Risultati per: Sindromi coronariche acute

Circulation, Volume 146, Issue Suppl_1, Page A12779-A12779, November 8, 2022. Introduction:Long-term prognostic implications of serial high-sensitivity troponin concentrations in subjects with suspected acute coronary syndrome (ACS) are unknown.Hypothesis:To determine mortality according to high-sensitivity troponin I (TnI) concentrations and their changes from baseline, in patients with suspected ACS.Methods:Using Danish registries, we identified individuals with a first diagnosis of myocardial infarction, unstable angina, observation for suspected myocardial infarction, or chest pain from 2012 through 2019 who underwent two high-sensitivity TnI (Siemens TnI Flex® Reagent, 99thpercentile 45 ng/l) measurements during the same hospitalization. Prognostic implications of serial sampling were examined stratifying subjects for normal and elevated concentrations, and for relative changes of 20% and 50%. Absolute and relative risks for death from any cause at days 0-30 and 31-365 were calculated through multivariable logistic regression with average treatment effect modeling.Results:Of the 20,609 individuals included, 2.3% had died at 30 days, while 4.7% of 30-day-survivors died between days 31-365. The standardized risk of death at both 0-30 and 31-365 days was highest among subjects with two elevated TnI concentrations (0-30 days: 8.0%, 31-365 days: 11.1%) and lowest among those with two normal TnI concentrations (0-30 days: 0.5%, 31-365 days: 2.6%). In neither case did relative changes between measurements clearly affect mortality. Nevertheless, among persons who went from a normal to an elevated TnI concentration, 30-day mortality was highest in those with a >50% rise versus subjects with a less pronounced rise (2.2% vs.

Circulation, Volume 146, Issue Suppl_1, Page A11761-A11761, November 8, 2022. Background:Acute myocardial infarction (AMI) in elderly patients who have previously undergone coronary artery bypass grafting (CABG) poses a diagnostic and therapeutic complexity. There is limited data on cardiovascular and mortality outcomes for this population.Methods:Using the National Inpatient Sample (NIS) from 2016-2019, we identified patients over 65 years with a prior CABG presenting with AMI, excluding those with a history of percutaneous coronary intervention. After assessing baseline characteristics, we analyzed trends in cardiovascular disease (CVD) risk and all-cause in hospital mortality (ACM) while stratifying for gender and race. Pearson’s chi-squared test was utilized to compare the CVD variables.Results:There were 266,365 hospitalizations included in the study with a median age of 77 years. They were predominantly males(69.5%), of Caucasian origin (81.7%), Medicare enrollees (91.4%) and were admitted in urban teaching hospitals (67.2%) located in the South of the US (39.5%) as non-elective cases (93.8%). Between 2016-19, Hyperlipidemia (HLD), smoking(Sm), and obesity(Ob) showed an increasing trend in males (2.8%, 1.3%, and 2% respectively) and females (2.1%, 2.4%, and 2% respectively), whereas hypertension (HTN) decreased by 4.5% in males and 6.3% in females.The length of stay remained constant at 4 days and the average cost of stay was 58963.5 USD. HTN among all races decreased from 2016 to 2019 except for Native Americans. HLD and obesity exhibited an upward trend among all races. Hispanics and Asians/Pacific Islanders(PI) had a consistent downtrend in mortality rates, with Native Americans showing the biggest drop in mortality rate (6.9%). All-cause mortality decreased from 2016 to 2019 by 1.4% except for Blacks which has increased by 2.6%, overtaking Asian/PI. All p

Circulation, Volume 146, Issue Suppl_1, Page A10267-A10267, November 8, 2022. INTRODUCTION:Haemorrhagic stroke (HS) is an important cardiovascular cause of mortality worldwide. In Australia, long term temporal trends in HS hospitalisation rates and predictors of mortality are unknown.Methods:All New South Wales residents with first-ever HS from 2002-2017 were identified from the Centre-for-Health-Record-Linkage statewide databases. Mortality tracked to 31 Dec 2018 via the death registry were adjusted for age, sex, admission year, referral source, surgical evacuation of HS status, and comorbidities in multivariable regression analyses.Results:There were 35433 patients (51% male) admitted for HS. Age-adjusted mean (±SD) admission rates were higher for males than females (63.6±6.2 vs 49.9±4.4 admissions-per-100,000-persons-per-annum respectively, p

Circulation, Volume 146, Issue Suppl_1, Page A11370-A11370, November 8, 2022. Introduction:The COVID-19 mRNA vaccines are effective in reducing COVID-19-related severe disease and death. Waning vaccine effectiveness has prompted the recommendation to administer additional (booster) doses. With additional doses of COVID-19 mRNA vaccines being recommended, it is essential to monitor its safety. Myocarditis has been reported following the second dose of COVID-19 mRNA vaccination. Whether administration of additional doses of COVID-19 vaccines further increases the risk of myocarditis is not known. This study aimed to evaluate whether a third dose of COVID-19 mRNA vaccine was associated with an increased risk of myocarditis in a large population-based cohort in California.Methods:We included individuals who received one to three doses of BNT162b2 (Pfizer) or mRNA-1273 (Moderna) mRNA vaccine between 12/14/2020 and 2/18/2022 in an integrated healthcare delivery system in the United States. Hospitalization for myocarditis within 21 days of vaccine administration was identified using electronic medical records.Results:Of 3,076,660 KPSC members who received at least one dose of COVID-19 mRNA vaccines, 2,916,739 (94.5%) received at least two doses, and 1,146,254 (47.0%) received three doses. The IRR for myocarditis was 0.86 (95% CI 0.31-1.93) for the first dose, 4.87 (95% CI 3.14-7.37) for the second dose, and 2.61 (1.13-5.29) for the third dose. The majority of myocarditis cases following the second and third dose occurred within seven days of vaccination.Conclusion:Myocarditis was a rare but serious event observed after the second or third dose of vaccination. Most cases presented within seven days of vaccination. The incidence of myocarditis following the third dose did not appear to be significantly higher than that observed after the second dose.

Circulation, Volume 146, Issue Suppl_1, Page A15802-A15802, November 8, 2022. Intracardiac cholinergic ganglia (ICG) neurons receive excitatory input from vagal pre-ganglionic fibers and are critical for the transmission of parasympathetic drive throughout the heart. During disease, electronic vagal stimulation improves cardiac function and reduces arrhythmias. However, vagal stimulation is not selective for efferent or cholinergic fibers and implanting an electronic device before unanticipated episodes of cardiac infarction is not clinically feasible. We addressed these limitations by testing the hypothesis that chemogenetic ICG activation immediately after an infarction would reduce arrhythmia incidence and improve ventricular function. Floxed DREADDs (AAV2-hSyn-DIOhM3D(Gq)-mcherry) were injected into the pericardial sac of neonatal rats that selectively express Cre recombinase in cholinergic neurons. At 8 weeks, hearts were excised for ex-vivo studies and excitatory hM3Dq DREADDs expressed in ICG cholinergic neurons were activated by clozapine-N-oxide (CNO). Heart rate (HR), LV developed pressure, and overall arrhythmia incidence were measured. In healthy hearts, CNO decreased HR for the duration of the experiment (247 ±10.56 to 189.35± 3.46 beats per minute, p

Circulation, Volume 146, Issue Suppl_1, Page A10985-A10985, November 8, 2022. Introduction:Studies have demonstrated a reduction in peak oxygen consumption (VO2) post-acute COVID-19. We sought to determine the association between acute COVID-19 severity, post-acute symptoms and peak VO2after recovery.Methods:This study analyzed data from patients who recovered from COVID-19 and underwent cardiopulmonary exercise testing (CPET) as part of prospective studies in 5 centers across UK and Europe. Patients were asked to report current symptoms. Peak VO2, lung volumes, gas exchange, ventilatory efficiency, heart rate and O2pulse were measured in a standard symptom-limited incremental cycle ergometer CPET.Results:Among 417 patients examined 136±63 days after recovery from COVID-19, 164 (39%) were female. Mean age was 56.9±13.3 years. The spectrum of acute COVID-19 severity included critical (N=47; 11.3%), severe (180; 43.2%), moderate (75; 18.0%) and mild (115; 27.5%) illness. The most common post-acute symptom was dyspnea (200; 48%), followed by muscle pain (173; 41%). Mean peak respiratory exchange ratio was 1.13±0.1, and did not vary across acute disease severity or post-acute symptom status. There was no significant difference in peak VO2as % from predicted in mild to critical acute disease: 84.0±2.1%, 91.4±2.6%, 82.9±1.7% and 83.7±3.2%, respectively (p=0.06). Patients with dyspnea or muscle pain had each lower peak VO2as % from predicted, compared to patients free of the specific symptom (81.3±21.2% vs. 88.1±22.9%, p=0.002 and 78.6±19.1% vs. 88.2±22.0%, p

Circulation, Volume 146, Issue Suppl_1, Page A10170-A10170, November 8, 2022. Introduction:Previous studies have compared Impella to intra-aortic balloon pump (IABP) in patients with acute myocardial infarction and cardiogenic shock (AMI-CS) undergoing percutaneous coronary intervention (PCI) but did not include a cohort of patients receiving vasopressors alone. We assessed the hypothesis that there would be a difference in clinical outcomes in patients with AMI-CS undergoing PCI who received Impella alone, IABP alone, and vasopressor therapy without MCS.Methods:We queried the National Inpatient Sample inclusive of 2015 to 2018 and created three propensity-matched cohorts (Impella alone vs IABP alone, Impella alone vs vasopressors without MCS, and IABP alone vs vasopressors without MCS). We performed propensity matching by adjusting for 21 clinical variables including age, comorbidities, and presence of lactic acidosis. Patients receiving both MCS and vasopressors were excluded, in order to best isolate the effect of each intervention.Results:Among 17,762 hospitalized patients with AMI-CS undergoing PCI, Impella use was associated with significantly higher in-hospital mortality (40.6% vs 27.4%; p=0.003), major bleeding (29.3% vs 13.5%; p < 0.001), acute kidney injury (56.4% vs 45.9%; p=0.04), and hospital charges compared to IABP use (p

Circulation, Volume 146, Issue Suppl_1, Page A15830-A15830, November 8, 2022. Introduction:Obesity is approaching epidemic status in the United States and is strongly associated with a higher risk of heart failure after myocardial infarction (MI), a major cause of morbidity and mortality in obese individuals. However, the mechanisms underlying obesity-associated heart failure are poorly understood. Lysophosphatidic acid (LPA), produced by autotaxin (ATX), is highly expressed in adipose tissue with increased levels in obesity and has been shown to mediate post-MI inflammation.Methods:3-week aged male C57BL/6J mice were randomly assigned to low-fat (LFD-10%) or high-fat (HFD-60%) diet based on the percentage of calories from fat. HFD-fed mice were randomly assigned to receive the specific ATX inhibitor, PF-8380 at 10 mg/kg twice daily. 2 months after initiating the diet, mice were randomized to undergo MI surgery (permanent ligation of the left anterior descending artery) or sham surgery.Results:MI was associated with an increased number of circulating inflammatory monocytes (CD45+/Ly6C+/CD115+), as well as cardiac total and pro-inflammatory macrophages (CD45+/F4-80+/CD11b+/CD86+), as assessed by flow cytometry (Fig. 1A). This effect was exacerbated in HFD-fed mice but significantly attenuated in HFD+PF8380 treated mice with effective ATX inhibition. Changes in circulating and cardiac immune cells were reflective of increased proliferation of bone marrow progenitors, a phenomenon that was blunted by ATX inhibition (Fig. 1B). Moreover, HFD was associated with larger scar size (Fig. 1C) and worse cardiac functional recovery (Fig. 1D) 30 days after MI. The obesity-asscoiated heart failure could be rescued by ATX inhibition.Conclusion:ATX/LPA plays an important role in modulating inflammation and could be a therapeutic target for obesity-related coronary heart diseases.

Circulation, Volume 146, Issue Suppl_1, Page A13194-A13194, November 8, 2022. SARS-CoV2 (CoV2) infection causes both acute and long-term health effects via damaging multiple organs including lung. The endothelial dysfunction associated with the infection may contribute to pathogenesis of acute COVID-19 and long COVID. However, the mechanisms underlying the endothelial dysfunction remain elusive. Development of mouse models for these diseases will help us better dissect these mechanisms and facilitate the development of therapeutics for treatment of the disease. Previously, we developed an acute COVID model by infecting human ACE2 transgenic (K18) mice with a lethal CoV2 dose. K18 mice developed severe COVID-19, including progressive body weight loss and fatality at days 7 post infection (DPI), severe lung interstitial inflammation, edema, hemorrhage, perivascular inflammation, systemic lymphocytopenia, and eosinopenia. We detected CoV2 in capillary endothelial cells, activation and adhesion of platelets and immune cells to the vascular wall of the alveolar septa, and increased complement deposition in the lungs in this model. These results indicate that CoV2 infection and infection-mediated immune activation caused endothelial dysfunction, which contributes to the pathogenesis of severe COVID-19. To further develop a model for long COVID, we infected K18 mice with sub lethal CoV2 dose, monitored the body weight and survival rate and characterized the lung and brain histological changes at 21 and 45 DPI. The infected mice progressively lost body weights from 5 to 7 DPI and started to rebound from 8 DPI and then returned to baseline at 13 DPI. Mice had extensive patchy inflammation in the lungs associated with collagen deposition and smooth muscle action expression. We also found moderate levels of total viral RNA in the lung but not brain while viral subgenomic RNA (a correlate of viral replication) was undetectable in lung or brain by qRT-PCR assay. Fluorescence staining showed co-localization of CoV2 spike protein and CD206 in lungs, suggesting macrophage engulfment CoV2 at late time points. Together, we have successfully established long-term COVID mouse models, which will be useful tools for further defining the role of endothelial dysfunction in pathogeneses of CoV2-related acute and long COVID.

Circulation, Volume 146, Issue Suppl_1, Page A11654-A11654, November 8, 2022. Introduction:Cardiac rehabilitation (CR) improves outcomes after acute myocardial infarction (AMI). The Bundled Payments for Care Improvement Advanced (BPCI-A) program holds participating hospitals accountable for all costs incurred within 90 days of discharge. There is concern that this financial incentive will lead participants to cut back on high-value care, including CR, in order to meet cost targets. We examined whether patients discharged from BPCI-A participating hospitals after an AMI had lower CR utilization compared to non-participating hospitals.Methods:We included patients from a 100% sample of fee-for-service Medicare beneficiaries discharged home after a hospitalization for AMI during a baseline period (January 1, 2016 to December 31, 2017) or an intervention period (October 1, 2018 to September 30, 2019). Our exposure was discharge from a hospital participating in BPCI-A. Our outcomes were the proportion attending ≥1 CR session and the mean number of CR sessions attended within 90 days of discharge. We adjusted for hospital, market, and patient level factors, including medical comorbidities. We performed difference-in-change analyses for both outcomes using linear mixed effects models, before and after adjustment for all confounders.Results:The baseline period included 50,274 discharges, with 33.7% from BPCI-A participating hospitals. The intervention period included 27,268 discharges, with 32.9% from participating hospitals. Overall, CR use was 11.3% in the baseline period and 11.7% in the intervention period. There were no differential changes between BPCI-participating and nonparticipating hospitals for either outcome over time (Table).Conclusions:Among Medicare patients discharged after an AMI, CR utilization was low, and we observed no difference in utilization associated with hospital participation in BPCI-A.

Circulation, Volume 146, Issue Suppl_1, Page A14685-A14685, November 8, 2022. Introduction:Despite modern treatment methods, cardiogenic shock mortality complicates acute myocardial infarction (CS-AMI) remains high.Hypothesis:The study of factors affecting CS-AMI outcomes is essential.Methods:Data from the all-comers’ National Registry of Coronary Interventions from 2016 to 2020 were evaluated. Of 50,745 patients with AMI (STEMI/NSTEMI) 2,822 patients (5.6%) had initially CS (72.6% men, mean age 67.6 (12) yrs). The study analyzed the predictive value of such traditional cardiovascular risk factors related to the MI (sex, age, previous PCI or CABG, renal failure, localization of MI, time delay to reperfusion), comorbidities (expressed by the Deyo modification of Charlson comorbidity index), the severity of the condition on admission (mechanical ventilation, resuscitation), the extent of coronary artery disease and procedural success (the number of affected vessels, TIMI flow before and after PCI, LM disease), and such untraditional factors as season, weekday and day time. Multivariable analysis was used to identify independent predictors of prognosis in patients with CS-AMI.Results:The 30days mortality was 50.7%. As independent predictors of prognosis were identified age (older 80yrs, OR 4.97;95% CI 3.73-6.61), resuscitation (1.34; 1.07-1.67), mechanical ventilation (1.39;1.10-1.75), 3-vessel disease 1.39;1.12-1.72), left main disease (1.26; 1.01-1.57), and post-procedural TIMI flow lower 3 (1.14; 0.79-1.66). The independent predictive value of the comorbidity index was not confirmed (1.062;0.796-1.417). The numerically higher mortality rate was shown during a) autumn time (54.2%) and winter (51.8%), b) weekend (51.45%) (vs. working week (50.03%)), c) working hours (49.3%) (vs. the after-working hours (47.6%)). The multivariate analysis did not confirm the independent predictive value of these variables.Conclusions:Mortality of CS-AMI patients is significantly and independently influenced by factors confounding their circulatory instability, such as resuscitation and respiratory failure, the extent of coronary disease, and the success of reperfusion therapy. The independent impact of comorbidity and non-traditional factors on the prognosis of these patients has not been confirmed.

Circulation, Volume 146, Issue Suppl_1, Page A15189-A15189, November 8, 2022. Introduction:Limited clinical experience of new trainees has been associated with poor outcomes in the first month of training (July) in teaching hospitals. It remains unclear if this ‘July effect’ continues to be present in contemporary era in patients with acute myocardial infarction (AMI).Methods:Adult hospitalizations for AMI in May and July in urban teaching and non-teaching hospitals in the United States were identified from the HCUP-NIS database (2000-2017). Admissions to rural hospitals, and those without in-hospital mortality data were excluded. In-hospital mortality was compared between those admitted in May and July. A difference-in-difference analysis comparing a change in outcome from May to July in teaching hospitals to a change in outcome from May to July in non-teaching hospitals was also performed to evaluate the July effect.Results:During the study period, there were a total of 1,312,006 hospitalizations for AMI admitted in urban teaching (54.2%) or non-teaching (45.8%) hospitals in the months of May and July. Demographic characteristics were comparable between those admitted in May and July, however, May admissions had greater comorbidity and higher rates of acute multiorgan failure when compared to July admissions in teaching and non-teaching hospitals. Additionally, May AMI admissions to non-teaching hospitals had higher rates of cardiogenic shock (4.6% vs 4.3%) and cardiac arrest (5.2% vs 5.0%) compared to July admissions (allp

Circulation, Volume 146, Issue Suppl_1, Page A12188-A12188, November 8, 2022. Background:For patients with functional mitral regurgitation (MR) who remain symptomatic despite GDMT, transcatheter mitral valve repair (TMVR) is emerging as a less-invasive alternatives and can improve symptoms and longevity. We describe a rare case of cardiogenic shock following TMVR.Case:63-year-old male with PMHx of CAD with prior CABG, severe MR with EF of 40% developed progressive dyspnea and evaluated for TMVR with a Mitraclip device. TEE pre-deployment confirmed moderate to severe MR (Figure 1). Right heart catheterization revealed preserved cardiac index.Intraoperative TEE after deployment showed improved MR. Post-procedure, he developed respiratory distress and progressive hypotension requiring vasopressors and inotropes. TTE showed mild MR with severely reduced biventricular function (EF 10%). Cardiac catheterization showed a severely reduced CO/CI 3.1/1.42. Mechanical circulatory support was initiated with Impella CP due to persistent cardiogenic shock. By POD 3, he was off all inotropes and MCS was discontinued. His EF recovered to 45% during a 3- month visit.Decision Making:Causes of cardiogenic shock post mitral valve procedure include cardiac tamponade, acute mitral stenosis, intrathoracic hemorrhage and afterload mismatch. Afterload mismatch is due to reduction in left ventricular stroke volume when preload is not compensated for an acute increase in afterload. It is a known complication after mitral valve surgery; however it is rarely seen post TMVR. This patient likely experienced afterload mismatch after his mitral clipping procedure as evidenced by the acute, transient decline in LVEF (55% to 10%).Conclusion:Afterload mismatch is a rare phenomenon that can cause cardiogenic shock post percutaneous mitral repair procedures. It must be rapidly addressed with inotropic and/or mechanical support to prevent permanent end organ dysfunction and circulatory collapse. Prompt treatment allows for excellent recovery.

Circulation, Volume 146, Issue Suppl_1, Page A11472-A11472, November 8, 2022. Background:Recent randomized controlled trials (RCTs) have demonstrated the superiority of treating patients with acute coronary syndrome (ACS) with dual antiplatelet therapy (DAPT) uniform de-escalation strategy (i.e., switching from potent P2Y12inhibitors to clopidogrel one month after the event). However, it remains unclear if this strategy would be effective in elderly patients. We aimed to assess the efficacy of the available DAPT strategies, including the uniform de-escalation strategy, in ACS patients older than 65.Methods:We searched the PubMed, EMBASE, and Cochrane CENTRAL databases up to December 2021 for RCTs or subgroup analyses investigating DAPT strategies for elderly ACS patients (age ≥65 years) and conducted a network meta-analysis. The endpoint was net clinical benefit outcome, defined as a composite of major adverse cardiovascular events and bleeding. The P-score was used to rank the treatments.Results:Seven RCTs with 5,079 patients were included. The uniform de-escalation strategy was associated with a better net clinical benefit outcome (hazard ratio: 0.62; 95% confidence interval [0.41-0.92]) compared with DAPT using potent P2Y12inhibitors, and it was similarly effective compared with other DAPT strategies. There was no significant heterogeneity (I2=0%;p=0.82) or inconsistency (p=0.40). The uniform de-escalation strategy was ranked as the most effective strategy (by P score) superior to DAPT using clopidogrel or low-dose prasugrel.Conclusions:The uniform de-escalation strategy was an effective strategy for older ACS patients. Compared with conventional DAPT using potent P2Y12inhibitors, this strategy decreased the composite of major adverse cardiovascular events and bleeding events.

Circulation, Volume 146, Issue Suppl_1, Page A14546-A14546, November 8, 2022. Introduction:Management of acute type A aortic dissection complicated by brain malperfusion remains controversial. We previously reported an excellent recovery of consciousness for patients with coma if aortic repair performed within 5 hours from onset of symptoms. This study evaluates neurological outcomes after 19 years with this approach.Methods:Between 8/03 and 12/21, aortic repair was performed in 400 patients with acute type A aortic dissection, including 59 (12.7%) presented with brain malperfusion on arrival. Brain malperfusion was defined as distributed consciousness or paralysis in patients with dissection in carotid artery on hospital arrival. Forty patients (67.8 %) were repaired within 5 hours from onset of symptoms (immediate repair) while 19 (32.2 %) were repaired after 5 hours (later repair). We compared the immediate repair group with the later repair group. The mean age of the patients was 70.0±11.7 and 70.0±9.0 years, respectively, and prevalence of shock, cardiac tamponade, EuroSCORE were not significantly different between two groups. Preoperative coma (GCS

Circulation, Volume 146, Issue Suppl_1, Page A11606-A11606, November 8, 2022. Introduction:Sarcoidosis (SD) has a higher prevalence among African Americans (AA). It is also associated with an increased risk of ischemic heart disease (IHD); however little is known of its effect on in-hospital outcomes after an acute myocardial infarction (AMI). Therefore, we sought to evaluate the association between SD and in-hospital outcomes among AA patients (pts).Methods:Using the National Inpatient Sample between 2005-2014, we evaluated admissions of AA presenting with AMI and a concurrent diagnosis of SD. We used propensity score matching in 1:3 fashion to create a comparison group of patients without SD based on age and comorbidities. Our primary outcome of interest was in-hospital mortality. Secondary outcomes were length of hospital stay and total cost of hospitalization.Results:We evaluated 416, 209 representative admissions of AA with AMI. Of these, we compared 2,647 had a concurrent diagnosis of SD to 7,942 pts without SD. The pt group with SD had mean age 58.1 years and were 61.5% female. When compared with the pts without SD, the pts with sarcoid were more likely to smoke (21.5% vs 19.5%, p=0.028), have liver failure (4.5% vs. 3.4%, p=0.007) and have a cancer diagnosis (2.8% vs. 2.1%, p=0.37), but less likely to have renal failure (25.0% vs 29.1%, p