Risultati per: Sindromi coronariche acute

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 A11336-A11336, November 8, 2022. Introduction:Acute myocardial infarction (AMI) is a leading cause of death in the US. More than 800,000 adults experience an AMI each year, and up to 20% of the patients are rehospitalized within 30 days. Predicting 30-day readmission accurately could help clinicians identify high-risk patients and tailor treatment accordingly.Hypothesis:The neural network will generate the best performing model for predicting 30-day readmissions following an AMI.Methods:The cohort included adults hospitalized with incident AMI (6,506) at Dartmouth Hitchcock Medical Center between 2011-2016. Patients who died before discharge (236) were excluded, leaving 6,270 patients. Our outcome was 30-day hospital readmissions. Candidate features were selected using an Extra Tree Classifier. Selected features included demographics and clinical characteristics. Multiple imputation using K-Nearest Neighbors was performed. Five machine learning models were implemented: logistic regression, LASSO, neural network, random forest, and XGBoost. Models were evaluated on a hold-out test-set, using AUROC.Results:Among the cohort, about 36% were female, the majority were white and non-Hispanic, and the 30-day readmission rate was 6.2%. Neural network was the best performing model with an AUROC of 0.80 (95% CI: 0.75, 0.84). However, the XGBoost and random forest models performed similarly with AUROCs of 0.80 (95% CI: 0.76, 0.85) and 0.79 (95% CI: 0.75, 0.84), respectively. The logistic regression and LASSO models performed poorly, with AUROCs below 0.5, respectively. Important predictor variables were major depression, race, and antidepressant at discharge.Conclusions:Neural network, random forest, and XGBoost models predicted 30-day readmission following an AMI with good performance. Across these models, depression was an important feature for predicting 30-day readmissions. Results reinforce the importance of mental health among patients hospitalized for AMI.

Circulation, Volume 146, Issue Suppl_1, Page A14403-A14403, November 8, 2022. Introduction:The efficacy of the quality indicators (QIs) using administrative data was unclear.Hypothesis:The use of QIs is associated with lower mortality in patients with acute coronary syndrome (ACS) at both hospital and patient levels.Methods:Patients with ACS who underwent percutaneous coronary intervention (PCI) between April 2014 and March 2018 in the National Database of Health Insurance Claims and Specific Health Checkups of Japan were included. Twelve quality indicators (QIs) were extracted from the administrative data and the association of the QIs with all-cause mortality was investigated.Results:A total of 221,267 patients from 1,220 hospitals were analyzed. The adherence to PCI on admission day, aspirin use on arrival, P2Y12 inhibitor use, and left ventricular function assessment was high (median proportion >90%), and adherence to outpatient cardiac rehabilitation was low (median proportion

Circulation, Volume 146, Issue Suppl_1, Page A15820-A15820, November 8, 2022. Background:There continues to be emerging data about the benefits of Sodium-glucose co-transporter 2 inhibitor (SGLT2i) in patients with heart failure. This has led to the addition of this medication to guideline-directed medical therapy for heart failure with reduced ejection fraction. There is a discrepancy in whether the use of SGLT2i is beneficial in patients hospitalized for decompensated heart failure.Methods:In this study, a search was completed through PubMed, Scopus, Cochrane Library, ProQuest for randomized controlled trials from 2020 to 2022 that evaluated the impact of the use of SGLT-2 inhibitors (Empagliflozin, Sotagliflozin) in patients admitted with acute HF. After screening for our preset inclusion and exclusion criteria, three randomized controlled clinical trials were eligible for inclusion. We carried out a Meta-analysis of the relative odds on the basis of the random effect model using the Mantel-Haenszel method for the major outcome of the incidence of death from any cause, the number of heart failure events, rehospitalization for heart failure, and time to first heart failure event in the acute setting. Comprehensive Meta-analysis version 3 software was used for analysis.Results:A total of 2,532 patients from the EMPULSE, SOLOIST-WHF, EMPA-RESPONSE-AHF trials were included. After analysis, it was found that the P-value was 0.000, Z-value was -4.103, and the OR 0.508 (95% CI 0.368; 0.702) for the patients on either Empagliflozin or Sotagliflozin.Conclusions:The systematic review and meta-analysis we conducted show that patients who received SGLT-2i (Empagliflozin, Sotagliflozin) during hospitalization within 24 hours or more had a statistically significant decreased odds of all-cause of death, number of heart failure events, and rehospitalization for heart failure.

Circulation, Volume 146, Issue Suppl_1, Page A10940-A10940, November 8, 2022. Introduction:The risk of myocarditis after mRNA vaccination against COVID-19 has emerged, recently. Current evidence suggests that young male patients are predominantly affected. In the majority of the cases only mild symptoms were observed. However, little is known about mRNA vaccination related myocarditis cardiac magnetic resonance (CMR) imaging patterns and their differences to classical viral myocarditis in the acute phase of inflammation.Methods:10 mRNA vaccination associated myocarditis patients were retrospectively enrolled in this study and compared to 10 patients suffering from viral myocarditis, matched with age, sex, comorbidities and laboratory markers. All patients (n = 20) were hospitalized and underwent a standardized clinical examination as well as an echocardiography and a CMR. Both, clinical and imaging findings were compared between both groups.Results:All patients described chest pain as the leading reason for their initial presentation. CMR volumetric and functional parameters did not differ significantly between both groups. In all cases the lateral left ventricular wall showed late gadolinium enhancement without significant differences in terms of the localisation or in-depth tissue characterization.Conclusions:COVID-19 mRNA vaccination associated myocarditis does not show specific CMR patterns during the very acute stage in the most affected patient group of young male patients. The observed imaging markers are closely related with regular viral myocarditis and did not yield any evidence implying adverse outcomes in the investigated patient group.

Circulation, Volume 146, Issue Suppl_1, Page A10914-A10914, November 8, 2022. Introduction:Rupture of an aortic aneurysm into the right atrium (RA) is extremely rare, while rupture into the thoracic cavity or pericardial sac is a common fatal complication. We describe a case of acute heart failure due to rupture of an aortic pseudoaneurysm with aorta-right atrial fistula.Case Summary:A 73-year-old man presented to the emergency department with dyspnea and abdominal distention. He had a history of ascending aortic replacement for type A aortic dissection 18 years ago. On arrival, physical examination revealed diminished breath sounds, leg edema but no cardiac murmurs. Investigations demonstrated abnormality of hepatic and kidney function, elevated BNP (490.9 pg/ml) in blood exam, and enlargement of ascending aortic aneurysm at the proximal anastomotic site with ascites/pleural effusion on computed tomography (CT), while left ventricular function was normal on transthoracic echocardiogram. We diagnosed acute heart failure with preserved ejection fraction and started to reduce fluid using diuretics. However, the response to diuretics was not good and the progression of lactic acidosis was observed regardless of using cardiotonic agent. Since it was becoming difficult to maintain systemic circulation, we performed further investigations before introducing mechanical support. The pulmonary artery catheterization revealed elevated RA pressure with wide pulse pressure (38/12 mmHg) and Oxygen step up in RA. An aortic root angiogram, contrast-enhanced CT and transesophageal echocardiogram showed a rupture of aortic pseudoaneurysm complicated with aorta-right atrial fistula (Figure). Although emergent surgery was performed, he unfortunately died the following day.Conclusions:This is a rare case of intracardiac perforation of aortic aneurysm diagnosed by various modalities. We should consider the possibility of developing shunt disease when we meet patients with rapidly progressive circulatory failure unresponsive to drugs.

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 A9504-A9504, November 8, 2022. Introduction:The pathobiological mechanisms of coronary plaque erosion are unclear. Low endothelial shear stress (ESS) is a proinflammatory/proatherogenic stimulus associated with coronary plaque progression/destabilization. Intravascular imaging studies suggest that high ESS gradient (low ESS areas adjacent to high ESS areas), and steepness of plaque upslope/downslope correlate with plaque erosion. We investigated the relationship of local fluid hemodynamics to the inflammatory microenvironment at the culprit site of erosion in patients with an acute coronary syndrome.Hypothesis:ESS metrics associate with proinflammatory/proatherogenic cells and cytokines, and contribute to plaque erosion.Methods:We studied 30 patients with erosion from the OPTIcal-COherence Tomography in Acute Coronary Syndrome study (OPTICO-ACS). OCT images were segmented, co-registered with the angiogram to create a 3D-reconstruction of the coronary artery. ESS metrics were calculated by Computational Fluid Dynamics. Systemic and local blood samples and thrombectomy specimens were collected at the culprit lesion and analyzed by flow cytometry-based immunophenotyping and plasma cytokine and chemokine profiling, and statistically tested for correlations of continuous variables using Spearman rank correlation (r).Results:Proinflammatory cytokines (IL6, MIP-1, IL1β, IL2) and local concentration of T-cells, including subsets of T-cells (CD4+, CD8+, and NKT-cells), were significantly higher at the culprit site of erosion and correlate with local adverse ESS metrics (Min ESS, Max ESS, Plaque Topographical Slope) (Table).Conclusion:Biomechanical features likely trigger activation of the adaptive immune system, including T-lymphocytes and their cytotoxic effector molecules. These results provide novel insights into the links between fluid hemodynamics, inflammatory activation, and mechanisms involved in the pathogenesis of coronary plaque erosion.

Circulation, Volume 146, Issue Suppl_1, Page A15281-A15281, November 8, 2022. Introduction:Spontaneous coronary artery dissection (SCAD) is an important cause of acute coronary syndrome especially in young patients. Factors associated with delays in presentation and care delivery are not well understood.Methods:We used data from the iSCAD Registry which is a prospective multicenter US registry of patients with SCAD. Early vs. delayed hospital presentation (< 24 vs. ≥ 24 hours), and early vs. delayed coronary angiography (time from hospital presentation to coronary angiography < 24 vs. ≥ 24 hours) for SCAD patients with AMI were assessed. Patient characteristics, and in-hospital events were compared between the two groups. Factors associated with delayed presentation and angiography were explored using multivariable logistic regression.Results:A total of 346 SCAD (294 white, 52 non-white) patients presented with STEMI (34%) or NSTEMI; 57 had a delayed presentation to the hospital after symptoms onset. No significant factors were identified for delays in seeking care. However, white race was less likely to have delayed invasive coronary angiography (multivariable OR=0.38; 95% CI 0.19 to 0.76; p=0.0059). Patients undergoing delayed angiography were also more likely to be medically managed (91.7% vs. 69.8%, p=0.0008), but less likely to receive dual antiplatelet therapy (57.0% vs. 73.1%, p=0.007). In-hospital outcomes were similar between the two groups.Conclusion:In this study, no patient-related variables were identified that predicted a delay in presentation with AMI secondary to SCAD. On the other hand, non-white race was associated with delays in performing invasive coronary angiography. Further investigation is required to determine the factors contributing to this potential disparity.

Circulation, Volume 146, Issue Suppl_1, Page A15122-A15122, November 8, 2022. Introduction:Despite well-established device selection algorithms, there remain wide variations in mechanical circulatory support (MCS) device utilization in patients with cardiogenic shock complicating acute myocardial infarction (AMI-CS). Further, there are limited national-level data on the contemporary practices of MCS device use.Methods:To evaluate national utilization patterns of MCS devices, we identified adult admissions ( >18 years) with AMI-CS from the HCUP-NIS data (2005-2017). Use of MCS devices including intraaortic balloon pump (IABP), percutaneous left ventricular assist devices (pLVAD) (Impella/Tandem Heart), and extracorporeal membrane oxygenation (ECMO) during hospitalization was identified. We evaluated trends in the initial MCS device used (IABP alone, pLVAD alone, or ≥2 MCS devices), device escalation, bridging to durable LVAD/heart transplantation, and predictors of in-hospital mortality and device escalation.Results:Among a total of 327,283 AMI-CS admissions in this 13-year period, 132,146 (40.2%) had an MCS device with information on timing of placement. IABP, pLVAD, ≥2 MCS, and ECMO devices were used as initial device in 120,928 (92.0%), 8,202 (6.2%), 2,305 (1.7%), and 711 (0.1%) admissions, respectively. Most admissions were maintained on initiated MCS device with 1-1.5% being escalated (IABP to pLVAD/ECMO, pLVAD to ECMO). The median time to escalation across all devices categories was 2 (IQR 1-4) days. Urban, medium, and large-sized hospitals, and acute multiorgan failure were significant independent predictors of MCS escalation. In admissions receiving MCS, escalation of MCS device was associated with higher in-hospital mortality (adjusted OR 1.56, 95% CI 1.38-1.75;p

Circulation, Volume 146, Issue Suppl_1, Page A10412-A10412, November 8, 2022. Introduction:Malnutrition has been associated with inferior outcomes in patients admitted with acute myocardial infarction (AMI). However, there is a lack of data to assess if the degree of malnutrition correlates with outcome severity.Methods:We used Nationwide Readmission Database (NRD) for 2016-2019 in our cross-sectional study. First, we extracted all cases older than 18-years that include a primary diagnosis of AMI. Appropriate survey and domain analyses were applied to obtain national estimates using SAS 9.4.Results:We identified 2,280,393 discharges for AMI. Malnutrition was present in 4% of the study cohort (or 89,490 cases). Half of the patients with malnutrition (or 44,919) had moderate to severe malnutrition. The other 44,371 (or 50%) had a milder degree of malnutrition. Patients with malnutrition were younger than those without malnutrition (mean age 72-years vs. 75-years, p

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 A11699-A11699, November 8, 2022. Introduction:Coronary artery dissection is an emergency condition due to a tear in the coronary arterial wall, and it’s an uncommon cause of acute coronary syndrome. The Effect of Obesity on the outcome of acute coronary artery dissection is poorly documented. Hence, our study sought to estimate the impact of Obesity on clinical outcomes of hospitalizations of patients with acute Coronary artery dissection using the national database.Methods:We queried the National Inpatient Sample (NIS) database from 2016 to 2019. The NIS is the largest inpatient hospitalization database in the United States. The NIS was searched for hospitalization of adult patients with acute Coronary artery dissection as a principal diagnosis with and without Obesity as a secondary diagnosis using ICD-10 codes. The primary outcome was inpatient mortality. The secondary results were Acute kidney injury (AKI), Cardiogenic shock (CS), Cardiac arrest (CA), Total hospital charge (THC), and length of stay (LOS). Multivariate logistic and linear regression analyses were used accordingly to adjust for confounders.Results:About 2440 patients were admitted for acute Coronary artery dissection; 17.4% (425) had underlying obesity. Cohorts with obesity vs No obesity had a mean age of 52.9 years [CI 50.4 – 55.5] vs 55.9 years [CI 54.5 – 57.4]; male (20% vs 25.8%), female (80% vs 74.2%); white (71.3% vs 73.3%), black (21.3% vs 12.0%), and Hispanic (6.3% vs 7.8%). Compared to patients without obesity, patients admitted with coexisting obesity had similar inpatient mortality (7.1% vs 3.2%, AOR 3.22, 95% CI 0.74 – 13.88, P=0.118), AKI (15.3% vs 9.9%, P 0.357), CS (9.4% vs 11.2% P=0.098), CA (5.9% vs 5.0% P=0.530), THC (IRR 0.94, 95% CI 0.64 – 1.37, P=0.738), and LOS (IRR 0.79, 95% CI 0.59 – 1.05, P=0.107).Conclusions:Patients admitted primarily for acute Coronary artery dissection with co-existing Obesity had similar inpatient mortality, AKI, CS, CA, THC, and LOS compared to patients without Obesity.

Circulation, Volume 146, Issue Suppl_1, Page A10987-A10987, November 8, 2022. Introduction:Female patients are significantly more likely than male patients to experience symptoms of depression and anxiety post-acute coronary syndrome (ACS), correlated with higher rates of cardiovascular morbidity and mortality. Yet, it is unclear if all female patients are impacted broadly or if specific subgroups of female patients are at elevated risk. We aimed to identify the cardiovascular and psychosocial variables correlated with increased depression and anxiety symptoms immediately post-ACS as well as at 3 and 6-month follow-up.Hypothesis:There is a combination of cardiovascular and psychosocial factors associated with elevated depressive/anxious symptoms (Hospital Anxiety and Depression Scale (HADS) score ≥8 on the depression/anxiety subscales) in female patients post-ACS.Methods:This was a prospective multi-center questionnaire-based clinical research study featuring data from 6 sites across Canada using a logistic regression model to delineate multivariate strength of association. Baseline visit (within 72 hours of ACS) included HADS and a sociodemographic questionnaire. Follow-up visits (3 and 6-months) include HADS, Cardiac Anxiety Questionnaire, new health events, mortality, Short Form-12 Health Survey, and Somatic Symptom Scale-8.Results:A total of 245 patients were included in analysis (Table 1). HADS-A≥8 was associated with increased health anxiety at baseline (OR6.56; p

Circulation, Volume 146, Issue Suppl_1, Page A15718-A15718, November 8, 2022. Introduction:Heart failure cardiogenic shock (HF-CS) constitutes a heterogenous population and has been identified as the leading type of shock among contemporary intensive care units. The in-hospital trajectory of shock severity and its association with mortality and transition to heart replacement therapy (HRT) or native heart survival (NHS) based on HF-CS phenotype has not been well described.Methods:The Cardiogenic Shock Working Group (CSWG) registry includes patients from 17 hospitals between 2016 and 2021. For this analysis, HF-CS patients were sub-classified as havingde novoHF-CS or acute-on-chronic (ACHF) CS. In-hospital trajectories were assessed using baseline and maximum Society for Cardiovascular Angiography and Interventions (SCAI) stages and clinical outcomes were analyzed.Results:A total of 1,767 patients with HF-CS were included. Of these, 349 hadde novoHF-CS (19.8%) and 1,371 (77.6%) had ACHF-CS. Overall, patients withde novoHF-CS had greater in-hospital death (32% vs 22%), NHS (58% vs 45%) and less HRT (33% vs 10%) when compared to ACHF-CS (all p

Circulation, Volume 146, Issue Suppl_1, Page A13402-A13402, November 8, 2022. Background:Racial differences in outcomes of STEMI patients continue to persist. Our study aimed to assess the difference in the incidence of acute kidney injury (AKI) post percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI), stratified by race into African Americans (AA) vs Caucasians.Methods:All STEMI patients who underwent PCI at the Cleveland Clinic main campus between January 1, 2011, to July 15, 2019, were included in our study. Patients were categorized into two groups depending on a diagnosis of the presence or absence of AKI post PCI. AKI was defined as >0.3mg/dl rise in post PCI creatinine from pre-procedure value. Relative risk of developing AKI depending on race was calculated with the help of a two by two table.Results:Overall, 1847 patients were admitted to our hospital with a STEMI and underwent PCI during the study period. Of these, 267 (15%) developed AKI post PCI. 19% of AA patients developed AKI compared to 13% of Caucasian. Comparison of baseline characteristics amongst patients who developed AKI revealed that AA patients with AKI were younger than their Caucasian counterparts (median age 63 vs 68, p=0.006), but were more likely to having smoking history (52% vs 35%, p=0.014). Upon analyzing the association between race and AKI, AA patients were 48% more likely to develop AKI post PCI compared to Caucasian patients (RR of 1.48, 95% CI 1.17-1.86, p=0.0015). This difference was observed in spite of no significant differences in radial access, contrast dose, or mechanical circulatory support use between the two races.Conclusion:African Americans STEMI patients are almost 50% more likely than Caucasians to develop AKI post PCI. Developing race-specific process measures and further optimization of procedural characteristics may be necessary to improve the outcomes of AA STEMI patients.