Risultati per: Sindromi coronariche acute

Circulation, Volume 146, Issue Suppl_1, Page A15858-A15858, November 8, 2022. Introduction:Non-invasive screening tools of cardiac function can play a significant role in the initial triage of patients with suspected acute coronary syndrome. Numerous ECG features have been previously linked with cardiac contractility in the general population. We sought to examine the prognostic value of positive T wave in lead aVR as a simple marker for real-time screening of reduced left ventricular ejection fraction (LVEF) in suspected acute coronary syndrome.Methods:We performed a secondary analysis of a prospective, observational cohort study of patients evaluated for suspected acute coronary syndrome. The parent study recruited consecutive patients evaluated at the emergency department of three UPMC-affiliated tertiary care hospitals. We included consecutive patients in whom an echocardiogram was performed during indexed encounter. LVEF were retrieved from the cardiologist-signed report. Baseline 12-lead ECGs were preprocessed using manufacturer specific algorithms. Amplitude of T wave in lead aVR were automatically measured at T peak in millivolts. Data analysis was performed using SPSS and alpha was set at 0.05 for two-sided hypothesis testing.Results:Our sample included 313 patients (aged 63 ± 15, 45% females, 35% Black). The mean LVEF was 57±13%. Most patients were in normal sinus rhythm (87%) or atrial fibrillation (13%). In Bivariate analysis, there was a significant and negative correlation between T wave amplitude in lead aVR and LVEF (Pearson r = -0.173, p = 0.002). T wave amplitude in lead aVR was significantly larger in patients with LVEF < 35% compared to their counterparts (-65±185 vs. -165±180, t(311) = -3.18, p = 0.002).Conclusions:Increasing T wave amplitude in lead aVR indicates lower LVEF in suspected acute coronary syndrome. This feature constitutes a simple visual marker to aid clinicians in identifying those with impaired cardiac function during emergency care.

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 A12945-A12945, November 8, 2022. Background:Non-alcoholic liver disease (NAFLD) is among leading causes of chronic liver disease. Recent evidence suggests an association of NAFLD with cardiovascular diseases; however, few studies have analyzed national level database for this relationships. We aimed to assess the trends and predictors of acute myocardial infarction (AMI) among NAFLD patients in the United States.Methods:The National Inpatient Sample (NIS) database from 2016 to 2019 was queried using international classification of disease (ICD-10) diagnostic codes to identify patients with primary diagnosis of NAFLD and secondary diagnosis of AMI. Basic demographic variables were analyzed to determine the disparities in prevalence of AMI among NAFLD patients. Univariate logistic regression model was used to compare the odds of development of AMI among NAFLD patients using demographic characteristics. Multivariate logistic regression analysis was done to determine whether NAFLD is an independent predictor of AMI.Results:A total of 58,519 patients had a diagnosis of NAFLD and of these, 5,448 had AMI. Of these, 61% were males, 82% were aged 50 years and over, 68% were white, 8% Black, 16% Hispanic, Asian or Pacific Islander. Females were less likely to have AMI [OR 0.46, 95% CI 0.43-0.48]. Patients

Circulation, Volume 146, Issue Suppl_1, Page A12101-A12101, November 8, 2022. Introduction:COVID-19 infection has increased the risk of thrombosis, and the pandemic has impacted the utilization of healthcare services.Hypothesis:The study aims to investigate the consequences of the COVID-19 pandemic on the incidence of hospitalization for acute myocardial infarction (IH-AMI) and out-of-hospital cardiovascular deaths rate (OH-CVD).Methods:The analysis was done on data collected in the National Database of Death Records, the National Health Information System, and the Information System of Infectious Diseases. Incidence and number of deaths were expressed per 100 000 inhabitants. For comparison of time periods incidence rate ratio was applied. Over-mortality was described as a change in % against the reference period 2016-2019.Results:The population for the analysis consisted of 50,745 AMI cases and 204,392 OH-deaths from any cause. In the pandemic year (vs. 2016-2019 period), there was a significant decrease in AMI hospitalizations with an incidence rate ratio of 0.949 (0.911;0.989) for acute STEMI and 0.949 (0.911;0.989) for NSTEMI, respectively. A significant relationship was found between the decrease in acute STEMI hospitalizations and the number of COVID-infected patients. The risk of OH-CVD increased significantly in 2020 compared to the mean death rates in 2016-2019. The analysis of over-mortality against the reference period 2016-2019 shows the increase of OH-CVD associated with the decrease in hospitalization for acute STEMI significantly related to the number of COVID19 cases (Figure).Conclusions:The COVID-19 pandemic significantly affected the number of IH-AMI while increasing the incidence of OH-CVD. These changes were directly impacted by the number of infected in the population. It is, therefore, necessary to focus efforts on informing the population about the safety of hospitalization and ensuring full availability of health care services even in pandemic times.

Circulation, Volume 146, Issue Suppl_1, Page A15293-A15293, November 8, 2022. Hypothesis:Introduction. Acute critically ill patients experience a rapid decline in plasma free thyroid hormone levels (free triiodothyronine (FT3) and free levothyroxine (FT4)), with a marked elevation of reverse T3, recognized as the euthyroid sick syndrome (ESS) or low-T3 syndrome. The ESS is also often associated with depressed myocardial function, sometimes referred to as the ‘stunned myocardium. The role of thyroid hormone levels in patients with cardiogenic shock complicated myocardial infarction has not been shownMethods:The purpose of the study was to assess the impact of thyroid hormone levels on hospital mortality in patients with infarction related cardiogenic shock. Thyroid hormone levels were measured from routine blood specimens and analyzed initial and up to 96 hours.Results:We identified 40 patients with infarction related cardiogenic shock treated at our university hospital. Majority of the CS-patients had on admission reduced TSH levels of 1,42 ± 0,22mU/l. Nevertheless, in-hospital mortality rate was higher in patients with lower admission TSH levels and levels over time. In addition, FT3 in CS-survivors showed a flat slope from normal levels. Non-survivor had a trend towards lower levels after 72 and 96 hours. When we analyzed for low T3 syndrome (i.e. FT3 >3,1pmol/l) we saw a 3x times higher mortality rate compared to CS patients with normal levels. In contrast, FT4 levels of non survivors were significantly elevated compared to surviving CS patients. After 96 hours both groups had similar levels. Predictors of hospital death in CS patients were low TSH levels, low T3 syndrome and elevated FT4.Conclusions:Thyroid hormone level on admission and over time (i.e. low TSH, low T3 and elevated FT4) are predictors of in-hospital death in patients with infarction related cardiogenic shock. Interestingly TSH stays almost stable over time whereas FT3 and FT4 declines over time. Further studies have to show if administration of thyroid hormone might be beneficial in patients with infarction related cardiogenic shock.

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 A13993-A13993, November 8, 2022. Introduction:Women have a higher incidence of heart failure (HF) hospitalizations than men following acute myocardial infarction (AMI). The extent to which differential cardiac remodeling between men and women might account for this higher risk in women is poorly understood.Hypothesis:Women and men have differences in cardiac remodeling after AMI that are predictive of clinical outcomes.Methods:The Prospective ARNI versus ACE inhibitor trial to Determine Superiority in reducing heart failure Events after Myocardial Infarction (PARADISE-MI) trial randomized patients within 0.5 to 7 days of AMI complicated by left ventricular (LV) dysfunction, pulmonary congestion, or both to sacubitril/valsartan or ramipril. In the pre-specified echocardiographic sub-study, 544 participants were enrolled to undergo protocol echocardiography at the time of randomization and after 8 months.Results:At baseline, women (n=142, 26%) were older, more likely to have a history of hypertension, and less likely to have a history of MI. Women had a higher LV ejection fraction (LVEF), lower LV end-diastolic index (LVEDVi) and end-systolic volume index (LVESVi), and LV mass index, but no difference in left atrium (LA) volume index compared with men (Table). Women had better diastolic function compared with men. The absolute and relative changes in these echocardiographic parameters from baseline to 8 months were not significantly different between women and men. In univariate analyses, baseline LVEF, LVEDVi, LVESVi, LA dimensions and diastolic measurements are associated with primary outcome (Table).Conclusion:In PARADISE-MI, women have higher LVEF and lower indexed LV and LA chamber sizes compared to men following high-risk MI. The changes between baseline and 8-month in LVEF, LV and LA dimensions did not differ significantly between men and women, suggesting that differential cardiac remodeling post-MI may not account for the increased HF risk in women compared with men.

Circulation, Volume 146, Issue Suppl_1, Page A15115-A15115, November 8, 2022. Introduction:Myocarditis contributes to the global burden of cardiovascular disease primarily through sudden death and dilated cardiomyopathy. We aimed to study patient characteristics, national readmission rates and predictors for patients admitted for acute myocarditis utilizing a nationally representative cohort of patients from the National Readmission Database.Methods:We utilized the National Readmission Database 2018 to identify the hospitalized adults with a primary diagnosis of acute myocarditis. We included subjects who were readmitted within 90 days after index admission. We excluded subjects with elective and traumatic admissions. We utilized a multivariate cox regression model to identify independent predictors of readmission.Results:During the study period, 3,524 hospitalized patients who had a primary diagnosis of acute myocarditis were discharged alive. Within 90 days of discharge, 356 (10.1%) subjects were readmitted. The top three causes of readmission were heart failure (37.1%), sepsis (16.1%) and ventricular tachycardia (10.6%). The in-hospital mortality rate (5.5 vs. 2.6%, p

Circulation, Volume 146, Issue Suppl_1, Page A10194-A10194, November 8, 2022. Introduction:Acute pericarditis has not been linked to long-term heart-specific morbidity in breast cancer patients. Carcinomatous pericardial involvement has been detected at autopsy in 10-20% of breast cancer patients. In clinical practice, when it comes to primarily echocardiographically-diagnosed pericardial diseases: pericardial effusion, cardiac tamponade, and pericardial constriction have all been reported in breast cancer patients. Acute pericarditis is primarily a clinical non-imaging bedside diagnosis derived from the combination of chest pain, pericardial rub, and typical electrocardiographic changes, irrespective of the presence or absence of pericardial fluid on imaging. It can be the initial clinical manifestation of a malignancy.Methods:The Myocardial Infarction Data Acquisition System (MIDAS) database is an ongoing, longitudinal, and validated database that comprises discharge data, along with demographics, comorbidities, and length of hospital stay; for all patients with cardiovascular diseases admitted to every non-federal acute care hospital in the state of New Jersey. We searched for the diagnosis of acute pericarditis (ICD-9 codes 420.0, 420.90, 420.91, and 420.99), in first hospital admissions of female patients with breast cancer (ICD-9 codes 174.0-174.9) between January 1995 to December 2015. Controls were female breast cancer patients without the diagnosis of acute pericarditis.Results:There were 60,435 female patients with breast cancer. Of those, 253 (0.4%) were also diagnosed with acute pericarditis on the same admission as the first breast cancer diagnosis, or later. Analysis for comorbidities showed that 116 (45.8%) of the 253 patients with acute pericarditis had admissions for heart failure, as opposed to 26.4% (15,895 out of 60,182) of breast cancer patients without acute pericarditis (p < 0.00001).Conclusions:Since New Jersey has a diverse population that resembles the profile of the United States in age, gender, and race/ethnicity; our findings could also be generalized to other geographic areas, and may help with future clinical guidelines. Although it is rare, acute pericarditis in breast cancer patients can indicate long-term cardiovascular morbidity.

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 A12743-A12743, November 8, 2022. Introduction:The association of patient satisfaction with hospital ACS care and risk for long-term outcomes is incompletely described. This is particularly relevant to the Gulf region, where the ACS burden is high and literature on patient satisfaction and outcomes is lacking. The aim was to compare determinants of 1-year mortality based on patient satisfaction with ACS care in the Gulf region.Methods:In a prospective registry of 3566 ACS patients from Bahrain, Kuwait, Oman, and UAE (Gulf COAST registry), we grouped patients by their self-reported overall satisfaction with ACS care reported at 1-month following ACS (low satisfaction [n=1654] vs. high satisfaction [n=1912]; Table). We examined associations of baseline characteristics and risk for 1-year mortality in logistic regression models adjusted for Global Registry of Acute Coronary Events (GRACE) score.Results:Mortality at 1-year following ACS was higher in patients reporting low satisfaction (8.8%; n=146/1654) vs. high satisfaction (5.4%; n=103/1912) (P

Circulation, Volume 146, Issue Suppl_1, Page A12760-A12760, November 8, 2022. Introduction:Post-acute sequelae of COVID-19 (PASC) is a novel clinical syndrome. We have previously reported that PASC patients can develop postural orthostatic tachycardia syndrome (POTS) and that COVID-19 induce microvascular endothelial dysfunction in acutely ill, hospitalized patients, that persist up to four months post discharge. Whether microvascular endothelial dysfunction contributes to POTS pathophysiology in PASC remains unclear.Hypothesis:Patients with PACS combined with POTS have impaired microvascular endothelial function.Methods:PASC patients (n=44) with mild SARS-CoV-2 infection (not hospitalized) were recruited from the post-COVID multidisciplinary clinic at Karolinska University Hospital. PASC diagnosis was based on the WHO PASC criteria. POTS was diagnosed in 21 patients (PASC + POTS) while 23 had a negative head-up tilt test (PASC – POTS). Age- and gender-matched healthy subjects (n=15) served as controls. Microvascular endothelial function was quantified as reactive hyperemia index (RHI) determined from the changes in pulse amplitude tonometry before and after a 5 min episode of arterial occlusion. Stress-perfusion cardiac magnetic resonance imaging (cMRI) with adenosine was performed in a subset of patients.Results:Mean age was 42±11 years and 95 % were women among PACS patients. Time from COVID-19 symptom onset to study inclusion was 18±3 months. RHI was significantly lower in PASC + POTS than in healthy controls and PASC – POTS (Figure 1). The prevalence of cardiac microvascular dysfunction on cMRI did not differ between the PASC groups (8% in PASC + POTS vs. 13% in PASC – POTS, p=1.00). All subjects with microvascular dysfunction on cMRI except one had a RHI below the cutoff (1.67) indicating microvascular dysfunction.Conclusions:Microvascular endothelial dysfunction is common in patients with PACS-associated POTS and may cause stress-induced myocardial ischemia up to 18 months after a mild primary infection.

Circulation, Volume 146, Issue Suppl_1, Page A11693-A11693, November 8, 2022. Objective:Improve angiotensin receptor-neprilysin inhibitor (ARNI) utilization among patients admitted with acute decompensated heart failure (HF) through a multidisciplinary quality improvement (QI) intervention.Background:ARNIs reduce mortality and hospitalizations for patients with HF and abnormal systolic function; current guidelines recommend them as first-line agents for Stage C HF. Inpatient initiation of ARNIs during an acute exacerbation is cost-effective and safe. Despite this, ARNI utilization remains low nationally and at our center.Methods:We implemented a multidisciplinary QI intervention at a large urban Veterans Affairs (VA) medical center. The intervention included electronic health record system redesign to provide clinical decision support, a new pharmacy-led screening process and recommendation system to the primary inpatient team, and an educational campaign. Our primary outcome metric was monthly ARNI initiation rate, defined as the number of new ARNI initiations divided by the number of eligible patients admitted for an acute HF exacerbation. We used a statistical process control (XmR) chart to measure change.Results:We observed a statistically significant, non-random improvement in mean monthly ARNI initiation rate from 8.4% pre-intervention to 35.7% post-intervention. An XmR chart is shown in Figure 1. Split limits analysis showed variation post-intervention was within statistical control, suggesting sustainable change.Conclusions:Our outcomes demonstrate successful implementation of a multidisciplinary intervention to improve ARNI utilization among patients admitted with acute decompensated HF at a large VA medical center. ARNI initiation rate increased significantly post-intervention, and the split limits analysis suggests that our results represent sustainable change. A longer period of data collection will be useful to assess HF readmission and mortality rates in response to this intervention.

Circulation, Volume 146, Issue Suppl_1, Page A12725-A12725, November 8, 2022. Introduction:Low serum albumin is a marker of protein malnutrition and is commonly associated with worse outcomes in various clinical settings. Furthermore, significant overlap exists between malnutrition and sarcopenia, which can be an independent predictor of worse outcomes.Hypothesis:We assessed the hypothesis that the presence of sarcopenia with low albumin (SLA) would lead to synergistically worse outcomes in patients with acute decompensated heart failure (ADHF).Methods:Patients hospitalized for ADHF from 2017 to 2019 with computed tomography of the abdomen/pelvis within 30 days and albumin level within 24 hours before discharge were studied (n=181). Given the high prevalence of hypoalbuminemia, low albumin was defined as the lower fiftieth percentile. Semi-automatic measurements of skeletal muscle area were made at L3 (Figure 1A) and adjusted using height squared to obtain skeletal muscle index (SMI). Sarcopenia was defined as the lowest sex-stratified SMI tertile.Results:The prevalence of sarcopenia alone was 11.6%, low albumin alone 28.7%, and SLA 20.4%. The groups had similar demographics but differed in BMI (lowest in sarcopenia alone, p

Circulation, Volume 146, Issue Suppl_1, Page A13191-A13191, November 8, 2022. Case Presentation:Infective endocarditis (IE) can sometimes be a diagnostic challenge because its presentation in its early stages may coincide with that of several other disease processes. It has an incidence of ~7 per 100,000 annually yet has an in-hospital mortality of about 20-25%. We present a case of a 56-year-old immunocompetent male with a recent diagnosis of leukocytoclastic vasculitis (LCV) who was admitted for acute renal failure (ARF). With his history of LCV (Figure 1), renal vasculitis was thought to be contributing to his ARF. On admission, he was afebrile and had a creatinine of 5.25 (baseline of 0.8), hyponatremia, anemia, mild leukocytosis, and mildly elevated lactate. No other infectious sequelae were noted. Nephrology was consulted for workup of renal failure, and a renal biopsy was recommended. Before the biopsy was able to be performed, blood cultures returned positive for Enterococcus faecalis. Transesophageal echocardiogram revealed a large, mobile 1.3-centimeter vegetation attached to the left ventricular outflow tract side of the non-coronary cusp of the aortic valve. Parenteral antibiotics were initiated, and cardiothoracic surgery was consulted for surgical correction. The patient ultimately underwent aortic valve replacement successfully with renal recovery to baseline and resolution of his leukocytoclastic vasculitis soon thereafter.Discussion:LCV has been established as a rare, but well-reported sign of IE. Similarly, only a few cases of IE presenting as ARF have been reported. In patients presenting with both LCV and ARF, it is important to maintain a high index of suspicion for IE. Going down the pathway to work up renal vasculitis may unnecessarily expose patients to invasive procedures, incorrect treatment modalities, and other complications.

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