Risultati per: Sindromi coronariche acute

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 A15758-A15758, November 8, 2022. Background:Socioeconomic, racial, and regional disparities have been associated with worse clinical outcomes among patients with coronary disease. We evaluated the association of income, race, and geographic variation and in-hospital mortality among acute myocardial infarction (AMI) admissions in the United States.Methods:We conducted a retrospective cohort study using the Nationwide Inpatient Sample from 2015 to 2019. A multi-level logistic regression model was used (with sampling weights) to investigate the association between in-hospital mortality and income quartiles by patient’s ZIP code, race, and hospital regions, while adjusting for hospital clustering, lifestyle factors, clinical history, and hospital-level factors.Results:A total of 2,798,225 hospitalizations (≥18 years) with a principal diagnosis of AMI were identified. In multivariable analysis, compared with the highest income quartile, residents in the lowest income quartile (OR=1.10 [1.08–1.13]P

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 A13493-A13493, November 8, 2022. Background:Microalbuminuria is associated with adverse outcome in acute coronary syndrome (ACS) patients.Methods:To evaluate the very long-term association between microalbuminuria during ACS and the overall mortality and causes of death, we prospectively studied 579 ACS patients admitted to three Italian hospitals. The baseline albumin-to-creatinine ratio (ACR) was measured on days 1, 3, and 7 in 24-h urine samples. Patients were followed for 22 years or until death.Results:Virtually all patients completed the follow-up, representing 6756 person-years. During follow-up, 449(78%) had died: 41% due to non-sudden cardiac death (non-SCD), 19% sudden cardiac death (SCD), 40% due to non-cardiac (non-CD) death. The unadjusted Cox regression analysis showed that ACR is a significant predictor of all-cause mortality (HR:1.26; 95%CI 1.22-1.31; p˂0.0001) and the 3 causes of death (HR:1.40; 95%CI 1.32-1.48; p˂0.0001), (HR:1.22; 95%CI 1.12-1.32; p˂0.0001) and (HR:1.16; 95%CI 1.09-1.23; p˂0.0001) for non-SCD, SCD and non-CD respectively. Yet the fully adjusted model showed that ACR is a significant independent predictor of all-cause mortality (HR:1.12; 95%CI 1.08-1.16; p˂0.0001) and only non-SCD (HR:1.21; 95%CI 1.14-1.29; p˂0.0001).A positive interaction between ACR and history of AMI (HR:1.15; 95%CI 1.03-1.29; p=0.01), and the presence of heart failure during admission (HR:1.11; 95%CI 1.01-1.24; p=0.04), and a negative interaction with LVEF (HR:0.89; 95%CI 0.80-0.99; p=0.03) for all-cause death was also observed at the multivariable level.Conclusion:This prospective study shows that baseline ACR during ACS seems to be a strong independent predictor of the very long-term mortality risk, chiefly associated with non-sudden cardiac death. A positive independent interaction with indicators of heart failure has been also observed.Figure 1:Relative hazard estimates for all-cause and cause-specific mortality 22 years after ACS according to baseline ACR.

Circulation, Volume 146, Issue Suppl_1, Page A15880-A15880, November 8, 2022. Acute pulmonary embolism classically presents with dyspnea, tachypnea, and hypoxia, but self-recognition of symptoms and clinical findings is often challenging. This is particularly true in elder patients or those with cognitive impairments. Digital health technologies offer opportunities to remotely detect pre-symptomatic illness. We present a prodrome of an acute pulmonary embolism as it emerges in the home during continuous respiratory monitoring using a non-contact adherence-independent home bed sensor. The patient is an 85-year-old woman who is morbidly obese, has limited mobility, and multiple comorbidities including a recent diagnosis of atrial fibrillation for which she was prescribed anticoagulation but has not yet initiated. As part of an observational study, nocturnal respiratory rates (NRR) were longitudinally monitored in her home bed using a non-contact, adherence-independent bed sensor. Eight days prior to admission, increasing NRR prompted a patient call to family who noted no acute symptomatic changes. During the call it was discovered she had not been started on apixaban. On subsequent days, persistently elevated NRR prompted a second phone call 4 days prior to admission (PTA), where again no acute symptoms were noted. Anticoagulation still had not been started at that time. NRR worsened further on days following the second call prompting a home visit by an RN who found the patient dyspneic, tachypneic in the high 20s, and hypoxic with oxygen saturations in the 80s, prompting a transfer to the emergency department for further evaluation. She was eventually diagnosed with an acute pulmonary embolism. After a week-long hospitalization, the patient was discharged on adequate anticoagulation therapy.This case suggests that adherence-independent home bed monitoring of nocturnal respiratory rate may enable early detection of chronic volume overload and acute pulmonary embolism, potentially facilitating early intervention.

Circulation, Volume 146, Issue Suppl_1, Page A14942-A14942, November 8, 2022. Background, hypothesis:Gyrencephalic large-animal models of acute ischemic stroke (AIS) such as swine gain attention in translating preclinical to clinical stroke research, with brain anatomy similar to humans. Most swine models employ young animals with AIS by permanent occlusion (P-AIS). This does not reflect the, often elderly, stroke patient. Therefore, recanalized AIS (R-AIS) in adult mini-pigs could improve preclinical to clinical translation.Methods:Anesthetized adult (2 yrs) Aachen mini-pigs (n=6) underwent craniotomy to occlude right-side middle cerebral arteries (MCA) with aneurysm clips. Clips were released at 4 hrs to allow recanalization for 2-4 hrs (R-AIS, n=4) or left in place until sacrifice (P-AIS, n=1). 3D angiography confirmed occlusion and recanalization. Infarct size was determined by TTC staining and expressed as % infarct per hemisphere (median, min-max). Qualitative neurovascular histology was performed in HE-stained sections of ischemic and remote (contralateral) tissue.Results:All animals survived until end-of-procedure. In 4 of 5 animals R-AIS successfully induced cortical infarcts (infarct size, 16.2% [9.1%-25.2%]). R-AIS was unsuccessful in 1 animal, with a smallstriatuminfarct (2.7%) without cortical involvement and unclear angiographic occlusion. P-AIS (n=1) resulted in 12.7% infarct. Assessment of ischemic (TTC-neg) tissue revealed characteristic histology of ischemia/reperfusion-derived neurovascular damage, including erythrocyte extravasation, vasostasis, increased perivascular space and intravascular platelet/fibrin aggregates (Figure 1) in all animals. Remote tissue did not show any of these features.Conclusions:Adult Aachen mini-pigs can be used for acute ischemic stroke modelling and display characteristic neurovascular features associated with ischemia and reperfusion. They may serve as a model for translational therapeutic neuro(vascular)-protective research.

Circulation, Volume 146, Issue Suppl_1, Page A15615-A15615, November 8, 2022. Introduction:Previous studies have suggested that SARS-CoV-2 causes microvascular inflammation and thrombosis, leading to microvascular angiopathy. A downstream sequela of microvascular angiopathy is AKI. Literature extensively describes the renoprotective effects of ACEI and ARB.Hypothesis:We hypothesize that using an ACEI/ARB in patients with SARS-CoV-2 is negatively associated with AKI.Methods:We conducted a retrospective chart review of patients 18 years and older who tested positive for SARS- CoV-2 using a polymerase chain reaction test between March 2020 and April 2021. Patients were divided into two groups, AKI, and non-AKI. The primary outcomes were all-cause mortality and hospitalization rate. The secondary outcomes were myocardial infarction, hypotension, intubation, use of vasopressors and ventricular tachycardia (VT). We used multivariate logistic regression to adjust for baseline characteristics.Results:We identified a total of 1,212 patients with AKI and 21,887 without AKI who tested positive for SARS-CoV-2. Incidence was 539 (44%) for all-cause mortality, 1144 (94.2%) for hospitalization, and 413 (34.6%) for patients taking ACEI/ARB. After logistic regression analysis, OR was 3.006 (95% Confidence Interval [CI]: 2.342-3.858; p

Circulation, Volume 146, Issue Suppl_1, Page A11920-A11920, November 8, 2022. Introduction:Due to dramatic advance in the development of highly active antiretroviral therapy, patients living with human immunodeficiency virus (HIV) (PLWH) have gained a near-normal life expectancy. As a result, cardiovascular diseases are now the most common causes of mortality among PLWH.Objectives:We aimed to investigate if HIV positive status affect the outcomes of PLWH hospitalized with acute myocardial infarction (AMI) or heart failure (HF) in the United States.Methods:Using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), we queried the national inpatient sample database to identify admission cases with AMI or HF between 2016 and 2019. Then, we stratified the AMI and HF cases according to their HIV status. Weighted data was analyzed to compare mortality rate, frequency of home disposition (HD), length of stay, and total hospital charges between HIV positive and HIV negative patients for AMI and HF admission cases.Results:Data pertaining to a total of 28,484,087 admissions was analyzed. Of this, there were 896,702 cases of AMI and 4,154,918 cases of HF. HIV status was positive in 0.24% and 0.32% of AMI and HF patients, respectively.Conclusion:HIV positive status is associated with a longer length of stay and total hospital charged among hospitalized patients with AMI or HF. While PLWH admitted with AMI have a higher mortality rate than HIV negative counterparts, the HIV status does not seem to impact the outcome of HF patients. Additionally, PLWH seem to be more frequently discharged home than HIV negative patients.

Circulation, Volume 146, Issue Suppl_1, Page A10464-A10464, November 8, 2022. Introduction:There are scarce data in the literature analyzing, in patients with acute myocardial infarction (AMI), the impact of right (RBBB) and left bundle-branch block (LBBB) on mortality, especially in the long-run after hospital discharge.Hypothesis:RBBB and LBBB is associated with in-hospital and long-term mortality in patients with AMI.Methods:Retrospective analysis from an administrative databank of patients (pts) with acute coronary syndromes, collected prospectively between 1998 and 2016. From a total of 6466 pts, we selected 2895 with AMI (72% men, mean age 63.7 years, 50% with ST-segment-elevation AMI) and complete follow-up for up to 17 years (mean 5.5 years). In-hospital and long-term mortality was compared with RBBB (incidence=5.8%) and LBBB (incidence=3.9%) in models unadjusted and adjusted for 14 variables including age, type/location of AMI and in-hospital cardiogenic shock.Results:In-hospital mortality was 15.5% vs. 7.0% for pts with or without RBBB, respectively (OR=2.41, P

Circulation, Volume 146, Issue Suppl_1, Page A9704-A9704, November 8, 2022. Introduction:Several risk factors and scores have been studied to predict in-hospital mortality [IHM] and rehospitalization [RH] in patients with AHF.Hypothesis:The impact of the initial therapies implemented for AHF on the variables of the acid base gases (ABG) has not been evaluated for prognostication of IHM and RH.Methods:We prospectively evaluated 216 patients admitted in CICU with AHF from 2015 to 2021. Demographic, clinical and ABG variables were analyzed on admission and at 24 hours. Patients were grouped according to whether they presented improvement in respiratory failure, defined as improvement in SaO2, PaO2 and PaCO2 as well as de-escalation of respiratory support devices (NIV or high flow). The aim of the study was to identify whether the improvement in ABG variables, O2 requirement or respiratory support within 24 hours of admission is associated with lower IHM and RH at 60 days. Data was analyzed using bivariate and multivariate analyzes by logistic regression.Results:Mean age was 75 years (44% female), normal EF 62% and reduced 38%. Mean NT-pro-BNP was 9280 ng/dl. RH at 60 days was 25% and IHM was 8.7%. Mean PaO2 on admission was 75 mmHg and at 24 hours 82 mmHg, PaCO2 on admission was 38 mmHg and at 24 hours 40 mmHg, mean SaO2 on admission was 94% and at 24 hours 95%. In bivariate analysis, the highest elevation of the PaCO2 on admission as well as PaCO2 at 24 hours were identified as predictors of IHM (38.42 vs 40.26 mmHg, p = 0.025) and (40.17 vs 46.84 mmHg, p = 0.002) respectively. In multivariate analysis, AKI on CKD (p = 0.03), cardiogenic shock (p =

Circulation, Volume 146, Issue Suppl_1, Page A13710-A13710, November 8, 2022. Introduction:The prognosis of reactive pulmonary hypertension (PH) due to left heart disease is poor, and the pathogenesis of the disease is not well understood. Rho-Kinase inhibitor, fasudil dilates vascular smooth muscle and may improve pulmonary hypertension. We evaluated the acute effects of fasudil on hemodynamic parameters in patients with pulmonary hypertension due to left heart disease prospectively.Methods:From 2016 June to 2022 May, 100 consecutive patients requiring hospitalization for worsening chronic heart failure were enrolled. All patients underwent invasive hemodynamic measurement though right heart catheterization.In patients with mean pulmonary arterial pressure greater than 25 mmHg at baseline, 30 mg of fasudil was administered intravenously for 30 minutes. The hemodynamic measurements were performed at baseline and after 30 minutes of fasudil. PH due to left heart disease is defined as mean pulmonary arterial pressure (mPAP) ≥25mmHg and mean pulmonary capillary wedge pressure (mPCWP) >15mmHg. Patients with PH were classified into 2 types, depending on the elevation of pulmonary vascular resistance (PVR) or the diastolic pressure gradient (DPG): Reactive-PH with elevated PVR ( >3.0 Wood units: WU) and/or DPG ( >7mmHg), and Passive-PH with normal PVR (≤3.0 WU) and DPG (≤7mmHg).Results:Fifty patients (mean age 70 years; 14 women and 36 men) received administration of fasudil. 30 patients had Passive-PH, and 20 patients had Reactive-PH. PVR significantly decreased after administration of fasudil in both Passive-PH and Reactive-PH group (1.7 to 1.4 WU, 3.5 to 2.7 WU, P

Circulation, Volume 146, Issue Suppl_1, Page A10602-A10602, November 8, 2022. Introduction:Layered plaque is a signature of previous subclinical plaque destabilization and healing, which can be identified by optical coherence tomography (OCT). Silent plaque rupture or erosion with formation of a layer might contribute to rapid step-wise progression of plaque. We examined the relationship between layered plaques detected by OCT and plaque burden detected by intravascular ultrasound (IVUS) in patients with acute coronary syndromes (ACS).Methods:Patients presented with ACS who underwent preintervention OCT and IVUS were included in the analysis. Layered plaque was identified by OCT, and plaque burden was measured by IVUS around the culprit lesion. IVUS findings were compared between patients with layered plaque versus those without layered plaque.Results:Among 150 patients, total atheroma volume (TAV) (183.27 mm3[114.2 mm3to 275.0 mm3] vs. 119.27 mm3[68.9 mm3to 185.5 mm3], p=0.004), percent atheroma volume (PAV) (60.06 % [54.7 % to 60.1 %] vs. 53.69 % [46.8 % to 60.6 %], p=0.001), and plaque burden (PB) (86.51 % [81.7 % to 85.7 %] vs. 82.58 % [77.9 % to 85.4 %], p=0.001) were significantly higher in patients with layered plaques than non-layered plaques (Figure). When multi, single, and non-layered plaques were compared, TAV (188.69 mm3[122.1 mm3to 293.6 mm3] vs. 137.85 mm3[100.1 mm3to 208.4 mm3] vs. 119.27 mm3[68.9 mm3to 185.5 mm3], p=0.021), PAV (62.12 % [56.8 % to 67.8 %] vs. 57.52 % [48.9 % to 60.1 %] vs. 53.69 % [46.8 % to 60.6 %] p

Circulation, Volume 146, Issue Suppl_1, Page A12589-A12589, November 8, 2022. Introduction:Left ventricular (LV) unloading by percutaneous ventricular assist device (pVAD) reduces myocardial workload and oxygen consumption and provides a new concept for improving outcome for acute myocardial infarction complicated with cardiogenic shock (AMI-CS). AMI results in reduced LV ejection fraction and left atrium remodeling, and increased the incidence of atrial fibrillation. The aim of this study is to investigate the effectiveness of LV unloading by pVAD in terms of mid-term mortality, LV function, and the incidence of atrial fibrillation.Methods:We retrospectively reviewed AMI-CS patients who were admitted to our hospital between July 2014 and December 2021. We investigated patient demographics and baseline characteristics, mid-term clinical outcome, re-admission rate as well as new-onset atrial fibrillation compared between the patients supported with pVAD and without pVAD group during 180-day follow-up.Results:A total of 82 AMI-CS patients treated with pVAD (n=54) or without pVAD (n=28) were analyzed. Mean age was 70±15 years old and 56 patients were male. Door to balloon time (110±56min vs. 91±53min, p=0.33) and Peak CK-MB (471.8±338mg/dl vs. 486.0±545mg/dl, p=0.43) were similar in both groups. During the 180-days follow-up, 23 patients died and 12 patients were re-hospitalized for heart failure (HF). New-onset atrial fibrillation occurred in 16 patients, which was significantly less frequent in pVAD group (11% vs. 36%. p=0.016). Between baseline and 180-days follow-up period, changes of LV ejection fraction (16% vs. 6%, p=0.02) and NT-proBNP (-28% vs. -5%, p=0.03) were significantly higher in pVAD group. There was no significant difference in 180-day all-cause mortality (28% vs. 29%, p=1.0) between the two groups. Multivariate logistic regression showed new-onset atrial fibrillation was independently associated with an increased risk of HF readmission (hazard ratio 2.63, 95% confidence interval 1.91-3.57; p=0.01).Conclusion:pVAD support preserves LV function following ventricular unloading and reduces new-onset atrial fibrillation, which might be contributed to the improvement of mid-term outcome.

Circulation, Volume 146, Issue Suppl_1, Page A14170-A14170, November 8, 2022. Background:The ratio of early transmitral filling velocity to early diastolic strain rate (E/e’sr) has been proposed as a new measurement of left ventricular filling pressure. We aimed to investigate the ability of E/e’sr to predict atrial fibrillation (AF) after ST-elevation myocardial infarction (STEMI).Methods:This was a prospective cohort study of patients with STEMI treated with primary percutaneous coronary intervention (pPCI). Patients underwent an echocardiographic examination a median of two days after pPCI. By echocardiography, transmittal early filling velocity (E) was measured by pulsed-wave Doppler, and early diastolic strain rate (e’sr) was measured by speckle tracking of the left ventricular. The E was indexed to e’sr to obtain the E/e’sr as well as to the early myocardial relaxation velocity to obtain the E/e’. The endpoint was new-onset AF.Results:During follow-up (median 5.6 years, IQR:5.0-6.1), 23 of the 369 patients developed AF. In unadjusted analyses, both E/e’sr and E/e’ were significantly associated with AF [E/e’sr: HR=1.06; (1.03-1.10); p

Circulation, Volume 146, Issue Suppl_1, Page A10757-A10757, November 8, 2022. Introduction:Prospectively identifying patient characteristics associated with myocardial infarction (MI) readmission would help target patients at high risk of recurrent events for improved clinical management. This study aimed to build and evaluate machine learning models based solely on real world data to identify predictors of rehospitalization or death within one year following acute MI.Methods:The study population consisted of adult patients who experienced a first hospitalization for MI between January 1, 2013 and December 31, 2017 in the Optum® Clinformatics® Data Mart, an administrative health claims database from a large US national managed care company. Logistic Regression (LR), Extreme Gradient Boosting (XGBoost), and Deep Neural Network (DNN) models were developed and tested. Model variables included patient demographics, clinical characteristics, and specific treatments. Variable importance for model prediction was ranked.Results:Among 96,244 patients who had an initial MI, 15,925 (16.5%) had rehospitalization/death within a year. The LR, XGBoost, and DNN models performed similarly (area under the curve 0.762, 0.774, and 0.785 respectively). The XGBoost was selected as the primary model to assess the relative importance of the variables in predicting MI rehospitalization/death. Of the most impactful variables, older age, higher Charlson Comorbidity Index, presence of chronic kidney disease (all stages), previous heart failure, and no previous coronary arterial bypass graft were highly predictive of MI rehospitalization/death (Figure).Conclusions:The machine learning models developed in this study can be implemented within clinical systems to identify patients at high risk for MI readmission to improve care and decision-making. However, these models require external validation in other datasets. Furthermore, performance of the models might be improved by including information such as LDL-C levels and PCSK9 inhibitor use.

Circulation, Volume 146, Issue Suppl_1, Page A9896-A9896, November 8, 2022. Introduction:Acute myocardial infarction (AMI) has been a major cause of death worldwide. Recently, living alone as a proxy for social isolation has been considered to increase the risk of cardiovascular disease. We thus investigated the impact of living alone on mortality in AMI patients.Methods:Subjects comprised 277 AMI patients who underwent percutaneous coronary intervention (PCI). Associations between all-cause death after PCI and baseline characteristics including living alone and Global Registry of Acute Coronary Events (GRACE) risk score, which is widely used for estimating mortality in AMI patients, were assessed.Results:Eighty-three patients (30%) were living alone and 194 patients (70%) were not. Median duration of follow-up was 1153 days (interquartile range, 560-1566 days). Thirty patients died after PCI including 20 cardiac deaths. Patients living alone showed higher incidences of both all-cause and cardiac deaths compared with patients not living alone (18% vs. 8%, p = 0.019 and 14% vs. 4%, p = 0.004, respectively). Multivariate Cox proportional hazards regression analysis modeling using relevant factors from univariate analysis showed living alone [hazard ratio (HR), 2.60; 95% confidence interval (CI), 1.20-5.62; p = 0.016] and GRACE risk score (HR, 1.02; 95%CI, 1.01-1.03; p = 0.003) correlated significantly with all-cause death. The interaction of GRACE risk score and living alone showed a value of p = 0.25. The optimal cut-off on the receiver-operating characteristic curve of GRACE risk score for predicting all-cause death was 162. Cox proportional hazards modeling using GRACE risk score and living alone revealed that patients living alone with GRACE risk score ≥162 showed a significantly greater risk of all-cause death than patients not living alone with GRACE risk score