Risultati per: Sindromi coronariche acute

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 A11732-A11732, November 8, 2022. Introduction:Recent data shows that when adults are discharged after hospitalization for acute heart failure (HF), a clinic follow up with either cardiology or general medicine within 7 days results in significantly lower chances of 30 day readmissions. We sought to analyze the trends of clinic follow up after acute HF hospitalization and the associated barriers and facilitators at our safety net hospital.Methods:Data was extracted from the electronic medical records using ICD 9,10 codes for acute HF admissions between Jan 2019 and Dec 2021. Quarterly trends of rates of clinic follow up were analyzed over the past 3 years; t-test was used to assess for statistical significance. Multivariable logistic regression models were constructed to test the association between patient level factors and clinic follow up after adjusting for sociodemographic factors. A p value < 0.05 was used to establish significance.Results:Of 1,037 patients admitted for acute HF between 2019-2021, 29.5% were 65 years or older, 64.7% were males, 48.7% were Black and 16.6% were uninsured. Only 8% and 23.1% had a 7 and 14 day clinic follow up respectively. Of those with scheduled follow up 65% and 56% showed up to their appointments at 7 and 14 days respectively. Overtime we noted an increase in the proportion of encounters with a 7 day follow up although the effective follow up (after accounting for no-shows) remained unchanged. Patients that had an inpatient cardiology consult had higher odds of getting a 7 day follow up (OR=1.42, p value = 0.001) after adjusting for age, gender, insurance status and race (black > white, OR = 1.34, p

Circulation, Volume 146, Issue Suppl_1, Page A12921-A12921, November 8, 2022. Introduction:Few studies have examined acute myocardial infarction (AMI) trends among adults < 35 years old. We analyzed hospitalization and mortality trends, risk factors, and sex differences among patients < 35 years old with AMI.Methods:We queried the National Readmissions Database (NRD) for all hospitalizations from 2010 to 2018 aged 20-34 with a principal diagnosis of AMI. We assessed the annual trend in AMI hospitalization rates and in-hospital mortality using linear regression, stratifying by sex. We analyzed procedures and risk factors both overall and by sex, and performed bivariate analyses using chi-square to compare sex differences. All frequencies were weighted to reflect national estimates provided by the NRD.Results:A total of 40,209 AMI hospitalizations in individuals < 35 years old were identified from 2010 to 2018. Hospitalization rates were higher in men as compared with women (9.6/100,000 vs. 4.0/100,000, p < 0.05) and remained stable for men while there was a trend towards increasing hospitalization rates for women (Figure, p = 0.06). Women were more likely to be hypertensive, diabetic, and obese, while men were more likely to have hyperlipidemia and a history of tobacco or cocaine use (all p < 0.01). The rate of obesity increased over time for both men and women while rates of hypertension and diabetes increased only for women (all p < 0.05). As compared with men, women were less likely to get PCI (47.8% vs. 54.9%, p < 0.01) but in-hospital mortality rates were similar (2.22% vs. 1.60%, p = 0.29).Conclusions:Among those < 35 years old with AMI, women were more likely to be hypertensive, diabetic, and obese, with increasing prevalence, while men were more likely to have hyperlipidemia and a history of tobacco or cocaine use. Hospitalization rates for AMI were higher in men and there was a significantly higher use of PCI in men compared to women although in-hospital mortality rates were similar.

Circulation, Volume 146, Issue Suppl_1, Page A10186-A10186, November 8, 2022. Objective:The fluctuations of blood pressure in the acute stage of stroke are associated with neurological deterioration and poor prognosis. Although continuous monitoring of blood pressure changes becomes possible with the emergence of wearable blood pressure monitoring equipment, the accuracy of the equipment is still in doubt. Here, the accuracy of the optoelectronic-based wearable device for blood pressure monitoring in hospitalized patients with acute stroke were investigated and verified.Methods:Thirty-five acute stroke patients in the Department of Neurology of a teaching hospital were recruited. With the blood pressure values measured by bedside ECG monitor as the gold standard, wearables devices (wearable wrist watch) and bedside ECG monitors were monitored sequentially the same upper limb at the same time and recorded every 2 hours during the first 24 hours of admission. Receiver operating characteristic (ROC) curves were employed to determine the optimal cut off points and tests of sensitivity, specificity, kappa coefficients were conducted.Results:The average age of participants (male 17, female 18) was 61.91 ±8.72 years. 414 groups of blood pressure values were measured and ranged from 74/41 to 221/124 mmHg. The kappa value of systolic blood pressure (SBP) measured by wearable wrist watch and bedside ECG monitor was 0.768, with 89.1% sensitivity and 87.7% specificity (Table 1-A). And the kappa value of diastolic blood pressure (DBP) was 0.648, with 94.6% sensitivity and 67.9% specificity (Table 1-B). The area under ROC curve for SBP diagnosis and DBP diagnosis of wearable wrist watches were 0.941(p< 0.001, Figure 1-A) and 0.939 (p< 0.001, Figure 1-B) respectively. There was no significant difference in SBP and DBP between these two methods (p >0.05, Table 3).Conclusions:The accuracy of wearable wrist watch for measuring patient blood pressure with acute stroke is good enough for ambulatory blood pressure monitoring of acute stroke patients.

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 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 A13185-A13185, November 8, 2022. Introduction:Hematopoietic stem cell transplantation (HSCT) is associated with various cardiovascular (CV) complications. Due to the lack of recent large cohort studies, the incidence and clinical determinants of acute HSCT-related CV events are ill-defined.Methods:We conducted a multi-center observational study (University of Michigan and Rush University) of adult (≥18 years) patients who underwent autologous or allogeneic HSCT for malignant or non-malignant bone marrow disorders from 2005-2021. Data on demographics, pre-HSCT clinical characteristics, imaging, laboratory findings, and acute (

Circulation, Volume 146, Issue Suppl_1, Page A12644-A12644, November 8, 2022. Introduction:Previously considered rare, spontaneous coronary artery dissection (SCAD) has emerged as an important cause of chest pain, acute coronary syndrome, and sudden cardiac death. Due to hormonal factors, SCAD often affects seemingly healthy women. SCAD in men remains little understood and under-recognized. We report a case of a 61-year-old gentleman who presented with NSTE-ACS and was found to have SCAD.Patient Presentation:A 61-year-old male with history of untreated hyperlipidemia presented with acute substernal chest pressure radiating to bilateral arms and back. On presentation, vitals and physical examination was normal.His labs showed troponin I at 0.015 ng/mL which later up trended to 21.7 ng/ml. ECG demonstrated sinus bradycardia with no ischemic changes. Decision was made to take him for cardiac catheterization.It demonstrated right coronary artery (RCA) was ecstatic. Distally, there was a a right conus branch fistula draining into pulmonary artery. There was evidence of microvascular dysfunction. An echocardiogram showed mid and basal inferolateral akinesis, normal EF.He was started on dual anti platelets (DAPT) and GDMT. At the time of discharge, he started having recurrence of his chest pain with exertion. Cardiac CT showed multiple spontaneous coronary artery dissections with healing dissections and remodeling throughout the ecstatic RCA and its distal branches with additional contour irregularities and non-obstructive dissection flaps in the diagonal branch of the left anterior dissecting artery. He was enrolled into cardiac rehabilitation.Conclusion:SCAD occurs by the formation of an intramural hematoma or intimal disruption causing a coronary obstruction. Coronary angiography remains the primary tool in the diagnosis. Alternative imaging modalities, such as intravascular ultrasound and optical coherence tomography, CT coronary angiography can be used to confirm the diagnosis. It is managed medically with DAPT and adequate control of blood pressure. Cardiac rehabilitation appears to be beneficial in preventing recurrence. We would also like to emphasize that SCAD can occur in any age group and gender, it’s crucial to recognize it early and is a condition that can be managed conservatively.

Circulation, Volume 146, Issue Suppl_1, Page A15868-A15868, November 8, 2022. Introduction:In the US, there are approximately 84 million cases of COVID-19 accounting for 1 million deaths. Though there are not many studies, acute myocardial infarction (AMI) is one of the most lethal complications of COVID-19. In this study, we looked for occurrence of AMI and its effects on hospital outcomes among COVID-19 patients.Hypothesis:AMI among COVID-19 hospitalizations could worsen the levels of adverse in-hospital outcomes.Methods:Data from the 2020 California State Inpatient Database was used retrospectively. All COVID-19 hospitalizations with age ≥18 years were included in the analyses. Adverse hospital outcomes included in-hospital mortality, prolonged length of stay, vasopressor use, mechanical ventilation, and ICU admission. Prolonged length of stay included any hospital length of stay ≥75th percentile. We explored for differences in adverse hospital outcomes between those with and without AMI. Multivariate logistic regression analyses were used to understand the strength of these associations after adjusting for cofactors.Results:Our analysis had a total of 94,114 COVID-19 hospitalizations and 1548 (1.6%) had AMI. Adverse hospital outcomes such as mortality (43.2% versus 10.8%, P

Circulation, Volume 146, Issue Suppl_1, Page A12777-A12777, November 8, 2022. Background:Pump thrombosis (PT) remains a dreaded complication of left ventricle assist device (LVAD) implantation. PT immediately after HeartMate 3 (HM3) implantation is rare but should be kelp in mind if early low flow alarms are noted.Case:A 57-year-old male with ischemic cardiomyopathy, Stage D heart failure (LVEF ~20%), INTERMACS category 3 on 5mcg/kg/min Dobutamine drip underwent advanced heart failure therapy evaluation and was deemed suitable candidate for LVAD implant. His ECHO showed LVIDD 6.04 cm and LV Diastolic Volume Index 122 mL. He underwent HM3 implantation via left anterior thoracotomy and upper-hemi sternotomy on 5/24/2022. Surgery was successful and the patient was taken off bypass. Pre-implant some LV trabeculations and debris were removed. However, less than 1 hour from being off bypass, the low flow alarms began which did not resolve after volume and blood pressure optimization. No RV failure was noted on TEE. Decision was made to re-open the sternum. Upon exploration, no compression of the outflow graft was noted, and inlet cannula was not mispositioned. Inspection of LVAD inlet and outlet cannula showed significant amount of white thrombus (Figure 1) and device was ultimately exchanged. Thrombus was confirmed on histopathological analysis. Post-operatively no low flow alarms were noted after pump exchange. Factor V Leiden screen and protein C activity were normal and Antithrombin 3 was falsely low (due to recent thrombus) on post-op day 1.Discussion:This is the second case of HM 3 device thrombosis within 1 hour of implant in the literature. Most of the earlier reported cases were on post-Op Day 3. The etiology of PT is unknown and further investigation is required to elucidate the same. This case will create awareness among physicians to keep PT in differentials when low flow alarms are encountered immediately post-op despite volume and BP optimization.

Circulation, Volume 146, Issue Suppl_1, Page A12732-A12732, November 8, 2022. BackgroundCardiac Sarcoidosis (CS) is a disease with variable presentation causing significant morbidity and mortality. Concurrent signs of myocardial injury as evidenced by troponin elevation add to the complexity of an already challenging diagnosis.CaseA 48-year-old female with no significant past medical history presented with episodes of presyncope for 2 months. ECG showed a bifascicular block. Troponin I was elevated to 7.29 ng/mL. 2D echo showed Left Ventricular (LV) systolic dysfunction with an LVEF of 40%. Heparin drip was initiated for a possible NSTEMI. Coronary angiography showed no evidence of epicardial coronary artery disease but showed an anomalous right coronary artery which on CT angiogram later showed no hemodynamically significant stenosis. Telemetry monitoring captured intermittent complete atrioventricular blocks. A biventricular implantable cardioverter-defibrillator was inserted. Due to concerns for infiltrative cardiac disease, a cardiac magnetic resonance (CMR) was done showing findings consistent with cardiac sarcoidosis (CS). CT scan of the chest showed radiographic evidence of pulmonary sarcoidosis, however, she declined further invasive workup. She was then started on systemic corticosteroids. 2D echo 6 months later revealed improvement in the LVEF to 55%.DiscussionOur case encompasses the variable presentation of CS including cardiac conduction abnormalities and LV systolic dysfunction. Concomitant troponin elevation in CS can mimic myocardial ischemia making the diagnosis more challenging. This highlights the importance of appropriate diagnostic acumen in approaching a case like this. Current guidelines now include non-invasive means for diagnosis including the use of CMR/PET CT, especially since endomyocardial biopsy has a low sensitivity. Treatment strategies aim to mitigate the long-term effects of CS on the heart, however, there is a paucity of data for appropriate pharmacological regimen.

Circulation, Volume 146, Issue Suppl_1, Page A13180-A13180, November 8, 2022. Background:The impact of mechanical left ventricular (LV) unloading before reperfusion on myocardial energetics in acute myocardial infarction (AMI) is unknown. We hypothesized that LV unloading reduces anaerobic glycolysis in models of ischemia reperfusion injury (IRI).Methods:Myocardial ischemia was induced by percutaneous occlusion of the left anterior descending (LAD) artery for 90 minutes in adult swine. In Groups A and B, an additional 120 minutes of LAD occlusion without reperfusion was performed in the presence or absence of a trans-valvular pump (TVP). In Group C and D, an additional 120 minutes of reperfusion was performed in the presence or absence TVP (Fig. 1A). Untargeted Metabolomics was performed on the tissues from the infarct zones.Results:Compared to Group A, infarct size normalized to the area at risk (IS/AAR) was significantly smaller with LV unloading after ischemia alone (Group B; Fig 1B) and reperfusion (Group D; Fig 1B). Principal component analysis analysis of 800 metabolites identified 5 distinct clusters corresponding to the 4 study groups and sham controls (Fig 1C). LV unloading without reperfusion reduced lactate by 30±4% (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 A13239-A13239, November 8, 2022. Introduction:The variation in medical cost by risk stratification using history, electrocardiogram, age, risk factors and troponin (HEART), after an emergency department (ED) evaluation for suspected acute coronary syndrome (ACS), is not well understood.Hypothesis:We hypothesized that annual total all cause cost will increase significantly with increasing HEART score and the primary driver of the total cost will be cardiovascular disease (CVD) related care.Methods:This was a retrospective cohort study of adults (age ≥18) with chest pain and complete data for HEART score, presenting at EDs within the Kaiser Permanente Southern California health system from 1/2016-12/2018. We analyzed direct medical cost associated with medical office visits, hospital facility and ED visits, pharmacy utilization, hospice stays, skilled nursing stays, home health, dialysis, laboratory, and radiology utilization during the 1-year following the index ED visit. Stratified by HEART score categories, we used one part and two part generalized linear models (log link & gamma family distribution) adjusted for socio-demographics, cardiovascular disease (CVD) history and treatment and non-CVD comorbidities, to estimate average adjusted total all cause expenditure as well as subgroups of utilization.Results:The cohort included 33,990 patients (60% Low risk; 37% intermediate risk and 3% high risk). The adjusted annual total cost varied from $6,544 (95% CI $6,228 to $6,860) in the low risk to $21,210 ($19,458 to $22,962) in the high-risk group (Table 1). In each group, the primary driver of total cost was CVD related care accounting for 41% to 46% of total cost. CVD care provided in a hospital setting accounted for 44%-76% of CVD total cost.Conclusions:Increased follow-up medical office visits, improved medications and lifestyle management may reduce the near exponential increase in cost driven by catastrophic hospital utilization, in higher HEART risk stratified patients.

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 A12866-A12866, November 8, 2022. Introduction:Myeloproliferative neoplasms (MPNs) are clonal stem cell neoplasms associated with increased thrombotic risk. However, long-term outcomes after acute coronary syndrome (ACS) and identification of MPN-specific risk factors have not been characterized.Methods:Single-center, retrospective cohort of patients with MPN admitted for ACS from 2000 to 2020 (n = 41). Primary outcomes were major adverse cardiac events (MACE) and bleeding. MACE was composite of cardiovascular (CV) death, myocardial infarction, ischemic stroke, and heart failure (HF) hospitalization. Patients with and without MACE and bleeding were compared to identify risk factors; univariable and multivariable Cox proportional hazards and competing-risk regression models were used.Results:Patient characteristics described in Table 1. After a median follow-up of 80 months, 28 patients had MACE and 14 experienced bleeding. Patients with MACE had shorter median time to index ACS event (35 mos vs 76) and higher rates of JAK2 mutation (82% vs 54%), history of HF (46% vs 15%), and median white blood cell count (WBC, 13 vs 8) at index event compared with patients without MACE. Patients with bleeding had higher rates of JAK2 mutation (93% vs 63%) and WBC (17 vs 10), and lower hydroxyurea use (50% vs 85%) compared with patients without bleeding. Cox and competing-risk regression results in Table 2.Conclusions:Patients with MPN and ACS are at high risk of MACE and bleeding. JAK2 mutation and elevated WBC count (≥ 20 K/μL) at time of index ACS were associated with MACE and bleeding. ACS event occurring within 12 months of MPN diagnosis was associated with MACE. Larger studies are needed to confirm our results.