Journal: Eur Heart J Acute Cardiovasc Care

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Abstract

2020 Update of the quality indicators for acute myocardial infarction: a position paper of the Association for Acute Cardiovascular Care: the study group for quality indicators from the ACVC and the NSTE-ACS guideline group.

Schiele F, Aktaa S, Rossello X, Ahrens I, ... Ibanez B, Hassager C
Aims
Quality indicators (QIs) are tools to improve the delivery of evidence-base medicine. In 2017, the European Society of Cardiology (ESC) Association for Acute Cardiovascular Care (ACVC) developed a set of QIs for acute myocardial infarction (AMI), which have been evaluated at national and international levels and across different populations. However, an update of these QIs is needed in light of the accumulated experience and the changes in the supporting evidence.
Methods and results
The ESC methodology for the QI development was used to update the 2017 ACVC QIs. We identified key domains of AMI care, conducted a literature review, developed a list of candidate QIs, and used a modified Delphi method to select the final set of indicators. The same seven domains of AMI care identified by the 2017 Study Group were retained for this update. For each domain, main and secondary QIs were developed reflecting the essential and complementary aspects of care, respectively. Overall, 26 QIs are proposed in this document, compared to 20 in the 2017 set. New QIs are proposed in this document (e.g. the centre use of high-sensitivity troponin), some were retained or modified (e.g. the in-hospital risk assessment), and others were retired in accordance with the changes in evidence [e.g. the proportion of patients with non-ST segment elevation myocardial infarction (NSTEMI) treated with fondaparinux] and the feasibility assessments (e.g. the proportion of patients with NSTEMI whom risk assessment is performed using the GRACE and CRUSADE risk scores).
Conclusion
Updated QIs for the management of AMI were developed according to contemporary knowledge and accumulated experience. These QIs may be applied to evaluate and improve the quality of AMI care.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 07 Apr 2021; 10:224-233
Schiele F, Aktaa S, Rossello X, Ahrens I, ... Ibanez B, Hassager C
Eur Heart J Acute Cardiovasc Care: 07 Apr 2021; 10:224-233 | PMID: 33550362
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Impact:
Abstract

Association between cardiac rhythm conversion and neurological outcome among cardiac arrest patients with initial shockable rhythm: a nationwide prospective study in Japan.

Kandori K, Okada Y, Okada A, Nakajima S, ... Narumiya H, Iizuka R
Aims
Initial cardiac rhythm, particularly shockable rhythm, is a key factor in resuscitation for out-of-hospital cardiac arrest (OHCA) patients. The purpose of this study was to clarify the association between cardiac rhythm conversion and neurologic prognosis in OHCA patients with initial shockable rhythm at the scene.
Methods and results
The study included adult patients with OHCA due to medical causes with pre-hospital initial shockable rhythm and who were still in cardiac arrest at hospital arrival. Multiple logistic regression analysis was conducted to identify the adjusted odds ratios (AORs) and 95% confidence interval (CI) of cardiac arrest rhythm at hospital arrival for 1-month favourable neurologic status and 1-month survival, adjusted for potential confounders. Of 34 754 patients in the 2014-2017 JAAM-OHCA Registry, 1880 were included in the final study analysis. The percentages of 1-month favourable neurologic status for shockable rhythm, pulseless electrical activity (PEA), and asystole at hospital arrival were 17.4% (137/789), 3.6% (18/507), and 1.5% (9/584), respectively. The AORs for 1-month favourable neurologic status comparing to OHCA patients who maintained shockable rhythm at hospital arrival were PEA, 0.19 (95% CI, 0.11-0.32) and asystole, 0.08 (95% CI, 0.04-0.16), respectively.
Conclusion
Findings showed that the 1-month neurologic outcome in OHCA patients who converted to non-shockable rhythm at hospital arrival was very poor compared with patients who had sustained shockable rhythm. Also, patients with conversion to PEA had better neurologic prognosis than conversion to asystole.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 07 Apr 2021; 10:119-126
Kandori K, Okada Y, Okada A, Nakajima S, ... Narumiya H, Iizuka R
Eur Heart J Acute Cardiovasc Care: 07 Apr 2021; 10:119-126 | PMID: 33620425
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Abstract

The value of urinary sodium assessment in acute heart failure.

Tersalvi G, Dauw J, Gasperetti A, Winterton D, ... Pedrazzini G, Mullens W
Acute heart failure (AHF) is a frequent medical condition that needs immediate evaluation and appropriate treatment. Patients with signs and symptoms of volume overload mostly require intravenous loop diuretics in the first hours of hospitalization. Some patients may develop diuretic resistance, resulting in insufficient and delayed decongestion, with increased mortality and morbidity. Urinary sodium measurement at baseline and/or during treatment has been proposed as a useful parameter to tailor diuretic therapy in these patients. This systematic review discusses the current sum of evidence regarding urinary sodium assessment to evaluate diuretic efficacy in AHF. We searched Medline, Embase, and Cochrane Clinical Trials Register for published studies that tested urinary sodium assessment in patients with AHF.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 07 Apr 2021; 10:216-223
Tersalvi G, Dauw J, Gasperetti A, Winterton D, ... Pedrazzini G, Mullens W
Eur Heart J Acute Cardiovasc Care: 07 Apr 2021; 10:216-223 | PMID: 33620424
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Abstract

Non-fatal cardiovascular events preceding sudden cardiac death in patients with an acute myocardial infarction complicated by heart failure: insights from the high-risk myocardial infarction database.

Hui SK, Sharma A, Docherty K, McMurray JJV, ... Ferreira JP, Zannad F
Aims
Among patients with acute myocardial infarction (AMI) complicated by heart failure [HF; clinical HF or left ventricular (LV) systolic dysfunction], we explored the probability of subsequent non-fatal cardiovascular (CV) events and sudden cardiac death (SCD).
Methods and results
The high-risk myocardial infarction (HRMI) database contains 28 771 patients with signs of HF or reduced LV ejection fraction (<40%) after AMI. We evaluated the temporal association between SCD with preceding non-fatal CV event [HF hospitalization, recurrent myocardial infarction (MI), or stroke]. Median follow-up was 1.9 years. Mean age was 65.0 ± 11.5 years and 70% were male. The incidence of CV death was 7.9 per 100 patient-years and for SCD was 3.1 per patient-years (40% of CV deaths). The incidence of SCD preceded by HF hospitalization was greater than SCD without preceding HF hospitalization (P < 0.05). However, overall, SCD was less likely to be preceded by a non-fatal CV event compared to other causes of death: 9.6% of SCD events were preceded by an MI (vs. 46.6% for non-sudden CV death); 17.0% of SCD events were preceded with an HF hospitalization (vs. 25.4% for non-sudden CV death); and 2.7% of SCD events were preceded by stroke (vs.12.9% for non-sudden CV death).
Conclusion
Among patients with AMI complicated by HF, SCD, compared with other causes of death, was less likely to be preceded by a non-fatal CV event. As patients are less likely to have preceding non-fatal CV events to alert the healthcare team of a possible impending SCD event, additional strategies for risk stratification for SCD are needed.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 07 Apr 2021; 10:127-131
Hui SK, Sharma A, Docherty K, McMurray JJV, ... Ferreira JP, Zannad F
Eur Heart J Acute Cardiovasc Care: 07 Apr 2021; 10:127-131 | PMID: 33620418
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Abstract

The 2020 ESC-ACVC quality indicators for the management of acute myocardial infarction applied to the FAST-MI registries.

Schiele F, Gale CP, Simon T, Fox KAA, ... Danchin N, Meneveau N
Aims
We estimated the 2020 European Society of Cardiology-Acute Cardio Vascular Care (ESC-ACVC) quality indicators (QI) for the management of acute myocardial infarction, from three existing registries to determine the feasibility of assessment, room for improvement, association with outcomes, and suitability for centre benchmarking.
Methods and results
Data were extracted from three French nationwide registries, namely FAST-MI 2005, 2010, and 2015. Feasibility of assessment and room for improvement were estimated by the denominator (patients in whom QI could be measured) and numerator (patients who satisfied the QI, among those eligible). Associations between composite QIs (CQIs) and mortality were assessed by multivariate analysis. Centre benchmarking was based on the centres mean CQI, vs. the national mean. The 2020 QIs were measured in 12 660/13 130 patients from FAST-MI. Measurement feasibility ranged from 15% to 100% with greater potential for implementation with the 2020 QI set. The mean (±SD) value of the opportunity-based CQI was 0.72 ± 0.01 and attainment of the all-or-none CQI 8.5%. Both CQIs were associated with adjusted 1-year mortality. Centre categorization into low, intermediate, and high quality was feasible, and distinguished centres with differing mortality.
Conclusion
Most of the 2020 QI can be measured from existing registries in all domains but not in the patient\'s satisfaction domain. This assessment shows potential for implementation. Both CQIs were inversely associated with one-year mortality and centre benchmarking was feasible.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 07 Apr 2021; 10:207-215
Schiele F, Gale CP, Simon T, Fox KAA, ... Danchin N, Meneveau N
Eur Heart J Acute Cardiovasc Care: 07 Apr 2021; 10:207-215 | PMID: 33675658
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Abstract

CA125 but not NT-proBNP predicts the presence of a congestive intrarenal venous flow in patients with acute heart failure.

Núñez-Marín G, de la Espriella R, Santas E, Lorenzo M, ... Bayés-Genís A, Núñez J
Background
Intrarenal venous flow (IRVF) measured by Doppler ultrasound has gained interest as a potential surrogate marker of renal congestion and adverse outcomes in heart failure. In this work, we aimed to determine if antigen carbohydrate 125 (CA125) and plasma amino-terminal pro-B-type natriuretic peptide (NT-proBNP) are associated with congestive IRVF patterns (i.e., biphasic and monophasic) in acute heart failure (AHF).
Methods and results
We prospectively enrolled a consecutive cohort of 70 patients hospitalized for AHF. Renal Doppler ultrasound was assessed within the first 24-h of hospital admission. The mean age of the sample was 73.5 ± 12.3 years; 47.1% were female, and 42.9% exhibited heart failure with preserved ejection fraction. The median (interquartile range) for NT-proBNP and CA125 were 6149 (3604-12 330) pg/mL and 64 (37-122) U/mL, respectively. The diagnostic performance of both exposures for identifying congestive IRVF patterns was tested using the receiving operating curve (ROC). The cut-off for CA125 of 63.5 U/mL showed a sensibility and specificity of 67% and 74% and an area under the ROC curve of 0.71. After multivariate adjustment, CA125 remained non-linearly and positively associated with congestive IRVF (P-value = 0.008) and emerged as the most important covariate explaining the variability of the model (R2: 47.5%). Under the same multivariate setting, NT-proBNP did not show to be associated with congestive IRVF patterns (P-value = 0.847).
Conclusions
CA125 and not NT-proBNP is a useful marker for identifying patients with AHF and congestive IRVF patterns.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 07 Apr 2021; epub ahead of print
Núñez-Marín G, de la Espriella R, Santas E, Lorenzo M, ... Bayés-Genís A, Núñez J
Eur Heart J Acute Cardiovasc Care: 07 Apr 2021; epub ahead of print | PMID: 33829233
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Abstract

Awake venoarterial extracorporeal membrane oxygenation for refractory cardiogenic shock.

Montero S, Huang F, Rivas-Lasarte M, Chommeloux J, ... Alvarez-Garcia J, Schmidt M
Background 
Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) is currently one of the first-line therapies for refractory cardiogenic shock (CS), but its applicability is undermined by the high morbidity associated with its complications, especially those related to mechanical ventilation (MV). We aimed to assess the prognostic impact of keeping patients in refractory CS awake at cannulation and during the VA-ECMO run.
Methods 
A 7-year database of patients given peripheral VA-ECMO support was used to conduct a propensity-score (PS)-matched analysis to balance their clinical profiles. Patients were classified as \'awake ECMO\' or \'non-awake ECMO\', respectively, if invasive MV was used during ≤50% or >50% of the VA-ECMO run. Primary outcomes included ventilator-associated pneumonia and ECMO-related complication rates, and secondary outcomes were 60-day and 1-year mortality. A multivariate logistic-regression analysis was used to identify whether MV at cannulation was independently associated with 60-day mortality.
Results 
Among 231 patients included, 91 (39%) were \'awake\' and 140 (61%) \'non-awake\'. After PS-matching adjustment, the \'awake ECMO\' group had significantly lower rates of pneumonia (35% vs. 59%, P = 0.017), tracheostomy, renal replacement therapy, and less antibiotic and sedative consumption. This strategy was also associated with reduced 60-day (20% vs. 41%, P = 0.018) and 1-year mortality rates (31% vs. 54%, P = 0.021) compared to the \'non-awake\' group, respectively. Lastly, MV at ECMO cannulation was independently associated with 60-day mortality.
Conclusion 
An \'awake ECMO\' management in VA-ECMO-supported CS patients is feasible, safe, and associated with improved short- and long-term outcomes.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 04 Apr 2021; epub ahead of print
Montero S, Huang F, Rivas-Lasarte M, Chommeloux J, ... Alvarez-Garcia J, Schmidt M
Eur Heart J Acute Cardiovasc Care: 04 Apr 2021; epub ahead of print | PMID: 33822901
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Impact:
Abstract

Novel device-based therapies to improve outcome in ST-segment elevation myocardial infarction.

De Maria GL, Garcia-Garcia HM, Scarsini R, Finn A, ... Stone GW, Banning AP
Primary percutaneous coronary intervention (PPCI) has dramatically changed the outcome of patients with ST-elevation myocardial infarction (STEMI). However, despite improvements in interventional technology, registry data show little recent change in the prognosis of patients who survive STEMI, with a significant incidence of cardiogenic shock, heart failure, and cardiac death. Despite a technically successful PPCI procedure, a variable proportion of patients experience suboptimal myocardial reperfusion. Large infarct size and coronary microvascular injury, as the consequence of ischaemia-reperfusion injury and distal embolization of atherothrombotic debris, account for suboptimal long-term prognosis of STEMI patients. In order to address this unmet therapeutic need, a broad-range of device-based treatments has been developed. These device-based therapies can be categorized according to the pathophysiological pathways they target: (i) techniques to prevent distal atherothrombotic embolization, (ii) techniques to prevent or mitigate ischaemia/reperfusion injury, and (iii) techniques to enhance coronary microvascular function/integrity. This review is an overview of these novel technologies with a focus on their pathophysiological background, procedural details, available evidence, and with a critical perspective about their potential future implementation in the clinical care of STEMI patients.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 23 Mar 2021; epub ahead of print
De Maria GL, Garcia-Garcia HM, Scarsini R, Finn A, ... Stone GW, Banning AP
Eur Heart J Acute Cardiovasc Care: 23 Mar 2021; epub ahead of print | PMID: 33760016
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Impact:
Abstract

Current status and needs for changes in critical care training: the voice of the young cardiologists.

Czerwińska-Jelonkiewicz K, Montero S, Bañeras J, Wood A, ... Young National Ambassadors (YNA) of Acute Cardiovascular Care Association (ACVC), European Society of Cardiology (ESC)
Aims
The implementation of the 2013 European Society of Cardiology (ESC) Core Curriculum guidelines for acute cardiovascular care (acc) training among European countries is unknown. We aimed to evaluate the current status of acc training among cardiology trainees and young cardiologists (<40 years) from ESC countries.
Methods and results
The survey (March-July 2019) asked about details of cardiology training, self-confidence in acc technical and non-technical skills, access to training opportunities, and needs for further training in the field. Overall 614 young doctors, 31 (26-43) years old, 55% males were surveyed. Place and duration of acc training differed between countries and between centres in the same country. Although the majority of the respondents (91%) had completed their acc training, the average self-confidence to perform invasive procedures and to manage acc clinical scenarios was low-44% (27.3-70.4). The opportunities for simulation-based learning were scarce-18% (5.8-51.3), as it was previous leadership training (32%) and knowledge about key teamwork principles was poor (48%). The need for further acc training was high-81% (61.9-94.3). Male gender, higher level of training centres, professional qualifications of respondents, longer duration of acc/intensive care training, debriefings, and previous leadership training as well as knowledge about teamwork were related to higher self-confidence in all investigated aspects.
Conclusions
The current cardiology training program is burdened by deficits in acc technical/non-technical skills, substantial variability in programs across ESC countries, and a clear gender-related disparity in outcomes. The forthcoming ESC Core Curriculum for General Cardiology is expected to address these deficiencies.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 04 Mar 2021; 10:94-101
Czerwińska-Jelonkiewicz K, Montero S, Bañeras J, Wood A, ... Young National Ambassadors (YNA) of Acute Cardiovascular Care Association (ACVC), European Society of Cardiology (ESC)
Eur Heart J Acute Cardiovasc Care: 04 Mar 2021; 10:94-101 | PMID: 33580774
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Impact:
Abstract

The peak levels of highly sensitive troponin I predicts in-hospital mortality in COVID-19 patients with cardiac injury: a retrospective study.

Wang Y, Shu H, Liu H, Li X, ... Wang Q, Shang Y
Aims
To investigate the association between levels of highly sensitive troponin I (hs-troponin I) and mortality in novel coronavirus disease 2019 (COVID-19) patients with cardiac injury.
Methods and results
We retrospectively reviewed the medical records of all COVID-19 patients with increased levels of hs-troponin I from two hospitals in Wuhan, China. Demographic information, laboratory test results, cardiac ultrasonographic findings, and electrocardiograms were collected, and their predictive value on in-hospital mortality was explored using multivariable logistic regression. Of 1500 patients screened, 242 COVID-19 patients were enrolled in our study. Their median age was 68 years, and (48.8%) had underlying cardiovascular diseases. One hundred and seventy-six (72.7%) patients died during hospitalization. Multivariable logistic regression showed that C-reactive protein (>75.5 mg/L), D-dimer (>1.5 μg/mL), and acute respiratory distress syndrome were risk factors of mortality, and the peak hs-troponin I levels (>259.4 pg/mL) instead of the hs-troponin I levels at admission was predictor of death. The area under the receiver operating characteristic curve of the peak levels of hs-troponin I for predicting in-hospital mortality was 0.79 (95% confidence interval, 0.73-0.86; sensitivity, 0.80; specificity, 0.72; P < 0.0001).
Conclusion
Our results demonstrated that the risk of in-hospital death among COVID-19 patients with cardiac injury can be predicted by the peak levels of hs-troponin I during hospitalization and was significantly associated with oxygen supply-demand mismatch, inflammation, and coagulation.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 04 Mar 2021; 10:6-15
Wang Y, Shu H, Liu H, Li X, ... Wang Q, Shang Y
Eur Heart J Acute Cardiovasc Care: 04 Mar 2021; 10:6-15 | PMID: 33620438
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Impact:
Abstract

Cardiogenic shock due to predominantly right ventricular failure complicating acute myocardial infarction.

Josiassen J, Helgestad OKL, Møller JE, Schmidt H, ... Ravn HB, Hassager C
Aims
The objective was to describe patient characteristics, interventions, and outcome in acute myocardial infarction complicated by cardiogenic shock (AMICS), due to predominantly right ventricular (RV) failure after revascularization, in comparison with patients suffering from left ventricular (LV) failure as these patients remain sparsely characterized.
Methods and results
From 2010 to 2017, consecutive AMICS patients admitted to either of two tertiary heart centres, covering 3.9 million citizens, corresponding to two-thirds of the Danish population, were identified and individually reviewed through patient records. A total of 1716 AMICS patients were identified, of which 1482 underwent acute revascularization and included for analysis. Hereof, 101 (7%) patients developed cardiogenic shock due to predominantly RV failure, while 1381 (93%) had significant LV involvement. Female sex was the only demographic factor associated with RV failure (35% vs. 25%, P = 0.01). Despite having a preserved LV ejection fraction, patients with predominantly RV failure were comparable to patients with LV involvement, in terms of haemodynamic and metabolic profile, here among variables commonly used in the cardiogenic shock definition including blood pressure (82 mmHg vs. 83 mmHg, P = 0.90) and lactate level (5.7 mmol/L vs. 5.4 mmol/L, P = 0.70). Patients with RV AMICS had significantly lower 30-day mortality than LV AMICS, and this result persisted after multivariable adjustment (RV vs. LV; hazard ratio 0.61, 95% confidence interval 0.41-0.92, P = 0.01).
Conclusion
In contemporary AMICS patients undergoing revascularization, patients with predominantly RV failure had comparable haemodynamics and metabolic derangement on admission compared to patients with LV failure but was associated with female sex and a significantly lower 30-day mortality.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 04 Mar 2021; 10:33-39
Josiassen J, Helgestad OKL, Møller JE, Schmidt H, ... Ravn HB, Hassager C
Eur Heart J Acute Cardiovasc Care: 04 Mar 2021; 10:33-39 | PMID: 33620420
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Impact:
Abstract

Hospitalization-related economic impact of patients with cardiogenic shock in a high-complexity reference centre.

Collado E, Luiso D, Ariza-Solé A, Lorente V, ... González-Costello J, Comin-Colet J
Aims 
Cardiogenic shock (CS) is associated with high mortality. Current guidelines strongly recommend centralizing the care of these patients in high-complexity centres. We described the hospitalization-related economic cost and its main determinants in patients with CS in a high-complexity reference centre.
Methods and results 
This is a single-centre, retrospective study. All patients with CS (2015-17) were included. Hospitalization-related cost per patient was calculated by analytical accountability method, including hospital stay-related expenditures, interventions, and consumption of devices. Expenditure was expressed in 2018 euros. All-cause mortality during follow-up was registered. Ratio of cost per life-year gained (LYG) was also calculated. A total of 230 patients were included, with mean age of 63 years. In-hospital mortality was 88/230 (38.3%). Hospital stay was longer in patients surviving after the admission (21.7 vs. 7.5 days, P < 0.001). Total economic cost for the overall cohort was 3 947 118€ (mean/patient 17 161€). Most of this cost was attributable to hospital stay (81.1%). The rest of the expenditure was due to in-hospital procedures (13.1%) and the use of devices (5.8%). Most of hospital stay-related costs (79.8%) were due to Critical Care Unit stay. Mean follow-up was 651 days. Total LYG was 409.77 years for the whole series. The observed ratio of cost per LYG was 9632.52 €/LYG.
Conclusions 
Management of CS in a reference centre is associated to a significant economic cost, but with a low ratio of cost per LYG. Most of this cost is attributable to hospital stay, specifically in critical care units.

Published on behalf of the European Society of Cardiology VC © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 04 Mar 2021; 10:50-53
Collado E, Luiso D, Ariza-Solé A, Lorente V, ... González-Costello J, Comin-Colet J
Eur Heart J Acute Cardiovasc Care: 04 Mar 2021; 10:50-53 | PMID: 33620377
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Impact:
Abstract

Composition, structure, and function of heart teams: a joint position paper of the ACVC, EAPCI, EACTS, and EACTA focused on the management of patients with complex coronary artery disease requiring myocardial revascularization.

Leonardi S, Capodanno D, Sousa-Uva M, Vrints C, ... Valgimigli M, Jeppsson A
Contemporary cardiovascular medicine is complex, dynamic, and interactive. Therefore, multidisciplinary dialogue between different specialists is required to deliver optimal and patient-centred care. This has led to the concept of explicit collaborations of different specialists caring for patients with complex cardiovascular diseases-that is \'heart teams\'. These teams are particularly valuable to minimize referral bias and improve guideline adherence as so to be responsive to patient preferences, needs, and values but may be challenging to coordinate, especially in the acute setting. This position paper-jointly developed by four cardiovascular associations-is intended to provide conceptual and practical considerations for the composition, structure, and function of multidisciplinary teams. It focuses on patients with complex coronary artery diseases in both elective and urgent setting and provide guidance on how to implement the heart team both in chronic and in acute coronary syndromes patients, including cases with mechanical complications and haemodynamic instability; it also discuss strategies for clear and transparent patient communication and provision of a patient-centric approach. Finally, gaps in evidence and research perspectives in this context are discussed.

This article has been co-published with permission in the European Heart Journal – Acute Cardiovascular Care and European Journal of Cardio-Thoracic Surgery. All rights reserved. © 2021 The Author(s). The articles are identical except for minor stylistic and spelling differences in keeping with each journal’s style. Either citation can be used when citing this article. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 04 Mar 2021; 10:83-93
Leonardi S, Capodanno D, Sousa-Uva M, Vrints C, ... Valgimigli M, Jeppsson A
Eur Heart J Acute Cardiovasc Care: 04 Mar 2021; 10:83-93 | PMID: 33721018
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Impact:
Abstract

Five-year risk of heart failure and death following myocardial infarction with cardiogenic shock: a nationwide cohort study.

Lauridsen MD, Rorth R, Butt JH, Kristensen SL, ... Kober L, Fosbol EL
Aims
More patients survive myocardial infarction (MI) with cardiogenic shock (CS), but long-term outcome data are sparse. We aimed to examine rates of heart failure hospitalization and mortality in MI hospital survivors.
Methods and results
First-time MI patients with and without CS alive until discharge were identified using Danish nationwide registries between 2005 and 2017. One-, 5-, and 1- to 5-year rates of heart failure hospitalization and mortality were compared using landmark cumulative incidence curves and Cox regression models. We identified 85 865 MI patients of whom 2865 had CS (3%). Cardiogenic shock patients were of similar age as patients without CS (median age years: 68 vs. 67), and more were men (70% vs. 65%). Cardiogenic shock was associated with a higher 5-year rate of heart failure hospitalization compared with patients without CS [40% vs. 20%, adjusted hazard ratio (HR) 2.90 (95% confidence interval (CI) 2.67-3.12)]. The increased rate of heart failure hospitalization was evident after 1 year and in the 1- to 5-year landmark analysis among 1-year survivors. All-cause mortality was higher at 1 year among CS patients compared with patients without CS [18% vs. 8%, adjusted HR 3.23 (95% CI 2.95-3.54)]. However, beyond the first year, the mortality for CS was not markedly different compared with patients without CS [12% vs. 13%, adjusted HR 1.15 (95% CI 1.00-1.33)].
Conclusion
Among MI hospital survivors, CS was associated with a markedly higher rate of heart failure hospitalization and 1-year mortality compared with patients without CS. However, among 1-year survivors, the remaining 5-year mortality was similar for MI patients with and without CS.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 04 Mar 2021; 10:40-49
Lauridsen MD, Rorth R, Butt JH, Kristensen SL, ... Kober L, Fosbol EL
Eur Heart J Acute Cardiovasc Care: 04 Mar 2021; 10:40-49 | PMID: 33721017
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Impact:
Abstract

Cardiovascular biomarkers in patients with COVID-19.

Mueller C, Giannitsis E, Jaffe AS, Huber K, ... Lindahl B, ESC Study Group on Biomarkers in Cardiology of the Acute Cardiovascular Care Association
The coronavirus disease 2019 (COVID-19) pandemic has increased awareness that severe acute respiratory distress syndrome coronavirus-2 (SARS-CoV-2) may have profound effects on the cardiovascular system. COVID-19 often affects patients with pre-existing cardiac disease, and may trigger acute respiratory distress syndrome (ARDS), venous thromboembolism (VTE), acute myocardial infarction (AMI), and acute heart failure (AHF). However, as COVID-19 is primarily a respiratory infectious disease, there remain substantial uncertainty and controversy whether and how cardiovascular biomarkers should be used in patients with suspected COVID-19. To help clinicians understand the possible value as well as the most appropriate interpretation of cardiovascular biomarkers in COVID-19, it is important to highlight that recent findings regarding the prognostic role of cardiovascular biomarkers in patients hospitalized with COVID-19 are similar to those obtained in studies for pneumonia and ARDS in general. Cardiovascular biomarkers reflecting pathophysiological processes involved in COVID-19/pneumonia and its complications have a role evaluating disease severity, cardiac involvement, and risk of death in COVID-19 as well as in pneumonias caused by other pathogens. First, cardiomyocyte injury, as quantified by cardiac troponin concentrations, and haemodynamic cardiac stress, as quantified by natriuretic peptide concentrations, may occur in COVID-19 as in other pneumonias. The level of those biomarkers correlates with disease severity and mortality. Interpretation of cardiac troponin and natriuretic peptide concentrations as quantitative variables may aid in risk stratification in COVID-19/pneumonia and also will ensure that these biomarkers maintain high diagnostic accuracy for AMI and AHF. Second, activated coagulation as quantified by D-dimers seems more prominent in COVID-19 as in other pneumonias. Due to the central role of endothelitis and VTE in COVID-19, serial measurements of D-dimers may help physicians in the selection of patients for VTE imaging and the intensification of the level of anticoagulation from prophylactic to slightly higher or even therapeutic doses.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 27 Feb 2021; epub ahead of print
Mueller C, Giannitsis E, Jaffe AS, Huber K, ... Lindahl B, ESC Study Group on Biomarkers in Cardiology of the Acute Cardiovascular Care Association
Eur Heart J Acute Cardiovasc Care: 27 Feb 2021; epub ahead of print | PMID: 33655301
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Abstract

Cardiac troponin and infective endocarditis prognosis: a systematic review and meta-analysis.

Postigo A, Vernooij RWM, Fernández-Avilés F, Martínez-Sellés M
Aims
Infective endocarditis (IE) is associated with high mortality and morbidity. Cardiac troponin (Tn) elevation seems to be common in patients with IE and could be associated with a poor prognosis. The aim of this study was to synthesize the prognostic value of Tn in patients with IE.
Methods and results
We searched in MEDLINE, EMBASE, and the Cochrane library, including the Cochrane Central Register of Controlled Trials (CENTRAL) until February 2020. Observational studies reporting on the association between Tn and in-hospital and 1-year mortality, and IE complications were considered eligible. As each centre uses different conventional or ultra-sensitive Tn, with different normality threshold, we considered them as normal or elevated according to the criteria specified in each article. Articles were systematically selected, assessed for bias, and, when possible, meta-analysed using a random effect model. After retrieving 542 articles, 18 were included for qualitative synthesis and 9 for quantitative meta-analysis. Compared with patients with normal Tn levels, patients with Tn elevation presented higher in-hospital mortality [odds ratio (OR) 5.96, 95% confidence interval (CI) 3.46-10.26; P < 0.0001], 1-year mortality (OR 2.67, 95% CI 1.42-5.02; P = 0.002), and surgery rates (OR 2.34, 95% CI 1.42-3.85; P = 0.0008). They also suffered more frequent complications: central nervous system events (OR 8.85, 95% CI 3.23-24.26; P < 0.0001) and cardiac abscesses (OR 4.96, 95% CI 1.94-12.70; P = 0.0008).
Conclusion
Tn elevation is associated with a poor prognosis in patients with IE. Troponin determination seems to provide additional help in the prognostic assessment of these patients.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 27 Feb 2021; epub ahead of print
Postigo A, Vernooij RWM, Fernández-Avilés F, Martínez-Sellés M
Eur Heart J Acute Cardiovasc Care: 27 Feb 2021; epub ahead of print | PMID: 33668065
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Abstract

Prognostic value of inflammatory biomarkers and GRACE score for cardiac death and acute kidney injury after acute coronary syndromes.

Rossi VA, Denegri A, Candreva A, Klingenberg R, ... Lüscher TF, Matter CM
Aims 
The aim of this study was to analyse the role of inflammation and established clinical scores in predicting acute kidney injury (AKI) after acute coronary syndromes (ACS).
Methods and results 
In a prospective multicentre cohort including 2034 patients with ACS undergoing percutaneous coronary intervention, high-sensitivity C-reactive protein (hsCRP), neutrophil count, neutrophil-to-lymphocyte ratio (NL-ratio), and creatinine were measured at the index procedure. AKI (n = 39, defined according to RIFLE criteria) and major cardiovascular and cerebrovascular events were adjudicated after 1 year. Associations between inflammation, AKI, and cardiac death (CD) were assessed by C-statistics and Cox proportional hazard models with log-rank test to compare survival. Patients with ACS with elevated neutrophil count >7.8 × 109/L, NL-ratio >5, combined neutrophil-count/creatinine, or NL-ratio/creatinine at baseline showed a higher incidence of AKI (all P < 0.05) and CD (all P < 0.001). The risk of AKI, CD, and their combination was increased in patients with higher neutrophil count/creatinine (heart rate (HR) = 3.7, 95% cardiac index (CI) 1.9-7.1; HR = 2.7, 95% CI 1.6-4.6; HR = 3.2, 95% CI 2.1-4.9); NL-ratio/creatinine (HR = 2.1, 95% CI 1.6-4.1; HR = 2.2, 95% CI 1.3-3.8; HR = 2.3, 95% CI 1.5-3.5); and hsCRP (HR = 1.8, 95% CI 0.9-3.5; HR = 2.2, 95% CI 1.3-3.6; HR = 1.9, 95% CI 1.2-2.8) after adjustment for age, diabetes, hypertension, previous heart failure, kidney function, haemodynamic instability at admission, statin, and renin-angiotensin-aldosterone antagonists use. Subjects with higher GRACE score 1.0/NL-ratio had higher rate of AKI, CD, and both (HR = 1.4, 95% CI 0.5-4.2; HR = 2.7, 95% CI 1.3-5.9; HR = 2.1, 95% CI 1-4.3).
Conclusions 
Inflammation markers may predict AKI after correction for renal function at the index procedure. hsCRP performed better than the NL-ratio. However, the integration of inflammation markers to traditional risk factors or scores does not add prognostic information.
Trial registration 
ClinicalTrials.gov, NCT01000701.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 23 Feb 2021; epub ahead of print
Rossi VA, Denegri A, Candreva A, Klingenberg R, ... Lüscher TF, Matter CM
Eur Heart J Acute Cardiovasc Care: 23 Feb 2021; epub ahead of print | PMID: 33624028
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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.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 03 Feb 2021; epub ahead of print
Mohamed MO, Van Spall HGC, Kontopantelis E, Alkhouli M, ... Bhatt DL, Mamas MA
Eur Heart J Acute Cardiovasc Care: 03 Feb 2021; epub ahead of print | PMID: 33587752
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Abstract

The FAST-FURO study: effect of very early administration of intravenous furosemide in the prehospital setting to patients with acute heart failure attending the emergency department.

Miró Ò, Harjola P, Rossello X, Gil V, ... Mebazaa A, ICA-SEMES Research Group
Aims
The effect of early administration of intravenous (IV) furosemide in the emergency department (ED) on short-term outcomes of acute heart failure (AHF) patients remains controversial, with one recent Japanese study reporting a decrease of in-hospital mortality and one Korean study reporting a lack of clinical benefit. Both studies excluded patients receiving prehospital IV furosemide and only included patients requiring hospitalization. To assess the impact on short-term outcomes of early IV furosemide administration by emergency medical services (EMS) before patient arrival to the ED.
Methods and results
In a secondary analysis of the Epidemiology of Acute Heart Failure in Emergency Departments (EAHFE) registry of consecutive AHF patients admitted to Spanish EDs, patients treated with IV furosemide at the ED were classified according to whether they received IV furosemide from the EMS (FAST-FURO group) or not (CONTROL group). In-hospital all-cause mortality, 30-day all-cause mortality, and prolonged hospitalization (>10 days) were assessed. We included 12 595 patients (FAST-FURO = 683; CONTROL = 11 912): 968 died during index hospitalization [7.7%; FAST-FURO = 10.3% vs. CONTROL = 7.5%; odds ratio (OR) = 1.403, 95% confidence interval (95% CI) = 1.085-1.813; P = 0.009], 1269 died during the first 30 days (10.2%; FAST-FURO = 13.4% vs. CONTROL = 9.9%; OR = 1.403, 95% CI = 1.146-1.764; P = 0.004), and 2844 had prolonged hospitalization (22.8%; FAST-FURO = 25.8% vs. CONTROL = 22.6%; OR = 1.189, 95% CI = 0.995-1.419; P = 0.056). FAST-FURO group patients had more diabetes mellitus, ischaemic cardiomyopathy, peripheral artery disease, left ventricular systolic dysfunction, and severe decompensations, and had a better New York Heart Association class and had less atrial fibrillation. After adjusting for these significant differences, early IV furosemide resulted in no impact on short-term outcomes: OR = 1.080 (95% CI = 0.817-1.427) for in-hospital mortality, OR = 1.086 (95% CI = 0.845-1.396) for 30-day mortality, and OR = 1.095 (95% CI = 0.915-1.312) for prolonged hospitalization. Several sensitivity analyses, including analysis of 599 pairs of patients matched by propensity score, showed consistent findings.
Conclusion
Early IV furosemide during the prehospital phase was administered to the sickest patients, was not associated with changes in short-term mortality or length of hospitalization after adjustment for several confounders.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 17 Jan 2021; epub ahead of print
Miró Ò, Harjola P, Rossello X, Gil V, ... Mebazaa A, ICA-SEMES Research Group
Eur Heart J Acute Cardiovasc Care: 17 Jan 2021; epub ahead of print | PMID: 33580790
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Abstract

Serum cholinesterase as a prognostic biomarker for acute heart failure.

Shiba M, Kato T, Morimoto T, Yaku H, ... Kuwahara K, Kimura T
Aims
The association between serum cholinesterase and prognosis in acute heart failure (AHF) remains to be elucidated. We investigated the serum cholinesterase level at discharge from hospitalization for AHF and its association with clinical outcomes in patients with AHF.
Methods and results
Among 4056 patients enrolled in the Kyoto Congestive Heart Failure multicentre registry, we analysed 2228 patients with available serum cholinesterase data. The study population was classified into three groups according to serum cholinesterase level at discharge: low tertile (<180 U/L, N = 733), middle tertile (≥180 U/L and <240 U/L, N = 746), and high tertile (≥240 U/L, N = 749). Patients in the low tertile had higher tricuspid pressure gradient, greater inferior vena cava diameter, and higher brain natriuretic peptide (BNP) levels than those in the high tertile. The cumulative 1-year incidence of the primary outcome measure (a composite endpoint of all-cause death and hospitalization for HF) was higher in the low and middle tertiles than in the high tertile [46.5% (low tertile) and 31.4% (middle tertile) vs. 22.1% (high tertile), P < 0.0001]. After adjustment for 26 variables, the excess risk of the low tertile relative to the high tertile for the primary outcome measure remained significant (hazard ratio 1.37, 95% confidence interval 1.10-1.70, P = 0.006). Restricted cubic spline models below the median of cholinesterase demonstrated incrementally higher hazards at low cholinesterase levels.
Conclusions
Low serum cholinesterase levels are associated with congestive findings on echocardiography, higher BNP, and higher risks for a composite of all-cause death and HF hospitalization in patients with AHF.

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

Eur Heart J Acute Cardiovasc Care: 17 Jan 2021; epub ahead of print
Shiba M, Kato T, Morimoto T, Yaku H, ... Kuwahara K, Kimura T
Eur Heart J Acute Cardiovasc Care: 17 Jan 2021; epub ahead of print | PMID: 33580775
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Abstract

Five-year survival after post-cardiotomy veno-arterial extracorporeal membrane oxygenation.

Biancari F, Perrotti A, Ruggieri VG, Mariscalco G, ... Fiore A, Welp H
Aims 
Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) support for post-cardiotomy cardiogenic shock (PCS) after adult cardiac surgery is associated with satisfactory hospital survival. However, data on long-term survival of these critically ill patients are scarce.
Methods and results
Between January 2010 and March 2018, 665 consecutive patients received VA-ECMO for PCS at 17 cardiac surgery centres and herein we evaluated their 5-year survival. The mean follow-up of this cohort was 1.7 ± 2.7 years (for hospital survivors, 4.6 ± 2.5 years). In this cohort, 240 (36.1%) patients survived to hospital discharge. Five-year survival of all patients was 27.7%. The PC-ECMO score was predictive of 5-year survival in these patients (0 point, 50.9%; 1 point, 44.9%; 2 points, 40.0%; 3 points, 34.7%; 4 points, 21.0%; 5 points, 17.6%; ≥6 points, 10.7%; P < 0.0001). Age was among factors independently associated with late survival, patients >70 years old having a remarkably poor 5-year survival (<60 years: 39.2%; 60-69 years: 29.9%; 70-79 years: 12.3%; ≥80 years: 13.0%, P < 0.0001). Implantation of a ventricular assist device or heart transplant was performed in 3.2% of patients and their 5-year survival was 42.9% (for heart transplant, 63.6%).
Conclusion 
Veno-arterial extracorporeal membrane oxygenation for PCS is associated with satisfactory 5-year survival in young patients without critical pre-ECMO conditions. The use of VA-ECMO for PCS in patients >70 years should be considered only after a judicious scrutiny of patient\'s life expectancy. Future studies should evaluate whether satisfactory mid-term survival of these patients translates into a good functional outcome.
Trial registration
Clinicaltrials.gov-NCT03508505.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 11 Jan 2021; epub ahead of print
Biancari F, Perrotti A, Ruggieri VG, Mariscalco G, ... Fiore A, Welp H
Eur Heart J Acute Cardiovasc Care: 11 Jan 2021; epub ahead of print | PMID: 33580776
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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.

© The Author(s) 2021. Published on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 03 Jan 2021; epub ahead of print
Sharkey SW, Alfadhel M, Thaler C, Lin D, ... Henry TD, Saw J
Eur Heart J Acute Cardiovasc Care: 03 Jan 2021; epub ahead of print | PMID: 33580787
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Abstract

Diagnostic value of circulating microRNAs compared to high-sensitivity troponin T for the detection of non-ST-segment elevation myocardial infarction.

Biener M, Giannitsis E, Thum T, Bär C, ... de Gonzalo-Calvo D, Mueller-Hennessen M
Aims
To assess the diagnostic value of microRNAs (miRNAs) for the detection of non-ST-segment elevation myocardial infarction (NSTEMI).
Methods and results
A total of 1042 patients presenting between August 2014 and April 2017 to the emergency department with the suspected acute coronary syndrome were included. Non-ST-segment elevation myocardial infarction was diagnosed per criteria of the fourth Universal definition of myocardial infarction (UDMI) using high-sensitivity troponin T (hs-cTnT). Expression levels of eleven microRNAs (miR-21, miR-22, miR-29a, miR-92a, miR-122, miR-126, miR-132, miR-133, miR-134, miR-191, and miR-423) were determined using RT-qPCR. Discrimination of NSTEMI was assessed for individual and a panel of miRNAs compared to the hs-cTnT reference using C-statistics and reclassification analysis. NSTEMI was diagnosed in 137 (13.1%) patients. The area under the curve (AUC) of the hs-cTnT based reference was 0.937. In a multivariate model, three miRNAs (miR-122, miR-133, and miR-134) were found to be associated with NSTEMI with AUCs between 0.506 and 0.656. A panel consisting of these miRNAs revealed an AUC of 0.662 for the diagnosis of NSTEMI. The AUC of the combination of the miRNA panel and troponin reference was significantly lower than the reference standard (AUC: 0.897 vs. 0.937, P = 0.006). Despite a significant improvement of NSTEMI reclassification measured by IDI and NRI, miRNAs did not improve the specificity of hs-cTnT kinetic changes for the diagnosis of NSTEMI (ΔAUC: 0.04).
Conclusion
Although single miRNAs are significantly associated with the diagnosis of NSTEMI a miRNA panel does not add diagnostic accuracy to the hs-cTnT reference considering baseline values and kinetic changes as recommended by the fourth version of UDMI.
Clinical trials identifier
NCT02116153.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 03 Jan 2021; epub ahead of print
Biener M, Giannitsis E, Thum T, Bär C, ... de Gonzalo-Calvo D, Mueller-Hennessen M
Eur Heart J Acute Cardiovasc Care: 03 Jan 2021; epub ahead of print | PMID: 33580779
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Abstract

Influence of age and shock severity on short-term survival in patients with cardiogenic shock.

Jentzer JC, Schrage B, Holmes DR, Dabboura S, ... Bell MR, Westermann D
Aims
Cardiogenic shock (CS) is associated with poor outcomes in older patients, but it remains unclear if this is due to higher shock severity. We sought to determine the associations between age and shock severity on mortality among patients with CS.
Methods and results
Patients with a diagnosis of CS from Mayo Clinic (2007-15) and University Clinic Hamburg (2009-17) were subdivided by age. Shock severity was graded using the Society for Cardiovascular Angiography and Intervention (SCAI) shock stages. Predictors of 30-day survival were determined using Cox proportional-hazards analysis. We included 1749 patients (934 from Mayo Clinic and 815 from University Clinic Hamburg), with a mean age of 67.6 ± 14.6 years, including 33.6% females. Acute coronary syndrome was the cause of CS in 54.0%. The distribution of SCAI shock stages was 24.1%; C, 28.0%; D, 33.2%; and E, 14.8%. Older patients had similar overall shock severity, more co-morbidities, worse kidney function, and decreased use of mechanical circulatory support compared to younger patients. Overall 30-day survival was 53.3% and progressively decreased as age or SCAI shock stage increased, with a clear gradient towards lower 30-day survival as a function of increasing age and SCAI shock stage. Progressively older age groups had incrementally lower adjusted 30-day survival than patients aged <50 years.
Conclusion
Older patients with CS have lower short-term survival, despite similar shock severity, with a high risk of death in older patients with more severe shock. Further research is needed to determine the optimal treatment strategies for older CS patients.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 03 Jan 2021; epub ahead of print
Jentzer JC, Schrage B, Holmes DR, Dabboura S, ... Bell MR, Westermann D
Eur Heart J Acute Cardiovasc Care: 03 Jan 2021; epub ahead of print | PMID: 33580778
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Impact:
Abstract

Left Impella®-device as bridge from cardiogenic shock with acute, severe mitral regurgitation to MitraClip®-procedure: a new option for critically ill patients.

Vandenbriele C, Balthazar T, Wilson J, Adriaenssens T, ... Verbrugghe P, Price S
Aims
Patients presenting with cardiogenic shock (CS) related to acute, severe mitral regurgitation (MR) are often considered too ill for immediate surgical intervention. Therefore, other less invasive techniques for haemodynamic stabilization should be explored. The purpose of this exploratory study was to investigate the feasibility and outcomes in patients with CS due to severe MR by using a novel approach combining haemodynamic stabilization with left Impella-support plus MR-reduction using MitraClip®.
Methods and results
We analysed whether a combined left Impella®/MitraClip®-procedure in a rare population of CS-patients with acute MR requiring mechanical ventilation is a feasible strategy to recovery in patients who had been declined cardiac surgery. Six INTERMACS-1 CS-patients with acute MR were studied at two tertiary cardiac intensive care units. The mean EURO-II score was 39 ± 19% and age 66.8 ± 4.9 years. All patients had an initial pulmonary capillary wedge pressure >20 mmHg and pulmonary oedema necessitating invasive ventilation. Cardiac output was severely impaired (left ventricular outflow tract velocity time index 9.8 ± 1.8 cm), requiring mechanical circulatory support (MCS) (Impella®-CP; mean flow 2.9 ± 1.8 L per minute; mean support 9.7 ± 6.0 days). Despite MCS-guided unloading, weaning from ventilation failed due to persisting pulmonary oedema necessitating MR-reduction. In all cases, the severe MR was reduced to mild using percutaneous MitraClip®-procedure, followed by successful weaning from invasive ventilation. Survival to discharge was 86%, with all surviving and rare readmission for heart failure at 6 months.
Conclusions
A combined Impella®/MitraClip®-strategy appears a novel, feasible alternative for weaning CS-patients presenting with acute, severe MR. Upfront Impella®-stabilization facilitates safe bridging to Mitraclip®-procedure and the staged approach facilitates successful weaning from ventilatory support.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 01 Dec 2020; epub ahead of print
Vandenbriele C, Balthazar T, Wilson J, Adriaenssens T, ... Verbrugghe P, Price S
Eur Heart J Acute Cardiovasc Care: 01 Dec 2020; epub ahead of print | PMID: 33620436
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Impact:
Abstract

Surgical management of an anomalous right coronary artery.

Pontailler M, Demondion P, Lebreton G
Anomalous aortic origin of coronary arteries is a rare congenital heart disease that can be associated with sudden death. We present the case of a young patient who sustained a cardiac arrest revealing an anomalous origin of the right coronary artery. Unroofing and pericardial enlargement of the coronary artery ostia was performed and the patient is actually asymptomatic.

© The European Society of Cardiology.

Eur Heart J Acute Cardiovasc Care: 30 Nov 2020; 9:NP1-NP2
Pontailler M, Demondion P, Lebreton G
Eur Heart J Acute Cardiovasc Care: 30 Nov 2020; 9:NP1-NP2 | PMID: 33596322
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Impact:
Abstract

Percutaneous coronary intervention under temporary peripheral veno-arterial extracorporeal membrane oxygenation.

Chaara J, Cikirikcioglu M, Roffi M
We describe the case of a 68-year old female presenting with subacute ST-elevation myocardial infarction and severe depressed left ventricular ejection fraction (15%) in the presence of severe three-vessel coronary artery disease. The patient was haemodynamically stable. After heart team discussion, a percutaneous coronary intervention was performed under peripheral veno-arterial extracorporeal membrane oxygenation without complications.

© The European Society of Cardiology.

Eur Heart J Acute Cardiovasc Care: 30 Nov 2020; 9:NP3-NP5
Chaara J, Cikirikcioglu M, Roffi M
Eur Heart J Acute Cardiovasc Care: 30 Nov 2020; 9:NP3-NP5 | PMID: 33596321
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Impact:
Abstract

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

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



Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:923-930
Woolridge S, Alemayehu W, Kaul P, Fordyce CB, ... Armstrong PW, van Diepen S
Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:923-930 | PMID: 31663772
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Impact:
Abstract

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

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



Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:902-910
Wein B, Bashkireva A, Au-Yeung A, Yoculan A, ... Wijns W, Naber CK
Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:902-910 | PMID: 31557050
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Impact:
Abstract

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

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



Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:958-965
Hakim R, Revue E, Saint Etienne C, Marcollet P, ... Grammatico-Guillon L, Rangé G
Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:958-965 | PMID: 31475563
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Impact:
Abstract

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

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



Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:966-974
Herscovici R, Mirocha J, Salomon J, Merz NB, Cercek B, Goldfarb M
Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:966-974 | PMID: 31452378
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Impact:
Abstract

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

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



Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:984-992
Andell P, James S, Östlund O, Yndigegn T, ... Erlinge D, Hofmann R
Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:984-992 | PMID: 31081342
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Impact:
Abstract

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

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



Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:836-847
Schaerli N, Abächerli R, Walter J, Honegger U, ... Mueller C, Reichlin T
Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:836-847 | PMID: 31008655
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Impact:
Abstract

Acute diagonal-induced ST-elevation myocardial infarction and electrocardiogram-guidance in the era of primary coronary intervention: New insights into an old tool.

Abu Fanne R, Kleiner Shochat M, Shotan A, Frimerman A, ... Levi Y, Meisel SR
Background
Previous studies, published before the advent of primary reperfusion, described the electrocardiographic features of ST-segment elevation myocardial infarction (STEMI) caused by total diagonal artery occlusion, as demonstrated at pre-discharge coronary angiography. We aimed to assess the electrocardiographic and echocardiographic features in STEMI unequivocally attributed to a diagonal lesion in the era of primary coronary intervention.
Methods
The electrocardiograms and echocardiograms of patients sustaining STEMI caused by diagonal artery involvement were compared with those of patients with STEMI attributed to proximal or mid left anterior descending artery (LAD) lesions. ST-segment deviations were measured at four different points in each lead and analyzed against TIMI flow and SNuH score. The electrocardiographic and echocardiographic features of each group were mapped.
Results
In contrast to previous studies claiming an ever-present incidence of at least 1-mm ST-segment elevation in leads I and aVL with diagonal STEMI, we report 86% of any ST-elevation in leads I, aVL and V2 (64-71% for ST-elevation >1 mm). Both higher SNuH score and pre-intervention TIMI flow were associated with larger lateral ST-elevations (85.7% and 86.4-95.5%, respectively). Higher prevalence of ST-depression in the inferior leads reflecting reciprocal changes was observed in patients with diagonal-induced STEMI (57-76% vs. 24-51% in LAD obstructions, p <0.05).
Conclusion
The most sensitive and predictive sign for acute ischemia was any degree of ST-deviation measured 1 mm beyond the J point. ST-elevations in I, aVL and V2, sparing V3-V5, strongly favor isolated diagonal lesion. Proximal LAD lesion lacking ST-segment elevations in leads I and aVL is primarily due to wraparound LAD anatomy.



Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:827-835
Abu Fanne R, Kleiner Shochat M, Shotan A, Frimerman A, ... Levi Y, Meisel SR
Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:827-835 | PMID: 30706721
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Impact:
Abstract

Assessment of quality of care of patients with ST-segment elevation myocardial infarction.

Hudzik B, Budaj A, Gierlotka M, Witkowski A, ... Dudek D, Gąsior M
Aims
The 2017 European Society of Cardiology guidelines for the management of ST-elevation myocardial infarction recommended assessing quality of care to establish measurable quality indicators in order to ensure that every ST-elevation myocardial infarction patient receives the best possible care. We investigated the quality indicators of healthcare services in Poland provided to ST-elevation myocardial infarction patients.
Methods and results
The Polish Registry of Acute Coronary Syndromes is a nationwide, multicentre, prospective study of acute coronary syndrome patients in Poland. For the purpose of assessing quality indicators, we included 8279 patients from the Polish Registry of Acute Coronary Syndromes hospitalised with ST-elevation myocardial infarction in 2018. Four hundred and eight of 8279 patients (4.9%) arrived at percutaneous coronary intervention centre by self-transport, 4791 (57.9%) arrived at percutaneous coronary intervention centre by direct emergency medical system transport, and 2900 (37.2%) were transferred from non-percutaneous coronary intervention facilities. Whilst 95.1% of ST-elevation myocardial infarction patients arriving in the first 12 h received reperfusion therapy, the rates of timely reperfusion were much lower (ranging from 39.4% to 55.0% for various ST-elevation myocardial infarction pathways). The median left ventricular ejection fraction was 46% and was assessed before discharge in 86.0% of patients. Four hundred and eighty-nine of 8279 patients (5.9%) died during hospital stay. Optimal medical therapy is prescribed in 50-85% of patients depending on various clinical settings. Only one in two ST-elevation myocardial infarction patients is enrolled in a cardiac rehabilitation program at discharge. No patient-reported outcomes were recorded in the Polish Registry of Acute Coronary Syndromes.
Conclusions
The results of this study identified areas of healthcare system that require solid improvement. These include direct transport to percutaneous coronary intervention centre, timely reperfusion, guidelines-based medical therapy (in particular in patients with heart failure), referral to cardiac rehabilitation/secondary prevention programs. Also, there is a need for recording quality indicators associated with patient-reported outcomes.



Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:893-901
Hudzik B, Budaj A, Gierlotka M, Witkowski A, ... Dudek D, Gąsior M
Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:893-901 | PMID: 31762288
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Impact:
Abstract

Guideline adherence and long-term clinical outcomes in patients with acute myocardial infarction: a Japanese Registry of Acute Myocardial Infarction Diagnosed by Universal Definition (J-MINUET) substudy.

Wada H, Ogita M, Suwa S, Nakao K, ... Ishihara M, J-MINUET investigators
Background
The association between guideline adherence and long-term outcomes in patients with acute myocardial infarction in real-world clinical practice remains unclear.
Methods
We investigated 3283 consecutive patients with acute myocardial infarction who were selected from a prospective, nation-wide, multicentre registry (J-MINUET) database covering 28 institutions in Japan between July 2012 and March 2014. Among the 2757 eligible patients, we evaluated the use of seven guideline-recommended therapies, including urgent revascularisation, door-to-balloon time of 90 minutes or less, and five discharge medications (P2Y12 inhibitors on aspirin, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, statins, lipid-lowering drugs). The primary endpoint was a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, cardiac failure and urgent revascularisation for unstable angina up to 3 years.
Results
The overall median composite guideline adherence was 85.7%. Patients were divided into the following three groups: complete (100%) adherence group (n=862); moderate adherence (75% to <100%) group (n=911); and low adherence (0-75%) group (n=984). The rate of adverse cardiovascular events was significantly lower in the complete adherence group than in the low and moderate adherence groups (log rank P<0.0001). Multivariate Cox regression analysis showed complete guideline adherence was also significantly associated with lower adverse cardiovascular events compared with low guideline adherence (hazard ratio 0.66; 95% confidence interval 0.52-0.85; P=0.001).
Conclusion
The use of guideline-based therapies for patients with acute myocardial infarction in contemporary clinical practice was associated with significant decreases in adverse long-term clinical outcomes.
Trial registration
UMIN Unique trial Number: UMIN000010037.



Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:939-947
Wada H, Ogita M, Suwa S, Nakao K, ... Ishihara M, J-MINUET investigators
Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:939-947 | PMID: 31976749
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Impact:
Abstract

Diagnostic and prognostic value of ST-segment deviation scores in suspected acute myocardial infarction.

Grimm K, Twerenbold R, Abaecherli R, Boeddinghaus J, ... Reichlin T, Mueller C
Background
Recent advances in digital electrocardiography technology allow evaluating ST-segment deviations in all 12 leads as quantitative variables and calculating summed ST-segment deviation scores. The diagnostic and prognostic utility of summed ST-segment deviation scores is largely unknown.
Methods
We aimed to explore the diagnostic and prognostic utility of the conventional and the modified ST-segment deviation score (Better Analysis of ST-segment Elevations and Depressions in a 12- Lead-ECG-Score (BASEL-Score): sum of elevations in the augmented voltage right - lead (aVR) plus absolute, unsigned ST-segment depressions in the remaining leads) in patients presenting with suspected non-ST-segment elevation myocardial infarction. The diagnostic endpoint was non-ST-segment elevation myocardial infarction, adjudicated by two independent cardiologists. Prognostic endpoint was mortality during two-year follow up.
Results
Among 1330 patients, non-ST-segment elevation myocardial infarction was present in 200 (15%) patients. Diagnostic accuracy for non-ST-segment elevation myocardial infarction as quantified by the area under the receiver-operating-characteristics curve was significantly higher for the BASEL-Score (0.73; 95% confidence interval 0.69-0.77) as compared to the conventional ST-segment deviation score (0.53; 95% confidence interval 0.49-0.57, p<0.001). The BASEL-Score provided additional independent diagnostic value to dichotomous electrocardiogram variables (ST-segment depression, T-inversion, both p<0.001) and to high-sensitivity cardiac troponin (p<0.001) as well as clinical judgment at 90 min (p<0.001). Similarly, only the BASEL-Score proved to be an independent predictor of two year mortality.
Conclusions
The modified ST-segment deviation score BASEL-Score focusing on ST-segment elevation in aVR and ST-segment depressions in the remaining leads provides incremental diagnostic and prognostic information.



Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:857-868
Grimm K, Twerenbold R, Abaecherli R, Boeddinghaus J, ... Reichlin T, Mueller C
Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:857-868 | PMID: 31976746
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Impact:
Abstract

Organization of intensive cardiac care units in Europe: Results of a multinational survey.

Claeys MJ, Roubille F, Casella G, Zukermann R, ... Price S, Bonnefoy E
Background
The present survey aims to describe the intensive cardiac care unit organization and admission policies in Europe.
Methods
A total of 228 hospitals (61% academic) from 27 countries participated in this survey. In addition to the organizational aspects of the intensive cardiac care units, including classification of the intensive cardiac care unit levels, data on the admission diagnoses were gathered from consecutive patients who were admitted during a two-day period. Admission policies were evaluated by comparing illness severity with the intensive cardiac care unit level. Gross national income was used to differentiate high-income countries (n=13) from middle-income countries (n=14).
Results
A total of 98% of the hospitals had an intensive cardiac care unit: 70% had a level 1 intensive cardiac care unit, 76% had a level 2 intensive cardiac care unit, 51% had a level 3 intensive cardiac care unit, and 60% of the hospitals had more than one intensive cardiac care unit level. High-income countries tended to have more level 3 intensive cardiac care units than middle-income countries (55% versus 41%, p=0.07). A total of 5159 admissions were scored on illness severity: 63% were low severity, 24% were intermediate severity, and 12% were high severity. Patients with low illness severity were predominantly admitted to level 1 intensive cardiac care units, whereas patients with high illness severity were predominantly admitted to level 2 and 3 intensive cardiac care units. A policy mismatch was observed in 12% of the patients; some patients with high illness severity were admitted to level 1 intensive cardiac care units, which occurred more often in middle-income countries, whereas some patients with low illness severity were admitted to level 3 intensive cardiac care units, which occurred more frequently in high-income countries.
Conclusion
More than one-third of the admitted patients were considered intermediate or high risk. Although patients with higher illness severity were mostly admitted to high-level intensive cardiac care units, an admission policy mismatch was observed in 12% of the patients; this mismatch was partly related to insufficient logistic intensive cardiac care unit capacity.



Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:993-1001
Claeys MJ, Roubille F, Casella G, Zukermann R, ... Price S, Bonnefoy E
Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:993-1001 | PMID: 31976740
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Impact:
Abstract

Trends in mortality, co-morbidity and treatment after acute myocardial infarction in patients with rheumatoid arthritis 1998-2013.

Skielta M, Söderström L, Rantapää-Dahlqvist S, Jonsson SW, Mooe T
Aims
Rheumatoid arthritis may influence the outcome after an acute myocardial infarction. We aimed to compare trends in one-year mortality, co-morbidities and treatments after a first acute myocardial infarction in patients with rheumatoid arthritis versus non-rheumatoid arthritis patients during 1998-2013. Furthermore, we wanted to identify characteristics associated with mortality.
Methods and results
Data for 245,377 patients with a first acute myocardial infarction were drawn from the Swedish Register of Information and Knowledge about Swedish Heart Intensive Care Admissions for 1998-2013. In total, 4268 patients were diagnosed with rheumatoid arthritis. Kaplan-Meier analysis was used to study mortality trends over time and multivariable Cox regression analysis was used to identify variables associated with mortality. The one-year mortality in rheumatoid arthritis patients was initially lower compared to non-rheumatoid arthritis patients (14.7% versus 19.7%) but thereafter increased above that in non-rheumatoid arthritis patients (17.1% versus 13.5%). In rheumatoid arthritis patients the mean age at admission and the prevalence of atrial fibrillation increased over time. Congestive heart failure decreased more in non-rheumatoid arthritis than in rheumatoid arthritis patients. Congestive heart failure, atrial fibrillation, kidney failure, rheumatoid arthritis, prior diabetes mellitus and hypertension were associated with significantly higher one-year mortality during the study period 1998-2013.
Conclusions
The decrease in one-year mortality after acute myocardial infarction in non-rheumatoid arthritis patients was not applicable to rheumatoid arthritis patients. This could partly be explained by an increased age at acute myocardial infarction onset and unfavourable trends with increased atrial fibrillation and congestive heart failure in rheumatoid arthritis. Rheumatoid arthritis per se was associated with a significantly worse prognosis.



Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:931-938
Skielta M, Söderström L, Rantapää-Dahlqvist S, Jonsson SW, Mooe T
Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:931-938 | PMID: 31990203
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Impact:
Abstract

Differences in presentation and clinical outcomes between left or right bundle branch block and ST segment elevation in patients with acute myocardial infarction.

Meyer MR, Radovanovic D, Pedrazzini G, Rickli H, ... Eberli FR, Kurz DJ
Background
In patients with acute myocardial infarction, the presence of a left bundle branch block or right bundle branch block may be associated with worse prognosis compared to isolated ST segment elevation. However, specificities in clinical presentation and outcomes of acute myocardial infarction patients with left bundle branch block or right bundle branch block are poorly characterized.
Methods
We analysed acute myocardial infarction patients with left bundle branch block (n=880), right bundle branch block (n=732) or ST segment elevation without bundle branch block (n=15,852) included in the Acute Myocardial Infarction in Switzerland-Plus registry between 2008-2019.
Results
Acute myocardial infarction patients with bundle branch block were older and had more pre-existing cardiovascular conditions compared to ST segment elevation. Pulmonary oedema and cardiogenic shock were most frequent in patients with left bundle branch block (18.8% vs 12.0% for right bundle branch block and 7.9% for ST segment elevation, p<0.001). Acute myocardial infarction patients with bundle branch block had more three-vessel (40.6% vs 25.3%, p<0.001 vs ST segment elevation) and left main disease (5.6% vs 2.0%, p<0.001 vs ST segment elevation). Major adverse cardiac and cerebrovascular events, a composite of reinfarction, stroke/transient ischaemic attack, and death during hospitalization, were highest in acute myocardial infarction patients with left bundle branch block (13.9% vs 9.9% for right bundle branch block and 6.7% for ST segment elevation, p<0.05), which was driven by hospital mortality. After multivariate adjustment, however, mortality was similar in patients with left bundle branch block and lower in patients with right bundle branch block, respectively, when compared to ST segment elevation. Mortality was only increased when a right bundle branch block with concomitant STE was present (odds ratio 1.77, 95% confidence interval 1.19-2.64, p<0.01 vs ST segment elevation).
Conclusions
Compared to ST segment elevation, an isolated bundle branch block reflects high-risk clinical characteristics but does not independently determine increased hospital mortality in acute myocardial infarction.



Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:848-856
Meyer MR, Radovanovic D, Pedrazzini G, Rickli H, ... Eberli FR, Kurz DJ
Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:848-856 | PMID: 32030999
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Impact:
Abstract

Efficacy of anakinra for idiopathic and non-idiopathic pericarditis refractory or intolerant to conventional therapy.

Shaukat MH, Singh S, Davis K, Torosoff M, Peredo-Wende R
Background
Anakinra, a recombinant interleukin-1 receptor antagonist is effective in treatment of idiopathic recurrent pericarditis. However, its efficacy in non-idiopathic pericarditis (secondary to a diagnosed inflammatory condition, or other known etiology) is unclear. We evaluated the efficacy of anakinra in patients with non-idiopathic (secondary to a diagnosed inflammatory condition, or other known etiology) and idiopathic pericarditis, who were intolerant or refractory to conventional therapy (colchicine and corticosteroids).
Methods
This was a single-center study in which we performed a retrospective chart review of consecutive adult patients hospitalized with pericarditis intolerant or refractory to conventional therapy who were treated with conventional therapy and anakinra between January 2016-October 2018. The control group included age-matched hospitalized pericarditis patients treated with conventional therapy only. Symptom relief at discharge, time to symptom relief and recurrence on treatment were compared. The effect of outpatient continuation of anakinra on post-treatment recurrence risk was assessed.
Results
Twelve patients received anakinra for pericarditis; 22 age-matched controls were identified. Ten patients (83.3%) in the conventional therapy and anakinra group and 13 patients (54.1%) in the conventional therapy groups had non-idiopathic pericarditis. All conventional therapy and anakinra patients and 16 of 22 patients in the conventional therapy group reported symptom relief at discharge (p=0.04). Time to symptom relief was decreased in the conventional therapy and anakinra group (3.75±1.87 vs 5.63±3.28 days, p=0.08). During treatment, all conventional therapy and anakinra-treated patients continued to be symptom free, while nine of 22 conventional therapy patients (40.9%) experienced recurrence (p=0.009). Recurrence risk after treatment discontinuation was similar in the conventional therapy and anakinra group and the conventional therapy group.
Conclusions
In hospitalized patients with non-idiopathic or idiopathic pericarditis refractory, or intolerant to, conventional therapy, anakinra is associated with improved symptom relief and decreased recurrence risk during treatment.



Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:888-892
Shaukat MH, Singh S, Davis K, Torosoff M, Peredo-Wende R
Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:888-892 | PMID: 32159368
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Impact:
Abstract

Assessment of quality indicators for acute myocardial infarction management in 28 countries and use of composite quality indicators for benchmarking.

Rossello X, Medina J, Pocock S, Van de Werf F, ... Huo Y, Bueno H
Background
The European Society of Cardiology established a set of quality indicators for the management of acute myocardial infarction. Our aim was to evaluate their degree of attainment, prognostic value and potential use for centre benchmarking in a large international cohort.
Methods
Quality indicators were extracted from the long-tErm follow-uP of antithrombotic management patterns In acute CORonary syndrome patients (EPICOR) (555 hospitals, 20 countries in Europe and Latin America, 2010-2011) and EPICOR Asia (218 hospitals, eight countries, 2011-2012) registries, including non-ST-segment elevation acute myocardial infarction (n=6558) and ST-segment elevation acute myocardial infarction (n=11,559) hospital survivors. The association between implementation rates for each quality indicator and two-year adjusted mortality was evaluated using adjusted Cox models. Composite quality indicators were categorized for benchmarking assessment at different levels.
Results
The degree of attainment of the 17 evaluated quality indicators ranged from 13% to 100%. Attainment of most individual quality indicators was associated with two-year survival. A higher compliance with composite quality indicators was associated with lower mortality at centre-, country- and region-level. Moreover, the higher the risk for two-year mortality, the lower the compliance with composite quality indicators.
Conclusions
When EPICOR and EPICOR Asia were conducted, the European Society of Cardiology quality indicators would have been attained to a limited extent, suggesting wide room for improvement in the management of acute myocardial infarction patients. After adjustment for confounding, most quality indicators were associated with reduced two-year mortality and their prognostic value should receive further attention. The two composite quality indicators can be used as a tool for benchmarking either at centre-, country- or world region-level.



Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:911-922
Rossello X, Medina J, Pocock S, Van de Werf F, ... Huo Y, Bueno H
Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:911-922 | PMID: 32159359
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Impact:
Abstract

Outcome of inter-hospital transfer versus direct admission for primary percutaneous coronary intervention: An observational study of 25,315 patients with ST-elevation myocardial infarction from the London Heart Attack Group.

Rathod KS, Jain AK, Firoozi S, Lim P, ... Wragg A, Jones DA
Background:
and aims
In patients with ST-segment elevation myocardial infarction (STEMI), mortality is directly related to time to reperfusion with guidelines recommending patients be delivered directly to centres for primary percutaneous coronary intervention (PCI). The aim of this study was to describe the impact of inter-hospital transfer on reperfusion time and to assess whether or not treatment delays influenced clinical outcomes in comparison with direct admission to a primary PCI centre in a large regional network.
Method and results
We undertook an observational cohort study of patients with STEMI treated with primary PCI between 2005 and 2015 in London, UK. Patient details were recorded at the time of the procedure in databases using the British Cardiovascular Intervention Society PCI dataset. The primary end-point was all-cause mortality at a median of 4.1 years (interquartile range: 2.2-5.8 years). Secondary outcomes were in-hospital major adverse cardiac events. Of 25,315 patients, 17,560 (69.4%) were admitted directly to a primary PCI centre and 7755 (31.6%) were transferred from a non-primary PCI centre. Patients in the direct admission group were older and more likely to have left ventricular impairment compared with the inter-hospital transfer group. Median time from call for help to reperfusion in transferred patients was 52 minutes longer compared with patients admitted directly (p <0.001). However, call to first hospital admission was similar. Kaplan-Meier analysis demonstrated significantly lower mortality rates in patients who were transferred directed to a primary PCI centre compared with patients who were transferred from a non-PCI centre (17.4% direct vs. 18.7% transfer, p=0.017). Furthermore, after propensity matching, direct admission for primary PCI was still a predictor of all-cause mortality (hazard ratio: 0.89, 95% confidence interval: 0.64-0.95).
Conclusions
In this large registry of over 25,000 STEMI patients treated by primary PCI survival was better in patients admitted directly to a cardiac centre versus patients transferred for primary PCI, most likely due to longer call to balloon times in patient transferred from other hospitals.



Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:948-957
Rathod KS, Jain AK, Firoozi S, Lim P, ... Wragg A, Jones DA
Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:948-957 | PMID: 32193943
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Impact:
Abstract

An innovative lipid-lowering approach to enhance attainment of low-density lipoprotein cholesterol goals.

Buonvino C, Chopard R, Guillon B, Puymirat E, ... Meneveau N, Schiele F
Aims
To improve attainment of LDL-cholesterol (LDL-c) targets, an expert group proposed an algorithm for lipid-lowering therapy during hospitalization for acute coronary syndrome and during follow-up. We aimed to assess adherence to this algorithm, and evaluate its impact on LDL-c levels and on attainment of therapeutic LDL-c targets in a population of post-acute coronary syndrome patients.
Methods and results
Prospective, observational study including patients admitted for acute coronary syndrome between February 2017 and September 2018. Patients admitted without statins or ezetimibe were considered \'naïve\'. Baseline LDL-c was admission LDL-c in naïve patients, and for those taking lipid-lowering therapy at admission, baseline LDL-c was back-calculated. In line with the most recent guidelines, the target was a >50% reduction in naïve LDL-c and <55 mg/dL. In total, 270 patients were analysed, mean age 67 ± 12 years, 78% men, 26% diabetic. At admission, 175 (65%) were naïve, 95 (35%) had previous lipid-lowering therapy, of which 13 (5%) statin+ezetimibe. Average LDL-c at admission was 120 ± 47 mg/dL (136 ± 44 mg/dL in naïve, 91 ± 39 mg/dL in pretreated patients). Discharge prescription was in compliance with the algorithm in 204 (76%) patients. Average LDL-c at two months was 57 ± 28 mg/dL; it was <55 mg/dL in 135 (50%), and 178 (66%) achieved a >50% reduction. Overall, 125/270 (46%) achieved the LDL-c goal. The reduction in LDL-c observed at two months persisted at five months.
Conclusion
Prescription of high-intensity statins, associated with ezetimibe where applicable, achieves LDL-c levels <55 mg/dL in 50% of patients at two months, and attains therapeutic goals defined by the European Society of Cardiology in 46% of cases.



Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:879-887
Buonvino C, Chopard R, Guillon B, Puymirat E, ... Meneveau N, Schiele F
Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:879-887 | PMID: 32363879
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Impact:
Abstract

Cardiac complications in patients hospitalised with COVID-19.

Linschoten M, Peters S, van Smeden M, Jewbali LS, ... Asselbergs FW, CAPACITY-COVID collaborative consortium
Aims
To determine the frequency and pattern of cardiac complications in patients hospitalised with coronavirus disease (COVID-19).
Methods and results
CAPACITY-COVID is an international patient registry established to determine the role of cardiovascular disease in the COVID-19 pandemic. In this registry, data generated during routine clinical practice are collected in a standardised manner for patients with a (highly suspected) severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection requiring hospitalisation. For the current analysis, consecutive patients with laboratory confirmed COVID-19 registered between 28 March and 3 July 2020 were included. Patients were followed for the occurrence of cardiac complications and pulmonary embolism from admission to discharge. In total, 3011 patients were included, of which 1890 (62.8%) were men. The median age was 67 years (interquartile range 56-76); 937 (31.0%) patients had a history of cardiac disease, with pre-existent coronary artery disease being most common (n=463, 15.4%). During hospitalisation, 595 (19.8%) patients died, including 16 patients (2.7%) with cardiac causes. Cardiac complications were diagnosed in 349 (11.6%) patients, with atrial fibrillation (n=142, 4.7%) being most common. The incidence of other cardiac complications was 1.8% for heart failure (n=55), 0.5% for acute coronary syndrome (n=15), 0.5% for ventricular arrhythmia (n=14), 0.1% for bacterial endocarditis (n=4) and myocarditis (n=3), respectively, and 0.03% for pericarditis (n=1). Pulmonary embolism was diagnosed in 198 (6.6%) patients.
Conclusion
This large study among 3011 hospitalised patients with COVID-19 shows that the incidence of cardiac complications during hospital admission is low, despite a frequent history of cardiovascular disease. Long-term cardiac outcomes and the role of pre-existing cardiovascular disease in COVID-19 outcome warrants further investigation.



Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:817-823
Linschoten M, Peters S, van Smeden M, Jewbali LS, ... Asselbergs FW, CAPACITY-COVID collaborative consortium
Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:817-823 | PMID: 33222494
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Impact:
Abstract

Prognostic role of plasma galectin-3 levels in acute coronary syndrome.

Obeid S, Yousif N, Davies A, Loretz R, ... von Eckardstein A, Lüscher TF
Aim
Cystatin C, neutrophil gelatinase-associated lipocalin and galectin-3 have emerged as biomarker candidates to predict cardiovascular outcomes and mortality in the general population as well as in patients with coronary artery or renal disease. However, their predictive role and clinical utility in patients with acute coronary syndromes alone or in combination beyond currently used risk scores remains to be determined.
Methods and results
Cystatin C, neutrophil gelatinase-associated lipocalin, and galectin-3 were measured in plasmas of 1832 patients at the time of presentation with acute coronary syndromes requiring percutaneous coronary intervention or coronary artery bypass grafting. The primary outcomes were major adverse cardiac and cerebrovascular events (defined as the composite of all-cause mortality, cerebrovascular events, any repeat revascularization or myocardial infarction) and all-cause mortality after 1 year and occurred in 192 (10.5%) and 78 (4.3%) of patients, respectively. All three biomarkers were increased in those with major adverse cardiac and cerebrovascular events compared with those without (p<0.001). However, only galectin-3 (all-cause mortality: hazard ratio=1.027 (95% confidence interval (1.011-1.043); p=0.001), major adverse cardiac and cerebrovascular events: hazard ratio=1.025 (95% confidence interval (1.012-1.037); p<0.001)) but not cystatin C nor neutrophil gelatinase-associated lipocalin emerged as independent predictors of both major adverse cardiac and cerebrovascular events and death. The risks were particularly high in the highest quartile of galectin-3. The integration of galectin-3 into the global registry of acute coronary events (GRACE) score improved the prediction of major adverse cardiac and cerebrovascular events and all-cause mortality significantly. The areas under the receiver operator characteristics curves increased from 0.6701 to 0.6932 for major adverse cardiac and cerebrovascular events (p=0.0474) and from 0.804 to 0.8199 for all-cause mortality (p=0.0197). Finally, we applied net reclassification improvement index using different cut-offs for major adverse cardiac and cerebrovascular events which showed negative results (for the cut-offs of 5% and 15%, net reclassification improvement index 0.028, p=0.586, for the cut-offs of 10% and 20%, net reclassification improvement index 0.072, p=0.1132 and for the cut-offs of 10% and 30% the net reclassification improvement index is 0.0843, p=0.077).
Conclusion
In acute coronary syndromes patients, galectin-3 has moderate prognostic accuracy, provides statistically significant incremental value in some, but not all models, and that the magnitude of any improvement would seem of questionable clinical value.



Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:869-878
Obeid S, Yousif N, Davies A, Loretz R, ... von Eckardstein A, Lüscher TF
Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; 9:869-878 | PMID: 33300826
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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).

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; epub ahead of print
Díez-Villanueva P, García-Guimaraes M, Sanz-Ruiz R, Roura G, ... Salamanca J, Alfonso F
Eur Heart J Acute Cardiovasc Care: 29 Nov 2020; epub ahead of print | PMID: 33620451
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Impact:
Abstract

Use of hospital resources in the care of patients with intermediate risk pulmonary embolism.

Sullivan AE, Holder T, Truong T, Green CL, ... Jones WS, Patel MR
Background
Risk stratification and management of hemodynamically stable pulmonary embolism remains challenging. Professional societies have published stratification schemes, but little is known about the management of patients with intermediate risk pulmonary embolism. We describe the care of these patients at an academic health system.
Methods
Patient encounters from 1 January 2016 to 30 June 2017 were retrospectively identified utilizing a multihospital, electronic health record-based data warehouse. Using the 2019 European Society of Cardiology criteria, differences in hospital resource utilization, defined as intensive care unit admission, use of invasive therapies, and length of stay, were examined in patients with intermediate risk characteristics.
Results
A cohort of 322 intermediate risk patients, including 165 intermediate-low and 157 intermediate-high risk patients, was identified. Intermediate-high risk patients more often underwent catheter-directed therapy (14.0% vs. 1.8%; P<0.001) compared to intermediate-low risk patients and had a 50% higher rate of intensive care unit admission (relative risk 1.50; 95% confidence interval 1.06, 2.12; P=0.023). There was no difference in median intensive care unit length of stay (2.7 vs. 2.0 days; P=0.761) or hospital length of stay (5.0 vs. 5.0 days; P=0.775) between intermediate-high risk and intermediate-low risk patients. Patients that underwent invasive therapies had a 3.8-day shorter hospital length of stay (beta -3.75; 95% confidence interval -6.17, -1.32; P=0.002).
Conclusion
This study presents insights into the hospital resource utilization of patients with intermediate risk pulmonary embolism. The 2019 European Society of Cardiology risk stratification criteria are a clinically relevant scheme that identifies patients more often treated with intensive care unit admission and advanced therapies.



Eur Heart J Acute Cardiovasc Care: 26 Nov 2020:2048872620921601; epub ahead of print
Sullivan AE, Holder T, Truong T, Green CL, ... Jones WS, Patel MR
Eur Heart J Acute Cardiovasc Care: 26 Nov 2020:2048872620921601; epub ahead of print | PMID: 33242980
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Impact:
Abstract

Use of hospital resources in the care of patients with intermediate risk pulmonary embolism.

Sullivan AE, Holder T, Truong T, Green CL, ... Jones WS, Patel MR
Background
Risk stratification and management of hemodynamically stable pulmonary embolism remains challenging. Professional societies have published stratification schemes, but little is known about the management of patients with intermediate risk pulmonary embolism. We describe the care of these patients at an academic health system.
Methods
Patient encounters from 1 January 2016 to 30 June 2017 were retrospectively identified utilizing a multihospital, electronic health record-based data warehouse. Using the 2019 European Society of Cardiology criteria, differences in hospital resource utilization, defined as intensive care unit admission, use of invasive therapies, and length of stay, were examined in patients with intermediate risk characteristics.
Results
A cohort of 322 intermediate risk patients, including 165 intermediate-low and 157 intermediate-high risk patients, was identified. Intermediate-high risk patients more often underwent catheter-directed therapy (14.0% vs. 1.8%; P<0.001) compared to intermediate-low risk patients and had a 50% higher rate of intensive care unit admission (relative risk 1.50; 95% confidence interval 1.06, 2.12; P=0.023). There was no difference in median intensive care unit length of stay (2.7 vs. 2.0 days; P=0.761) or hospital length of stay (5.0 vs. 5.0 days; P=0.775) between intermediate-high risk and intermediate-low risk patients. Patients that underwent invasive therapies had a 3.8-day shorter hospital length of stay (beta -3.75; 95% confidence interval -6.17, -1.32; P=0.002).
Conclusion
This study presents insights into the hospital resource utilization of patients with intermediate risk pulmonary embolism. The 2019 European Society of Cardiology risk stratification criteria are a clinically relevant scheme that identifies patients more often treated with intensive care unit admission and advanced therapies.

© The European Society of Cardiology 2020.

Eur Heart J Acute Cardiovasc Care: 26 Nov 2020; epub ahead of print
Sullivan AE, Holder T, Truong T, Green CL, ... Jones WS, Patel MR
Eur Heart J Acute Cardiovasc Care: 26 Nov 2020; epub ahead of print | PMID: 33609111
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Impact:
Abstract

In-hospital outcomes of catheter-directed thrombolysis in patients with pulmonary embolism.

Hobohm L, Schmidt FP, Gori T, Schmidtmann I, ... Konstantinides SV, Keller K
Aims
Catheter-directed treatment of acute pulmonary embolism (PE) is technically advancing. Recent guidelines acknowledge this treatment option for patients with overt or imminent haemodynamic decompensation, particularly when systemic thrombolysis is contraindicated. We investigated patients with PE who underwent catheter-directed thrombolysis (CDT) in the German nationwide inpatient cohort.
Methods and results
Data from hospitalizations with PE (International Classification of Disease code I26) between 2005 and 2016 were collected by the Federal Office of Statistics in Germany. Patients with PE who underwent CDT (OPS 8-838.60 or OPS code 8-83b.j) were compared with patients receiving systemic thrombolysis (OPS code 8-020.8), and those without thrombolytic or other reperfusion treatment. The analysis was not prespecified; therefore, our findings can only be considered to be hypothesis generating. We analysed data from 978 094 hospitalized patients with PE. Of these, 41 903 (4.3%) patients received thrombolytic treatment [systemic thrombolysis in 4.2%, CDT in 0.1% (1175 patients)]. Among patients with shock, CDT was associated with lower in-hospital mortality compared to systemic thrombolysis [odds ratios (OR) 0.30 (95% 0.14-0.67); P = 0.003]. Intracranial bleeding occurred in 14 (1.2%) patients who received CDT. Among haemodynamically stable patients with right ventricular dysfunction (intermediate-risk PE), CDT also was associated with a lower risk of in-hospital mortality compared to systemic thrombolysis {OR 0.55 [95% confidence interval (CI) 0.40-0.75]; P < 0.001} or no thrombolytic treatment [0.45 (95% CI 0.33-0.62); P < 0.001].
Conclusion
In the German nationwide inpatient cohort, based on administrative data, CDT was associated with lower in-hospital mortality rates compared to systemic thrombolysis, but the overall rate of intracranial bleeding in patients who received CDT was not negligible. Prospective controlled data are urgently needed to determine the true value of this treatment option in acute PE.

© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.

Eur Heart J Acute Cardiovasc Care: 24 Nov 2020; epub ahead of print
Hobohm L, Schmidt FP, Gori T, Schmidtmann I, ... Konstantinides SV, Keller K
Eur Heart J Acute Cardiovasc Care: 24 Nov 2020; epub ahead of print | PMID: 33620441
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Impact:
Abstract

Right ventricular function and iron deficiency in acute heart failure.

Miñana G, Santas E, de la Espriella R, Núñez E, ... Bayés-Genís A, Núñez J
Aims
Iron deficiency (ID) is a frequent finding in patients with chronic and acute heart failure (AHF) along the full spectrum of left ventricular ejection fraction (LVEF). Iron deficiency has been related to ventricular systolic dysfunction, but its role in right ventricular function has not been evaluated. We sought to evaluate whether ID identifies patients with greater right ventricular dysfunction in the setting of AHF.
Methods and results
We prospectively included 903 patients admitted with AHF. Right systolic function was evaluated by tricuspid annular plane systolic excursion (TAPSE) and the ratio TAPSE/pulmonary artery systolic pressure (TAPSE/PASP). Iron deficiency was defined, according to European Society of Cardiology criteria, as serum ferritin <100 mg/dL (absolute ID) or ferritin 100-299 mg/dL and transferrin saturation (TSAT) <20% (functional ID). The relationships among the exposures with right ventricular systolic function were evaluated by multivariate linear regression analyses. The mean age of the sample was 74.3 ± 10.6 years, 441 (48.8%) were female, 471 (52.2%) exhibited heart failure with preserved ejection fraction, and 677 (75.0%) showed ID. The mean LVEF, TAPSE, and TAPSE/PASP were 49 ± 15%, 18.6 ± 3.9 mm, and 0.45 ± 0.18, respectively. The median (interquartile range) amino-terminal pro-brain natriuretic peptide was 4015 (1807-8775) pg/mL. In a multivariable setting, lower TSAT and ferritin were independently associated with lower TAPSE (P < 0.05 for both comparisons). Transferrin saturation (P = 0.017), and not ferritin (P = 0.633), was independently associated with TAPSE/PASP.
Conclusion
In AHF, proxies of ID were associated with right ventricular dysfunction. Further studies should confirm these findings and evaluate the pathophysiological facts behind this association.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 11 Nov 2020; epub ahead of print
Miñana G, Santas E, de la Espriella R, Núñez E, ... Bayés-Genís A, Núñez J
Eur Heart J Acute Cardiovasc Care: 11 Nov 2020; epub ahead of print | PMID: 33620455
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Impact:
Abstract

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

Koechlin L, Boeddinghaus J, Nestelberger T, Miró Ò, ... Twerenbold R, Mueller C
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: [email protected]

Eur Heart J Acute Cardiovasc Care: 11 Nov 2020; epub ahead of print
Koechlin L, Boeddinghaus J, Nestelberger T, Miró Ò, ... Twerenbold R, Mueller C
Eur Heart J Acute Cardiovasc Care: 11 Nov 2020; epub ahead of print | PMID: 33620434
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Impact:
Abstract

The cardiac arrest centre for the treatment of sudden cardiac arrest due to presumed cardiac cause: aims, function, and structure: position paper of the ACVC association of the ESC, EAPCI, EHRA, ERC, EUSEM, and ESICM.

Sinning C, Ahrens I, Cariou A, Beygui F, ... Kutyifa V, Bossaert L
Approximately 10% of patients resuscitated from out-of-hospital cardiac arrest (OHCA) survive to hospital discharge. Improved management to improve outcomes are required, and it is proposed that such patients should be preferentially treated in cardiac arrest centres (CACs). The minimum requirements of therapy modalities for the CAC are 24/7 availability of an on-site coronary angiography laboratory, an emergency department, an intensive care unit, imaging facilities, such as echocardiography, computed tomography, and magnetic resonance imaging, and a protocol outlining transfer of selected patients to CACs with additional resources (OHCA hub hospitals). These hub hospitals are regularly treating a high volume of patients and offer further treatment modalities. This consensus document describes the aims, the minimal requirements for therapeutic modalities and expertise, and the structure, of a CAC. It represents a consensus among the major European medical associations and societies involved in the treatment of OHCA patients.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 06 Nov 2020; epub ahead of print
Sinning C, Ahrens I, Cariou A, Beygui F, ... Kutyifa V, Bossaert L
Eur Heart J Acute Cardiovasc Care: 06 Nov 2020; epub ahead of print | PMID: 33620452
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Impact:
Abstract

Biomarkers of coagulation and fibrinolysis in acute myocardial infarction: a joint position paper of the Association for Acute CardioVascular Care and the European Society of Cardiology Working Group on Thrombosis.

Krychtiuk KA, Speidl WS, Giannitsis E, Gigante B, ... Lindahl B, Thygesen K
The formation of a thrombus in an epicardial artery may result in an acute myocardial infarction (AMI). Despite major advances in acute treatment using network approaches to allocate patients to timely reperfusion and optimal antithrombotic treatment, patients remain at high risk for thrombotic complications. Ongoing activation of the coagulation system as well as thrombin-mediated platelet activation may both play a crucial role in this context. Whether measurement of circulating biomarkers of coagulation and fibrinolysis could be useful for risk stratification in secondary prevention is currently not fully understood. In addition, measurement of such biomarkers could be helpful to identify thrombus formation as the leading mechanism for AMI. The introduction of biomarkers of myocardial injury such as high-sensitivity cardiac troponins made rule-out of AMI even more precise. However, elevated markers of myocardial injury cannot provide proof of a type 1 AMI, let alone thrombus formation. The combined measurement of markers of myocardial injury with biomarkers reflecting ongoing thrombus formation might be helpful for the fast and correct diagnosis of an atherothrombotic type 1 AMI. This position paper gives an overview of the current knowledge and possible role of biomarkers of coagulation and fibrinolysis for the diagnosis of AMI, risk stratification, and individualized treatment strategies in patients with AMI.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 06 Nov 2020; epub ahead of print
Krychtiuk KA, Speidl WS, Giannitsis E, Gigante B, ... Lindahl B, Thygesen K
Eur Heart J Acute Cardiovasc Care: 06 Nov 2020; epub ahead of print | PMID: 33620437
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Impact:
Abstract

Development and validation of a novel prediction score for cardiac tamponade in emergency department patients with pericardial effusion.

Duanmu Y, Choi DS, Tracy S, Harris OM, ... Wu JC, Platz E
Aims
Determining which patients with pericardial effusion require urgent intervention can be challenging. We sought to develop a novel, simple risk prediction score for patients with pericardial effusion.
Methods and results
Adult patients admitted through the emergency department (ED) with pericardial effusion were retrospectively evaluated. The overall cohort was divided into a derivation and validation cohort for the generation and validation of a novel risk score using logistic regression. The primary outcome was a pericardial drainage procedure or death attributed to cardiac tamponade within 24 h of ED arrival. Among 195 eligible patients, 102 (52%) experienced the primary outcome. Four variables were selected for the novel score: systolic blood pressure < 100 mmHg (1.5 points), effusion diameter [1-2 cm (0 points), 2-3 cm (1.5 points), >3 cm (2 points)], right ventricular diastolic collapse (2 points), and mitral inflow velocity variation > 25% (1 point). The need for pericardial drainage within 24 h was stratified as low (<2 points), intermediate (2-4 points), or high (≥4 points), which corresponded to risks of 8.1% [95% confidence interval (CI) 3.0-16.8%], 63.8% [95% CI 50.1-76.0%], and 93.7% [95% CI 84.5-98.2%]. The area under the curve of the simplified score was 0.94 for the derivation and 0.91 for the validation cohort.
Conclusion
Among ED patients with pericardial effusion, a four-variable prediction score consisting of systolic blood pressure, effusion diameter, right ventricular collapse, and mitral inflow velocity variation can accurately predict the need for urgent pericardial drainage. Prospective validation of this novel score is warranted.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 06 Nov 2020; epub ahead of print
Duanmu Y, Choi DS, Tracy S, Harris OM, ... Wu JC, Platz E
Eur Heart J Acute Cardiovasc Care: 06 Nov 2020; epub ahead of print | PMID: 33823539
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Impact:
Abstract

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

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



Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S145-S152
Bro-Jeppesen J, Jeppesen AN, Haugaard S, Troldborg A, ... Hvas AM, Thiel S
Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S145-S152 | PMID: 31538810
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Impact:
Abstract

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

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



Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S153-S160
Salah M, Gevaert S, Coussement P, Beauloye C, ... Saenen J, Claeys MJ
Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S153-S160 | PMID: 31452398
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Impact:
Abstract

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

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



Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S122-S130
Grand J, Lilja G, Kjaergaard J, Bro-Jeppesen J, ... Nielsen N, Hassager C
Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S122-S130 | PMID: 31246109
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Impact:
Abstract

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

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



Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S131-S137
Viana-Tejedor A, Ariza-Solé A, Martínez-Sellés M, Mena MJ, ... Ortiz AF, Macaya C
Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S131-S137 | PMID: 31237435
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Impact:
Abstract

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

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



Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S175-S183
Shida H, Matsuyama T, Iwami T, Okabayashi S, ... Kitamura T, Kawamura T
Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S175-S183 | PMID: 31081678
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Impact:
Abstract

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

Wiberg S, Stride N, Bro-Jeppesen J, Holmberg MJ, ... Hassager C, Dela F
Background
While preclinical studies suggest that mitochondria play a pivotal role in ischaemia-reperfusion injury, the knowledge of mitochondrial function in human out-of-hospital cardiac arrest remains scarce. The present study sought to compare oxidative phosphorylation capacity in skeletal muscle biopsies from out-of-hospital cardiac arrest patients to healthy controls.
Methods
This was a substudy of a randomised trial comparing targeted temperature management at 33°C versus 36°C for out-of-hospital cardiac arrest patients. Skeletal muscle biopsies were obtained from adult resuscitated comatose out-of-hospital cardiac arrest patients 28 hours after initiation of targeted temperature management, i.e. at target temperature prior to rewarming, and from age-matched healthy controls. Mitochondrial function was analysed by high-resolution respirometry. Maximal sustained respiration through complex I, maximal coupled respiration through complex I and complex II and maximal electron transport system capacity was compared.
Results
A total of 20 out-of-hospital cardiac arrest patients and 21 controls were included in the analysis. We found no difference in mitochondrial function between temperature allocations. We found no difference in complex I sustained respiration between out-of-hospital cardiac arrest and controls (23 (18-26) vs. 22 (19-26) pmol O2/mg/s, P=0.76), whereas coupled complex I and complex II respiration was significantly lower in out-of-hospital cardiac arrest patients versus controls (53 (42-59) vs. 64 (54-68) pmol O2/mg/s, P=0.01). Furthermore, electron transport system capacity was lower in out-of-hospital cardiac arrest versus controls (63 (51-69) vs. 73 (66-78) pmol O2/mg/s, P=0.005).
Conclusions
Mitochondrial oxidative phosphorylation capacity in skeletal muscle biopsies was reduced in out-of-hospital cardiac arrest patients undergoing targeted temperature management compared to age-matched, healthy controls. The role of mitochondria as risk markers and potential targets for post-resuscitation care remains unknown.



Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S138-S144
Wiberg S, Stride N, Bro-Jeppesen J, Holmberg MJ, ... Hassager C, Dela F
Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S138-S144 | PMID: 30854867
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Impact:
Abstract

A randomised double-blind pilot trial comparing a mean arterial pressure target of 65 mm Hg versus 72 mm Hg after out-of-hospital cardiac arrest.

Grand J, Meyer AS, Kjaergaard J, Wiberg S, ... Johansson PI, Hassager C
Background
After resuscitation from out-of-hospital cardiac arrest, mean arterial pressure below 65 mm Hg is avoided with vasopressors. A higher blood-pressure target could potentially improve outcome. The aim of this pilot trial was to investigate the effect of a higher mean arterial pressure target on biomarkers of organ injury.
Methods
This was a single-centre, double-blind trial of 50 consecutive, comatose out-of-hospital cardiac arrest patients randomly assigned in a 1:1 ratio to a mean arterial pressure target of 65 mm Hg (MAP65) or 72 mm Hg (MAP72). Modified blood pressure modules with a -10% offset were used, enabling a double-blind study design. End-points were biomarkers of organ injury including markers of endothelial integrity (soluble trombomodulin) brain damage (neuron-specific enolase) and renal function (estimated glomerular filtration rate).
Results
Mean arterial pressure was significantly higher in MAP72 with a mean difference of 5 mm Hg (pgroup=0.03). After 48 h, soluble trombomodulin (median (interquartile range)) was 8.2 (6.7-12.9) ng/ml and 8.3 (6.0-10.8) ng/ml (p=0.29), neuron-specific enolase was 20 (13-31 μg/l) and 18 (13-44 μg/l) p=0.79) and estimated glomerular filtration rate (mean (±standard deviation)) was 61±19 ml/min/1.73m2 and 48±22 ml/min/1.73 m2 (p=0.08) for the MAP72 and MAP65 groups, respectively. Renal replacement therapy was needed in eight patients (31%) in MAP65 and three patients (13%) in MAP72 (p=0.14).
Conclusions
Double-blind allocation to different mean arterial pressure targets is feasible in comatose out-of-hospital cardiac arrest patients. A mean arterial pressure target of 72 mm Hg compared to 65 mm Hg did not result in improved biomarkers of organ injury. We observed a trend towards preserved renal function in the MAP72 group.



Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S100-S109
Grand J, Meyer AS, Kjaergaard J, Wiberg S, ... Johansson PI, Hassager C
Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S100-S109 | PMID: 32004081
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Impact:
Abstract

Acute respiratory failure and inflammatory response after out-of-hospital cardiac arrest: results of the Post-Cardiac Arrest Syndrome (PCAS) pilot study.

Czerwińska-Jelonkiewicz K, Grand J, Tavazzi G, Sans-Rosello J, ... Hassager C, Stępińska J
Background
Although the lungs are potentially highly susceptible to post-cardiac arrest syndrome injury, the issue of acute respiratory failure after out-of-hospital cardiac arrest has not been investigated. The objectives of this analysis were to determine the prevalence of acute respiratory failure after out-of-hospital cardiac arrest, its association with post-cardiac arrest syndrome inflammatory response and to clarify its importance for early mortality.
Methods
The Post-Cardiac Arrest Syndrome (PCAS) pilot study was a prospective, observational, six-centre project (Poland 2, Denmark 1, Spain 1, Italy 1, UK 1), studying patients resuscitated after out-of-hospital cardiac arrest of cardiac origin. Primary outcomes were: (a) the profile of organ failure within the first 72 hours after out-of-hospital cardiac arrest; (b) in-hospital and short-term mortality, up to 30 days of follow-up. Respiratory failure was defined using a modified version of the Berlin acute respiratory distress syndrome definition. Inflammatory response was defined using leukocytes (white blood cells), platelet count and C-reactive protein concentration. All parameters were assessed every 24 hours, from admission until 72 hours of stay.
Results
Overall, 148 patients (age 62.9±15.27 years; 27.7% women) were included. Acute respiratory failure was noted in between 50 (33.8%) and 75 (50.7%) patients over the first 72 hours. In-hospital and short-term mortality was 68 (46.9%) and 72 (48.6%), respectively. Inflammation was significantly associated with the risk of acute respiratory failure, with the highest cumulative odds ratio of 748 at 72 hours (C-reactive protein 1.035 (1.001-1.070); 0.043, white blood cells 1.086 (1.039-1.136); 0.001, platelets 1.004 (1.001-1.007); <0.005). Early acute respiratory failure was related to in-hospital mortality (3.172, 95% confidence interval 1.496-6.725; 0.002) and to short-term mortality (3.335 (1.815-6.129); 0.0001).
Conclusions
An inflammatory response is significantly associated with acute respiratory failure early after out-of-hospital cardiac arrest. Acute respiratory failure is associated with a worse early prognosis after out-of-hospital cardiac arrest.



Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S110-S121
Czerwińska-Jelonkiewicz K, Grand J, Tavazzi G, Sans-Rosello J, ... Hassager C, Stępińska J
Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S110-S121 | PMID: 32004080
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Impact:
Abstract

Improving bystander defibrillation in out-of-hospital cardiac arrests at home.

Karlsson L, Hansen CM, Vourakis C, Sun CL, ... Torp-Pedersen C, Folke F
Aims
Most out-of-hospital cardiac arrests occur at home with dismal bystander defibrillation rates. We investigated automated external defibrillator coverage of home arrests, and the proportion potentially reachable with an automated external defibrillator before emergency medical service arrival according to different bystander activation strategies.
Methods and results
Cardiac arrests in homes (private/nursing/senior homes) in Copenhagen, Denmark (2008-2016) and registered automated external defibrillators (2007-2016), were identified. Automated external defibrillator coverage (distance from arrest to automated external defibrillator) and accessibility at the time of arrest were examined according to route distance to nearest automated external defibrillator and emergency medical service response time. The proportion of arrests reachable with an automated external defibrillator by bystander was calculated using two-way (from patient to automated external defibrillator and back) and one-way (from automated external defibrillator to patient) potential activation strategies. Of 1879 home arrests, automated external defibrillator coverage ≤100 m was low (6.3%) and a two-way bystander could potentially only retrieve an accessible automated external defibrillator before emergency medical service in 31.1% (n=37) of cases. If a bystander only needed to travel one-way to bring an automated external defibrillator (≤100 m, ≤250 m and ≤500 m), 45.4% (n=54/119), 37.1% (n=196/529) and 29.8% (n=350/1174) could potentially be reached before the emergency medical service based on current automated external defibrillator accessibility.
Conclusions
Few home arrests were reachable with an automated external defibrillator before emergency medical service if bystanders needed to travel from patient to automated external defibrillator and back. However, nearly one-third of arrests ≤500 m of an automated external defibrillator could be reached before emergency medical service arrival if the bystander only needed to travel one-way from the automated external defibrillator to the patient.



Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S74-S81
Karlsson L, Hansen CM, Vourakis C, Sun CL, ... Torp-Pedersen C, Folke F
Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S74-S81 | PMID: 32166951
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Impact:
Abstract

Prehospital cardiopulmonary resuscitation duration and neurological outcome after adult out-of-hospital cardiac arrest by location of arrest.

Kishimori T, Matsuyama T, Kiyohara K, Kitamura T, ... Kawamura T, Iwami T
Background
Little is known about the association between prehospital cardiopulmonary resuscitation duration for adults with out-of-hospital cardiac arrest and outcome by the location of arrests. This study aimed to investigate the association between prehospital cardiopulmonary resuscitation duration and one-month survival with favourable neurological outcome.
Methods
We analysed 276,391 adults aged 18 years and older with out-of-hospital cardiac arrest of medical origin before emergency medical service arrival. Prehospital cardiopulmonary resuscitation duration was defined as the time from emergency medical service-initiated cardiopulmonary resuscitation to prehospital return of spontaneous circulation or to hospital arrival. The primary outcome was one-month survival with favourable neurological outcome (cerebral performance category 1 or 2). The association between prehospital cardiopulmonary resuscitation duration and favourable neurological outcome was assessed using univariable and multivariable logistic regression analyses.
Results
The proportion of favourable neurological outcomes was 2.3% in total, 7.6% in public locations, 1.5% in residential locations and 0.7% in nursing homes (P < 0.001). In univariable and multivariable logistic regression analyses, longer prehospital cardiopulmonary resuscitation duration was associated with poor neurological outcome, regardless of arrest location (P for trend < 0.001). Patients with shockable rhythm in both public and residential locations had better neurological outcome than those in nursing homes at any time point, and residential and public locations had a similar neurological outcome tendency among patients with shockable rhythm.
Conclusions
Longer prehospital cardiopulmonary resuscitation duration was independently associated with a lower proportion of patients with favourable neurological outcomes. Moreover, the association between prehospital cardiopulmonary resuscitation duration and neurological outcome differed according to the location of arrest and the first documented rhythm.



Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S90-S99
Kishimori T, Matsuyama T, Kiyohara K, Kitamura T, ... Kawamura T, Iwami T
Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S90-S99 | PMID: 32345027
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Impact:
Abstract

Management of EMS on-scene time during advanced life support in out-of-hospital cardiac arrest: a retrospective observational trial.

Poppe M, Krammel M, Clodi C, Schriefl C, ... Holzer M, Weiser C
Objective
Most western emergency medical services provide advanced life support in out-of-hospital cardiac arrest aiming for a return of spontaneous circulation at the scene. Little attention is given to prehospital time management in the case of out-of-hospital cardiac arrest with regard to early coronary angiography or to the start of extracorporeal cardiopulmonary resuscitation treatment within 60 minutes after out-of-hospital cardiac arrest onset. We investigated the emergency medical services on-scene time, defined as emergency medical services arrival at the scene until departure to the hospital, and its association with 30-day survival with favourable neurological outcome after out-of-hospital cardiac arrest.
Methods
All patients of over 18 years of age with non-traumatic, non-emergency medical services witnessed out-of-hospital cardiac arrest between July 2013 and August 2015 from the Vienna Cardiac Arrest Registry were included in this retrospective observational study.
Results
Out of 2149 out-of-hospital cardiac arrest patients, a total of 1687 (79%) patients were eligible for analyses. These patients were stratified into groups according to the on-scene time (<35 minutes, 35-45 minutes, 45-60 minutes, >60 minutes). Within short on-scene time groups, out-of-hospital cardiac arrest occurred more often in public and bystander cardiopulmonary resuscitation was more common (both P<0.001). Patients who did not achieve return of spontaneous circulation at the scene showed higher rates of 30-day survival with favourable neurological outcome with an on-scene time of less than 35 minutes (adjusted odds ratio 5.00, 95% confidence interval 1.39-17.96).
Conclusion
An emergency medical services on-scene time of less than 35 minutes was associated with higher rates of survival and favourable outcomes. It seems to be reasonable to develop time optimised advance life support protocols to minimise the on-scene time in view of further treatments such as early coronary angiography as part of post-resuscitation care or extracorporeal cardiopulmonary resuscitation in refractory out-of-hospital cardiac arrest.



Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S82-S89
Poppe M, Krammel M, Clodi C, Schriefl C, ... Holzer M, Weiser C
Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S82-S89 | PMID: 32403939
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Impact:
Abstract

An observational study assessing the impact of a cardiac arrest centre on patient outcomes after out-of-hospital cardiac arrest (OHCA).

Kelham M, Jones TN, Rathod KS, Guttmann O, ... Mathur A, Jones DA
Background
Out-of-hospital cardiac arrest (OHCA) is a major cause of death worldwide. Recent guidelines recommend the centralisation of OHCA services in cardiac arrest centres to improve outcomes. In 2015, two major tertiary cardiac centres in London merged to form a large dedicated tertiary cardiac centre. This study aimed to compare the short-term mortality of patients admitted with an OHCA before-and-after the merger of services had taken place and admission criteria were relaxed, which led to managing OHCA in higher volume.
Methods
We retrospectively analysed the data of OHCA patients pre- and post-merger. Baseline demographic and medical characteristics were recorded, along with factors relating to the cardiac arrest. The primary endpoint was in-hospital mortality.
Results
OHCA patients (N =728; 267 pre- and 461 post-merger) between 2013 and 2018 were analysed. Patients admitted pre-merger were older (65.0 vs. 62.4 years, p=0.027), otherwise there were similar baseline demographic and peri-arrest characteristics. There was a greater proportion of non-acute coronary syndrome-related OHCA admission post-merger (10.1% vs. 23.4%, p=0.0001) and a corresponding decrease in those admitted with ST-elevation myocardial infarction (80.2% vs. 57.0%, p=0.0001) and those treated with percutaneous coronary intervention (78.8% vs. 54.0%, p=0.0001). Despite this, in-hospital mortality was lower post-merger (63.7% vs. 44.3%, p=0.0001), which persisted after adjustment for demographic and arrest-related characteristics using stepwise logistic regression (p=0.036) between the groups.
Conclusion
Despite an increase in non-acute coronary syndrome-related OHCA cases, the formation of a centralised invasive heart centre was associated with improved survival in OHCA patients. This suggests there may be a benefit of a cardiac arrest centre model of care.



Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S67-S73
Kelham M, Jones TN, Rathod KS, Guttmann O, ... Mathur A, Jones DA
Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S67-S73 | PMID: 33241716
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Impact:
Abstract

The cardiac arrest centre for the treatment of sudden cardiac arrest due to presumed cardiac cause - aims, function and structure: Position paper of the Association for Acute CardioVascular Care of the European Society of Cardiology (AVCV), European Association of Percutaneous Coronary Interventions (EAPCI), European Heart Rhythm Association (EHRA), European Resuscitation Council (ERC), European Society for Emergency Medicine (EUSEM) and European Society of Intensive Care Medicine (ESICM).

Sinning C, Ahrens I, Cariou A, Beygui F, ... Jouven X, Hassager C
Approximately 10% of patients resuscitated from out-of-hospital cardiac arrest survive to hospital discharge. Improved management to improve outcomes is required, and it is proposed that such patients should be preferentially treated in cardiac arrest centres. The minimum requirements of therapy modalities for the cardiac arrest centre are 24/7 availability of an on-site coronary angiography laboratory, an emergency department, an intensive care unit, imaging facilities such as echocardiography, computed tomography and magnetic resonance imaging, and a protocol outlining transfer of selected patients to cardiac arrest centres with additional resources (out-of-hospital cardiac arrest hub hospitals). These hub hospitals are regularly treating a high volume of patients and offer further treatment modalities. This consensus document describes the aims, the minimal requirements for therapeutic modalities and expertise, and the structure, of a cardiac arrest centre. It represents a consensus among the major European medical associations and societies involved in the treatment of out-of-hospital cardiac arrest patients.



Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S193-S202
Sinning C, Ahrens I, Cariou A, Beygui F, ... Jouven X, Hassager C
Eur Heart J Acute Cardiovasc Care: 30 Oct 2020; 9:S193-S202 | PMID: 33327761
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Impact:
Abstract

Outcomes in non-ST-segment elevation myocardial infarction patients according to heart failure at admission: Insights from a large trial with systematic early invasive strategy.

Popovic B, Sorbets E, Abtan J, Cohen M, ... Steg PG, TAO investigators
Background
Previous studies published before the era of systematic early invasive strategy have reported a higher mortality in non-ST-segment elevation myocardial infarction patients with heart failure. The aim of our study was to compare the clinical characteristics, outcomes and causes of death of patients according to their heart failure status at admission in a large non-ST-segment elevation myocardial infarction population with planned early invasive management.
Methods
We performed a post-hoc analysis of the Treatment of Acute Coronary Syndrome with Otamixaban randomised trial which included non-ST-segment elevation myocardial infarction patients with systematic coronary angiography within 72 h. Patients were categorised according to presence or absence of heart failure (Killip grade ≥2) at admission.
Results
A total of 13,172 patients were enrolled, of whom 944 (7.2%) had heart failure. At day 30, death occurred in 213 patients (1.6%) and cardiovascular death was the dominant cause of death in both groups ((with vs without heart failure) 78.8% vs 78.4%, p = 0.94). At six months, death occurred in 90/944 (9.5%) patients with heart failure and 258/12228 patients without heart failure (2.1%) (p < 0.001). After adjustment on Global Registry of Acute Coronary Events risk score, heart failure was an independent predictor of all-cause mortality at day 30 (odds ratio: 1.58; 95% confidence interval, 1.06-2.36, p = 0.02) and at day 180 (odds ratio: 1.77; 95% confidence interval, 1.3-2.42, p < 0.001) as well as of ischaemic complications (cardiovascular death, myocardial infarction, stent thrombosis or stroke at day 30 (odds ratio: 1.28; 95% confidence interval, 1.01-1.62, p = 0.04).
Conclusion
Non-ST-segment elevation myocardial infarction patients with heart failure at admission still have worse outcomes than those without heart failure, even with systematic early invasive strategy. Further efforts are needed to improve the prognosis of these high risk patients.



Eur Heart J Acute Cardiovasc Care: 19 Oct 2020:2048872619896205; epub ahead of print
Popovic B, Sorbets E, Abtan J, Cohen M, ... Steg PG, TAO investigators
Eur Heart J Acute Cardiovasc Care: 19 Oct 2020:2048872619896205; epub ahead of print | PMID: 33081496
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Abstract

Outcomes in non-ST-segment elevation myocardial infarction patients according to heart failure at admission: Insights from a large trial with systematic early invasive strategy.

Popovic B, Sorbets E, Abtan J, Cohen M, ... Ducrocq G, Steg PG
Background
Previous studies published before the era of systematic early invasive strategy have reported a higher mortality in non-ST-segment elevation myocardial infarction patients with heart failure. The aim of our study was to compare the clinical characteristics, outcomes and causes of death of patients according to their heart failure status at admission in a large non-ST-segment elevation myocardial infarction population with planned early invasive management.
Methods
We performed a post-hoc analysis of the Treatment of Acute Coronary Syndrome with Otamixaban randomised trial which included non-ST-segment elevation myocardial infarction patients with systematic coronary angiography within 72 h. Patients were categorised according to presence or absence of heart failure (Killip grade ≥2) at admission.
Results
A total of 13,172 patients were enrolled, of whom 944 (7.2%) had heart failure. At day 30, death occurred in 213 patients (1.6%) and cardiovascular death was the dominant cause of death in both groups ((with vs without heart failure) 78.8% vs 78.4%, p = 0.94). At six months, death occurred in 90/944 (9.5%) patients with heart failure and 258/12228 patients without heart failure (2.1%) (p < 0.001). After adjustment on Global Registry of Acute Coronary Events risk score, heart failure was an independent predictor of all-cause mortality at day 30 (odds ratio: 1.58; 95% confidence interval, 1.06-2.36, p = 0.02) and at day 180 (odds ratio: 1.77; 95% confidence interval, 1.3-2.42, p < 0.001) as well as of ischaemic complications (cardiovascular death, myocardial infarction, stent thrombosis or stroke at day 30 (odds ratio: 1.28; 95% confidence interval, 1.01-1.62, p = 0.04).
Conclusion
Non-ST-segment elevation myocardial infarction patients with heart failure at admission still have worse outcomes than those without heart failure, even with systematic early invasive strategy. Further efforts are needed to improve the prognosis of these high risk patients.

© The European Society of Cardiology 2020.

Eur Heart J Acute Cardiovasc Care: 19 Oct 2020; epub ahead of print
Popovic B, Sorbets E, Abtan J, Cohen M, ... Ducrocq G, Steg PG
Eur Heart J Acute Cardiovasc Care: 19 Oct 2020; epub ahead of print | PMID: 33609103
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Abstract

Mortality risk stratification using artificial intelligence-augmented electrocardiogram in cardiac intensive care unit patients.

Jentzer JC, Kashou AH, Lopez-Jimenez F, Attia ZI, ... Friedman PA, Noseworthy PA
Aims
An artificial intelligence-augmented electrocardiogram (AI-ECG) algorithm can identify left ventricular systolic dysfunction (LVSD). We sought to determine whether this AI-ECG algorithm could stratify mortality risk in cardiac intensive care unit (CICU) patients, independent of the presence of LVSD by transthoracic echocardiography (TTE).
Methods and results
We included 11 266 unique Mayo Clinic CICU patients admitted from 2007 to 2018 who underwent AI-ECG after CICU admission. Left ventricular ejection fraction (LVEF) data were extracted for patients with a TTE during hospitalization. Hospital mortality was analysed using multivariable logistic regression. Mean age was 68 ± 15 years, including 37% females. Higher AI-ECG probability of LVSD remained associated with higher hospital mortality [adjusted odds ratio (OR) 1.05 per 0.1 higher, 95% confidence interval (CI) 1.02-1.08, P = 0.003] after adjustment for LVEF, which itself was inversely related with the risk of hospital mortality (adjusted OR 0.96 per 5% higher, 95% CI 0.93-0.99, P = 0.02). Patients with available LVEF data (n = 8242) were divided based on the presence of predicted (by AI-ECG) vs. observed (by TTE) LVSD (defined as LVEF ≤ 35%), using TTE as the gold standard. A stepwise increase in hospital mortality was observed for patients with a true negative, false positive, false negative, and true positive AI-ECG.
Conclusion
The AI-ECG prediction of LVSD is associated with hospital mortality in CICU patients, affording risk stratification in addition to that provided by echocardiographic LVEF. Our results emphasize the prognostic value of electrocardiographic patterns reflecting underlying myocardial disease that are recognized by the AI-ECG.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 15 Oct 2020; epub ahead of print
Jentzer JC, Kashou AH, Lopez-Jimenez F, Attia ZI, ... Friedman PA, Noseworthy PA
Eur Heart J Acute Cardiovasc Care: 15 Oct 2020; epub ahead of print | PMID: 33620440
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Abstract

The addition of echocardiographic parameters to PESI risk score improves mortality prediction in patients with acute pulmonary embolism: PESI-Echo score.

Burgos LM, Scatularo CE, Cigalini IM, Jauregui JC, ... Thierer J, Zaidel EJ
Aims
Pulmonary embolism severity index (PESI) has been developed to help physicians make decisions about the treatment of patients with pulmonary embolism (PE). The combination of echocardiographic parameters could potentially improve PESI\'s mortality prediction. To assess the additional prognostic value of tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP) when combined with the PESI score in patients with PE to predict short-term mortality.
Methods and results
A multicentric prospective study database of patients admitted with PE in 75 academic centres in Argentina between 2016 and 2017 was analysed. Patients with an echocardiogram at admission with simultaneous measurement of TAPSE and PASP were included. PESI risk score was calculated blindly and prospectively, and in-hospital all-cause mortality was assessed. Of 684 patients, 91% had an echocardiogram, PASP and TAPSE could be estimated simultaneously in 355 (57%). All-cause in-hospital mortality was 11%. The receiver operating characteristic analysis showed an area under the curve (AUC) [95% confidence interval (CI)] of 0.76 (0.72-0.81), 0.74 (0.69-0.79), and 0.71 (0.62-0.79), for the PESI score, PASP, and TAPSE parameters, respectively. When PESI score was combined with the echocardiogram parameters (PESI + PASP-TAPSE = PESI-Echo), an AUC of 0.82 (0.77-0.86) was achieved (P = 0.007). A PESI-Echo score ≥128 was the optimal cut-off point for predicting hospital mortality: sensitivity 82% (95% CI 67-90%), specificity 69% (95% CI 64-74%). The global net reclassification improvement was 9.9%.
Conclusions
PESI-Echo score is a novel tool for assessing mortality risk in patients with acute PE. The addition of echocardiographic parameters to a validated clinical score improved the prediction of hospital mortality.

Published on behalf of the European Society of Cardiology VC © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 13 Oct 2020; epub ahead of print
Burgos LM, Scatularo CE, Cigalini IM, Jauregui JC, ... Thierer J, Zaidel EJ
Eur Heart J Acute Cardiovasc Care: 13 Oct 2020; epub ahead of print | PMID: 33620435
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Abstract

Incidence of major adverse cardiac events following non-cardiac surgery.

Sazgary L, Puelacher C, Lurati Buse G, Glarner N, ... Mueller C, BASEL-PMI Investigators
Aims
Major adverse cardiac events (MACE) triggered by non-cardiac surgery are prognostically important perioperative complications. However, due to often asymptomatic presentation, the incidence and timing of postoperative MACE are incompletely understood.
Methods and results
We conducted a prospective observational study implementing a perioperative screening for postoperative MACE [cardiovascular death (CVD), acute heart failure (AHF), haemodynamically relevant arrhythmias, spontaneous myocardial infarction (MI), and perioperative myocardial infarction/injury (PMI)] in patients at increased cardiovascular risk (≥65 years OR ≥45 years with history of cardiovascular disease) undergoing non-cardiac surgery at a tertiary hospital. All patients received serial measurements of cardiac troponin to detect asymptomatic MACE. Among 2265 patients (mean age 73 years, 43.4% women), the incidence of MACE was 15.2% within 30 days, and 20.6% within 365 days. CVD occurred in 1.2% [95% confidence interval (CI) 0.9-1.8] and in 3.7% (95% CI 3.0-4.5), haemodynamically relevant arrhythmias in 1.2% (95% CI 0.9-1.8) and in 2.1% (95% CI 1.6-2.8), AHF in 1.6% (95% CI 1.2-2.2) and in 4.2% (95% CI 3.4-5.1), spontaneous MI in 0.5% (95% CI 0.3-0.9) and in 1.6% (95% CI 1.2-2.2), and PMI in 13.2% (95% CI 11.9-14.7) and in 14.8% (95% CI 13.4-16.4) within 30 days and within 365 days, respectively. The MACE-incidence was increased above presumed baseline rate until Day 135 (95% CI 104-163), indicating a vulnerable period of 3-5 months.
Conclusion
One out of five high-risk patients undergoing non-cardiac surgery will develop one or more MACE within 365 days. The risk for MACE remains increased for about 5 months after non-cardiac surgery.
Trial registration
https://www.clinicaltrials.gov. Unique identifier: NCT02573532.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 13 Oct 2020; epub ahead of print
Sazgary L, Puelacher C, Lurati Buse G, Glarner N, ... Mueller C, BASEL-PMI Investigators
Eur Heart J Acute Cardiovasc Care: 13 Oct 2020; epub ahead of print | PMID: 33620378
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Abstract

Life-threatening arrhythmias in anterior ST-segment elevation myocardial infarction patients treated by percutaneous coronary intervention: adverse impact of morphine.

Sauer F, Jesel L, Marchandot B, Derimay F, ... Ovize M, Morel O
Aims
Important controversies remain concerning the determinants of life-threatening arrhythmias during ST-segment elevation myocardial infarction (STEMI) and their impact on late adverse events. This study sought to investigate which factors might facilitate ventricular tachycardia (VT) and ventricular fibrillation (VF), in a homogeneous population of anterior STEMI patients defined by abrupt left anterior descending coronary artery (LAD) occlusion and no collateral flow.
Methods and results
The 967 patients, who entered into the CIRCUS (Does Cyclosporine ImpRove Clinical oUtcome in ST elevation myocardial infarction patients) study, were assessed for further analysis. Acute VT/VF was defined as VT (run of tachycardia >30 s either self-terminated or requiring electrical/pharmacological cardioversion) or VF documented by electrocardiogram or cardiac monitoring, during transportation to the cathlab or initial hospitalization. VT/VF was documented in 136 patients (14.1%). Patients with VT/VF were younger and had shorter time from symptom onset to hospital arrival. Site of LAD occlusion, thrombus burden, area at risk, pre-percutaneous coronary intervention Thrombolysis in Myocardial Infarction flow, and ST-segment resolution were similar to that of patients without VT/VF. There was no impact of VT/VF on left ventricular remodelling or clinical outcomes. By multivariate analysis, the use of morphine (odds ratio 1.71; 95% confidence interval (1.13-2.60); P = 0.012) was the sole independent predictor of VT/VF occurrence.
Conclusions
In STEMI patients with LAD occlusion, our findings support the view that morphine could favour severe ventricular arrhythmias.

Published on behalf of the European Society of Cardiology VC © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 13 Oct 2020; epub ahead of print
Sauer F, Jesel L, Marchandot B, Derimay F, ... Ovize M, Morel O
Eur Heart J Acute Cardiovasc Care: 13 Oct 2020; epub ahead of print | PMID: 33620376
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Abstract

Role of perilipin 2 in microvascular obstruction in patients with ST-elevation myocardial infarction.

Russo M, Montone RA, D\'Amario D, Camilli M, ... Niccoli G, Crea F
Aims
Coronary microvascular obstruction (MVO) occurs frequently in patients with ST-elevation myocardial infarction (STEMI) after percutaneous coronary intervention (PCI). However, mechanisms are multiple and not yet fully understood. Perilipin 2 (PLIN2) is involved in lipid metabolism of macrophages resident in atherosclerotic plaques, along with a role in enhancing plaque inflammation. We studied the association between PLIN2 and MVO in STEMI patients undergoing primary PCI, and we assessed the role of PLIN2 to predict major adverse cardiovascular events (MACEs).
Methods and results
STEMI patients undergoing primary PCI were enrolled. PLIN2 was evaluated in peripheral blood monocytes; MVO was assessed using coronary angiogram. MACEs, as a composite of cardiac death, non-fatal myocardial infarction, re-admission for heart failure, and target vessel revascularization were investigated at follow-up. Among 100 STEMI patients, 33 (33.0%) had MVO. Patients with MVO had higher levels of PLIN2 (1.03 ± 0.28 vs. 0.90 ± 0.16, P = 0.019). Age [odds ratio (OR) (95% confidence interval, CI), 1.045 (1.005-1.087), P = 0.026] and PLIN2 [OR (95% CI), 16.606 (2.027-136.030), P = 0.009] were associated with MVO at univariate analysis, although only PLIN2 [OR (95% CI), 12.325 (1.446-105.039), P = 0.022] was associated with MVO at multivariate analysis. After a mean follow-up of 182.2 ± 126.6 days, 13 MACEs occurred. MVO [hazard ratio (HR) (95% CI), 6.791 (2.053-22.462), P = 0.002], hypercholesterolaemia [HR (95% CI), 3.563 (1.094-11.599), P = 0.035], and PLIN2 [HR (95% CI), 82.991 (9.857-698.746), P < 0.001] were predictors of MACEs at univariate analysis, although only PLIN2 [HR (95% CI), 26.904 (2.461-294.100), P = 0.007] predicted MACEs at multivariate analysis.
Conclusions
In STEMI patients undergoing primary PCI, PLIN2 was independently associated with MVO and was an independent predictor of MACEs at follow-up, suggesting to further explore PLIN2 as a target for future cardioprotection therapies.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 01 Oct 2020; epub ahead of print
Russo M, Montone RA, D'Amario D, Camilli M, ... Niccoli G, Crea F
Eur Heart J Acute Cardiovasc Care: 01 Oct 2020; epub ahead of print | PMID: 33620432
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Abstract

Clinical risk scores identify more patients at risk for cardiovascular events within 30 days as compared to standard ACS risk criteria: the WESTCOR study.

Steiro OT, Tjora HL, Langørgen J, Bjørneklett R, ... Vikenes K, Aakre KM
Aims
Troponin-based algorithms are made to identify myocardial infarctions (MIs) but adding either standard acute coronary syndrome (ACS) risk criteria or a clinical risk score may identify more patients eligible for early discharge and patients in need of urgent revascularization.
Methods and results
Post-hoc analysis of the WESTCOR study including 932 patients (mean 63 years, 61% male) with suspected NSTE-ACS. Serum samples were collected at 0, 3, and 8-12 h and high-sensitivity cTnT (Roche Diagnostics) and cTnI (Abbott Diagnostics) were analysed. The primary endpoint was MI, all-cause mortality, and unplanned revascularizations within 30 days. Secondary endpoint was non-ST-elevation myocardial infarction (NSTEMI) during index hospitalization. Two combinations were compared: troponin-based algorithms (ESC 0/3 h and the High-STEACS algorithm) and either ACS risk criteria recommended in the ESC guidelines, or one of eleven clinical risk scores, HEART, mHEART, CARE, GRACE, T-MACS, sT-MACS, TIMI, EDACS, sEDACS, Goldman, and Geleijnse-Sanchis. The prevalence of primary events was 21%. Patients ruled out for NSTEMI and regarded low risk of ACS according to ESC guidelines had 3.8-4.9% risk of an event, primarily unplanned revascularizations. Using HEART score instead of ACS risk criteria reduced the number of events to 2.2-2.7%, with maintained efficacy. The secondary endpoint was met by 13%. The troponin-based algorithms without evaluation of ACS risk missed three-index NSTEMIs with a negative predictive value (NPV) of 99.5% and 99.6%.
Conclusion
Combining ESC 0/3 h or the High-STEACS algorithm with standardized clinical risk scores instead of ACS risk criteria halved the prevalence of rule-out patients in need of revascularization, with maintained efficacy.

Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: [email protected]

Eur Heart J Acute Cardiovasc Care: 01 Oct 2020; epub ahead of print
Steiro OT, Tjora HL, Langørgen J, Bjørneklett R, ... Vikenes K, Aakre KM
Eur Heart J Acute Cardiovasc Care: 01 Oct 2020; epub ahead of print | PMID: 33620429
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Abstract

Allogeneic peripheral blood stem cell transplantation and accelerated atherosclerosis: An intriguing association needing targeted surveillance. Lessons from a rare case of acute anterior myocardial infarction.

Scudiero L, Soriano F, Morici N, Grillo G, ... Klugmann S, Oliva F
We report the case of a 23-year-old man who developed an acute ST-elevation myocardial infarction secondary to acute thrombotic occlusion of the proximal left anterior descending coronary artery five years after undergoing chemotherapy, radiotherapy, haematopoietic stem cell transplantation for acute lymphoblastic leukaemia and bulky mediastinal mass involving the pleura and pericardium. His medical history also included Graft versus Host Disease developed 13 months after transplantation and acute myocarditis three months before the actual hospital admission. To the best of our knowledge, coronary artery disease as a complication of haematopoietic stem cell transplantation and low-dose mediastinal radiation therapy in young patients has been rarely reported in the medical literature. Clinicians should have a high degree of suspicion of coronary artery disease in patients treated with allogeneic haematopoietic stem cell transplantation, especially in patients previously treated with target mediastinal radiotherapy, as a group at risk of premature and significantly accelerated atherosclerosis, in order to make a timely and correct diagnosis.

© The European Society of Cardiology.

Eur Heart J Acute Cardiovasc Care: 30 Sep 2020; 9:NP3-NP7
Scudiero L, Soriano F, Morici N, Grillo G, ... Klugmann S, Oliva F
Eur Heart J Acute Cardiovasc Care: 30 Sep 2020; 9:NP3-NP7 | PMID: 33596323
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Abstract

Prognostic relevance of GRACE risk score in Takotsubo syndrome.

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



Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:721-728
Scudiero F, Arcari L, Cacciotti L, De Vito E, ... Di Mario C, Parodi G
Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:721-728 | PMID: 31642689
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Abstract

Predictors and prognosis of delirium among older subjects in cardiac intensive care unit: focus on potentially preventable forms.

Mossello E, Baroncini C, Pecorella L, Giulietti C, ... Marchionni N, Bari MD
Background
Delirium is a common and potentially preventable condition in older individuals admitted to acute and intensive care wards, associated with negative prognostic effects. Its clinical relevance is being increasingly recognised also in cardiology settings. The aim of the present study was to assess the prevalence, incidence, predictors and prognostic role of delirium in older individuals admitted to two cardiology intensive care units.
Methods
All patients aged over 65 years consecutively admitted to the two participating cardiology intensive care units were enrolled. Assessment on admission included acute physiological derangement (modified rapid emergency medicine score, REMS), chronic comorbidity, premorbid disability and dementia. The Confusion Assessment Method-Intensive Care Unit was applied daily for delirium detection.
Results
Of 497 patients (40% women, mean age 79 years), 18% had delirium over the entire cardiology intensive care unit course, half of whom more than 24 hours after admission (incident delirium). Advanced age, a main diagnosis of ST-segment elevation myocardial infarction or acute respiratory failure, modified REMS, comorbidity and dementia were independent predictors of delirium. Adjusting for patient\'s features on admission, incident delirium was predicted by invasive procedures (insertion of peripheral arterial catheter, urinary catheter, central venous catheter, naso-gastric tube and intra-aortic balloon pump). In a logistic regression model, delirium was an independent predictor of inhospital mortality (odds ratio 3.18, 95% confidence interval 1.02, 9.93).
Conclusions
Eighteen per cent of older cardiology intensive care unit patients had delirium, with half of the cases being incident, thus potentially preventable. Invasive procedures were independently associated with incident delirium. Delirium was an independent predictor of inhospital mortality. Awareness of delirium should be increased in the cardiology intensive care unit setting and prevention studies are warranted.



Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:771-778
Mossello E, Baroncini C, Pecorella L, Giulietti C, ... Marchionni N, Bari MD
Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:771-778 | PMID: 31617374
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Abstract

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

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



Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:S21-S31
Yamaguchi T, Nakai M, Sumita Y, Miyamoto Y, ... Ueda Y, Ogino H
Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:S21-S31 | PMID: 31460772
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Impact:
Abstract

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

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



Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:741-747
Wahrenberg A, Magnusson PK, Discacciati A, Ljung L, ... Linder R, Svensson P
Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:741-747 | PMID: 31124704
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Impact:
Abstract

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

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



Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:764-770
Raposeiras-Roubín S, Abu-Assi E, Caneiro Queija B, Cobas Paz R, ... Kedev S, Íñiguez-Romo A
Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:764-770 | PMID: 31042052
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Impact:
Abstract

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

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



Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:S58-S62
Nishanth KR, Shankar M, Srinivasa KH, Manjunath CN, Ravindranath KS
Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:S58-S62 | PMID: 31025873
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Abstract

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

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



Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:788-801
Schiele F, Lemesle G, Angoulvant D, Krempf M, ... Ferrières J, French Group
Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:788-801 | PMID: 30990337
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Abstract

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

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



Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:779-787
Obling L, Hassager C, Illum C, Grand J, ... Kondziella D, Kjaergaard J
Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:779-787 | PMID: 30950641
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Abstract

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

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



Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:703-710
Kimura A, Yoshikawa T, Isogai T, Tanaka H, ... Yamamoto T, Takayama M
Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:703-710 | PMID: 31691595
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Abstract

Clinical outcomes of patients presenting with spontaneous coronary artery dissection versus takotsubo syndrome: a propensity score analysis.

Macaya F, Vedia Ó, Salazar CH, Mejía-Rentería H, ... Escaned J, Núñez-Gil IJ
Background
Spontaneous coronary artery dissection and takotsubo syndrome are non-atherosclerotic causes of acute coronary syndromes. They share clinical features including female predominance and frequent triggers. We compared the outcomes of patients with spontaneous coronary artery dissection and patients with takotsubo syndrome with similar clinical characteristics.
Methods
Patients with spontaneous coronary artery dissection (n=81) or takotsubo syndrome (n=341) were 1:1 propensity matched according to age, sex, cardiovascular risk factors and clinical presentation. We compared baseline characteristics, effects on left ventricular function, and recurrence of major adverse cardiovascular events; defined as a composite of new hospitalisation for cardiac cause, clinical recurrence (spontaneous coronary artery dissection/takotsubo syndrome), myocardial infarction and death.
Results
Propensity score yielded 78 pairs: 85% were women, whose average age was 55.3±12.6 years, 28% had two or more cardiovascular risk factors, 37% presented with ST-segment elevation and 5% presented with cardiogenic shock. In the spontaneous coronary artery dissection group, 50% (39/78) of cases involved the left anterior descending artery and 18% (14/78) underwent revascularisation. After a median follow-up of 5 years (interquartile range 2.4-5), major adverse cardiovascular events were significantly higher in the spontaneous coronary artery dissection group (18% (14/78) vs. 8% (6/78); hazard ratio 3.40, 95% confidence interval 1.2-9.4). This was mainly driven by early readmissions for cardiac causes (17% vs. 5%, P=0.007). Spontaneous coronary artery dissection was associated with higher peak values of creatinine kinase during admission (creatinine kinase/upper limit of normality 2.49 vs. 1.21, P<0.001). Binary left ventricular systolic dysfunction was more prevalent in the takotsubo syndrome group (22% vs. 53%, P<0.001), but no significant differences were noted at follow-up (6% vs. 1%, P=0.181).
Conclusions
In this cohort of middle-aged predominantly female patients presenting with acute coronary syndromes, the diagnosis of spontaneous coronary artery dissection compared to takotsubo syndrome conferred a worse long-term clinical outcome, mainly driven by an increased risk of rehospitalisation for cardiac causes.



Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:694-702
Macaya F, Vedia Ó, Salazar CH, Mejía-Rentería H, ... Escaned J, Núñez-Gil IJ
Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:694-702 | PMID: 31729884
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Abstract

Accuracy of aortic dissection detection risk score alone or with D-dimer: A systematic review and meta-analysis.

Tsutsumi Y, Tsujimoto Y, Takahashi S, Tsuchiya A, ... Yamamoto Y, Fukuhara S
Background
To evaluate the diagnostic accuracy and clinical utility of the acute aortic dissection detection risk score (ADD-RS) alone or with D-dimer as a screening test to exclude acute aortic syndrome.
Methods
We conducted a systematic review and meta-analysis of studies examining the diagnostic accuracy of ADD-RS. We searched MEDLINE, Embase and Cochrane Controlled Register of Trials up to 12 December 2018.
Results
We identified nine studies involving 26,598 patients for ADD-RS alone and 3421 patients with D-dimer. Overall, the methodological quality based on the Quality Assessment of Diagnostic Accuracy Studies 2 was moderate to high. Bivariate meta-analyses showed that the pooled sensitivities were 0.94 (95% confidence interval (CI) 0.90, 0.96) at the threshold of ADD-RS ≥1, 0.46 (95% CI, 0.34, 0.59) at ADD-RS ≥2, 1.00 (95% CI 0.99, 1.00) at ADD-RS ≥1 with D-dimer and 0.99 (95% CI 0.97, 1.00) at ADD-RS ≥2 with D-dimer. For the low prevalence population, failure rate and efficiency were 0.8% and 38.3% at ADD-RS ≥1, 0.03% and 14.5% at ADD-RS ≥1 with D-dimer, and 0.1% and 33.6% at ADD-RS ≥2 with D-dimer, respectively. For the high prevalence population, failure rate and efficiency were 3.8% and 33.3% at ADD-RS ≥1, 0.2% and 12.3% at ADD-RS ≥1 with D-dimer and 0.6% and 28.4% at ADD-RS ≥2 with D-dimer, respectively.
Conclusions
ADD-RS alone or with D-dimer was a useful screening test with high sensitivity to exclude acute aortic syndrome. However, the optimal threshold of ADD-RS alone or with D-dimer may depend on the clinical setting.



Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:S32-S39
Tsutsumi Y, Tsujimoto Y, Takahashi S, Tsuchiya A, ... Yamamoto Y, Fukuhara S
Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:S32-S39 | PMID: 31970996
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Abstract

Impact of previous coronary artery bypass grafting in patients presenting with an acute coronary syndrome: Current trends and clinical implications.

Ribeiro JM, Teixeira R, Siserman A, Puga L, ... Belo A, Gonçalves L
Background
Among patients presenting with an acute coronary syndrome, those with previous coronary artery bypass grafting are a particular subset.
Aims
The purpose of this study was to investigate the prognostic impact of previous coronary artery bypass grafting in acute coronary syndrome patients and to identify the current trends in their clinical management.
Methods
We performed a cohort analysis of patients prospectively enrolled in the Portuguese Registry of acute coronary syndrome between 2010-2019 with known previous coronary artery bypass grafting status. The co-primary endpoints were in-hospital and one-year mortality.
Results
A total of 19,334 (962 coronary artery bypass grafting and 18,372 non-coronary artery bypass grafting) and 9402 (479 coronary artery bypass grafting and 8923 non-coronary artery bypass grafting) patients were included in the analyses of in-hospital and mid-term outcomes, respectively. Coronary artery bypass grafting patients were older and had a higher incidence of comorbidities. They were less likely to undergo invasive angiography (74.9 vs 84.6%, p<0.001), but were equally likely to receive dual antiplatelet therapy (91.0 vs 90.8%, p=0.823). In-hospital mortality was similar between groups (3.6 vs 3.4%, p=0.722). Unadjusted one-year mortality was higher in the coronary artery bypass grafting group (hazard ratio 1.48, 95% confidence interval 1.09-2.01, p=0.012), but similar in both groups after propensity-matching and multivariate analysis (hazard ratio 0.63, 95% confidence interval 0.37-1.09, p=0.098).
Conclusions
Among patients with acute coronary syndrome, a previous history of coronary artery bypass grafting was associated with a high burden of comorbidities and a high-risk profile but was not an independent predictor of adverse events. Treatment decisions should be made on a case-by-case basis, and should not be based on previous coronary artery bypass grafting status alone.



Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:731-740
Ribeiro JM, Teixeira R, Siserman A, Puga L, ... Belo A, Gonçalves L
Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:731-740 | PMID: 32180440
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Abstract

Acute type A aortic dissection: Aortic Dissection Detection Risk Score in emergency care - surgical delay because of initial misdiagnosis.

Zaschke L, Habazettl H, Thurau J, Matschilles C, ... Falk V, Kurz SD
Background
Acute type A aortic dissection requires immediate surgical treatment, but the correct diagnosis is often delayed. This study aimed to analyse how initial misdiagnosis affected the time intervals before surgical treatment, symptoms associated with correct or incorrect initial diagnosis and the potential of the Aortic Dissection Detection Risk Score to improve the sensitivity of initial diagnosis.
Methods
We conducted a retrospective analysis of 350 patients with acute type A aortic dissection. Patients were divided into two groups: initial misdiagnosis (group 0) and correct initial diagnosis of acute type A aortic dissection (group 1). Symptoms were analysed as predictors for the correct or incorrect initial diagnosis by multivariate analysis. Based on these findings, the Aortic Dissection Detection Risk Score was calculated retrospectively; a result ⩾2 was defined as a positive score.
Results
The early suspicion of aortic dissection significantly shortened the median time from pain to surgical correction from 8.6 h in patients with an initial misdiagnosis to 5.5 h in patients with the correct initial diagnosis (p<0.001). Of all acute type A aortic dissection patients, 49% had a positive Aortic Dissection Detection Risk Score. Of all initial misdiagnosed patients, 41% had a positive score (⩾2). The presence of lumbar pain (p<0.001), any paresis (p=0.037) and sweating (p=0.042) was more likely to lead to the correct initial diagnosis.
Conclusion
An early consideration of acute aortic dissection may reduce the delay of surgical care. The suggested Aortic Dissection Detection Risk Score may be a useful tool to improve the preclinical assessment.



Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:S40-S47
Zaschke L, Habazettl H, Thurau J, Matschilles C, ... Falk V, Kurz SD
Eur Heart J Acute Cardiovasc Care: 29 Sep 2020; 9:S40-S47 | PMID: 32223297
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