Number NCT00470587.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.

Eur Heart J Acute Cardiovasc Care: 01 Oct 2021; 10:746-755
Koechlin L, Boeddinghaus J, Nestelberger T, Miró Ò, ... Mueller C, APACE investigators
Eur Heart J Acute Cardiovasc Care: 01 Oct 2021; 10:746-755 | PMID: 33620434
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Abstract

Initiation of and persistence with P2Y12 inhibitors in patients with myocardial infarction according to revascularization strategy: a nationwide study.

Tajchman DH, Nabi H, Aslam M, Butt JH, ... Køber L, Sørensen R
Background
We aimed to analyse initiation of and persistence with P2Y12 inhibitors after first-time myocardial infarction (MI).
Methods and results
Using Danish nationwide registries, we identified patients ≥30 years with first-time MI during 1 January 2005-30 June 2016 and subsequent prescriptions of P2Y12 inhibitors. Independent factors related to initiation of and persistence with P2Y12 inhibitors were analysed by multivariable logistic regression and a Cox proportional hazards model. Patients were stratified by revascularization strategy: percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or medical therapy alone (MTA). Overall, 79 597 MI patients were included with 39 172 undergoing PCI, 2619 CABG, and 16 640 MTA, showing initiation of P2Y12 inhibitors of 93.4%, 49.0%, and 51.5%, respectively. Congestive heart failure, cerebrovascular disease, cardiac dysrhythmias, renal failure, previous bleeding, and oral anticoagulants were associated with less initiation of P2Y12 inhibitors. Female sex was associated with less initiation of P2Y12 inhibitors following MTA. MTA, coronary angiography, cerebrovascular disease, diabetes with complications, previous bleeding, antidiabetics, and ticagrelor as P2Y12 inhibitor were associated with non-persistence, whereas female sex, advanced age, and concomitant pharmacotherapy with angiotensin-converting enzyme inhibitors, beta-blockers, statins, oral anticoagulants, and aspirin were associated with high persistence.
Conclusion
Initiation of P2Y12 inhibitors in PCI-treated MI patients was high in contrast to those treated with CABG or MTA and patients with certain comorbidities. Further studies on the benefit-risk ratio of P2Y12 inhibitors in CABG-treated or MTA-treated patients and patients with comorbidities after first-time MI are warranted, as is focus on persistence among patients receiving MTA, patients with comorbidities, and users of ticagrelor.

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Eur Heart J Acute Cardiovasc Care: 01 Oct 2021; 10:774-786
Tajchman DH, Nabi H, Aslam M, Butt JH, ... Køber L, Sørensen R
Eur Heart J Acute Cardiovasc Care: 01 Oct 2021; 10:774-786 | PMID: 34570197
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