Risultati per: Sindromi coronariche acute

Circulation, Volume 146, Issue Suppl_1, Page A10291-A10291, November 8, 2022. Background:In the ODYSSEY OUTCOMES trial (NCT01663402) the PCSK9 inhibitor alirocumab [ALI] reduced the risk of cardiovascular events [CVE] after acute coronary syndrome [ACS] in patients [pts] with elevated atherogenic lipoproteins despite optimized statin treatment, an effect modified by baseline levels of lipoprotein [Lp](a). Levels of the inflammatory biomarker high-sensitivity C-reactive protein [hsCRP] are associated with risk after ACS. In this post hoc analysis, we determined whether Lp(a)-associated risk of CVE after ACS and reduction in that risk with ALI are modified by concurrent hsCRP levels.Methods:18,924 pts were randomized to ALI or placebo [PBO] 1-12 months after ACS and followed for median 2.8 years. Baseline Lp(a) and hsCRP were available in 18,290 pts. CVE [CV death, non-fatal MI, stroke, unstable angina or heart failure hospitalization, ischemia-driven coronary revascularization, peripheral artery events, and venous thromboembolism] were evaluated by baseline quartile of Lp(a) and by hsCRP dichotomized at 0.2 mg/dL.Results:Median (Q1-Q3) baseline Lp(a) was 21.3 (6.7-59.6) mg/dL. In 10,323 pts with baseline hsCRP

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 A15498-A15498, November 8, 2022. Introduction:Optimal medical treatment demonstrated a reduction in cardiovascular outcomes after acute coronary syndrome. Treatment adherence results crucial to obtain that benefit, we do not have current data on the adherence in our population. Our objective was to evaluate the treatment adherence at 6 and 15 months in patients post non-ST elevation acute coronary syndrome (NST-ACS).Methods:It’s a prespecified sub-analysis in the prospective registry BUENOS AIRES 1 that include 1100 patients. The adherence was evaluated using the modified Morisky-Green scale.Results:The mean age was 65 ±11 years. At 6 month 76.4% were consider as adherents to pharmacological treatment. We didn’t find any predictors for adherence. Adherent patients had a rate of combined isquemic events (myocardial infarction, death or stroke) of 11.5% (52/452) versus 20% (27/135) in non-adherent patients at 15 months. Treatment adherence was an independent predictor of combined isquemic events (HR 0.517, IC95% 0.308-0.869, p=0.013). There weren’t any differences in the hemorrhagic events between the two groups.Conclusions:Our population had a high adherence treatment without any clinical predictor of this phenomenon. Adherence was related to a reduction in isquemic events without changing the hemorrhagic events. Nonetheless, one of four patients was considered as non-adherent after a hospitalization for NST-ACS, showing that we need intervention to reduce this number.

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 A9746-A9746, November 8, 2022. Introduction:Amyloidosis can disrupt several tissues, including the heart, causing various cardiac arrhythmias. Factors influencing the presence of Atrial Fibrillation in the elderly with amyloidosis admitted for Acute Ischemic Stroke (AIS) have been sparsely studied.Methods:Elderly patients of ages 60 and more with a diagnosis of amyloidosis and a principal diagnosis of Acute Ischemic Stroke (I63.x) were filtered from the 2019 National Inpatient Sample (NIS). All forms of Atrial Fibrillation and multiple risk factors were also identified via their appropriate codes provided by HCUP and based on recommendations from past studies.Results:Our analysis found 1570 elderly amyloidosis patients admitted for AIS in 2019. Among them, 490 cases (31.2%) also had a diagnosis of Atrial Fibrillation. Predictors of atrial fibrillation included hypertension (aOR 1.543, p=0.024), chronic pulmonary disease (aOR 1.541, p

Circulation, Volume 146, Issue Suppl_1, Page A11206-A11206, November 8, 2022. Background:Translational studies showed positive results of stem cell therapy against myocardial infarction (MI)-induced cardiac dysfunction. Programmed death ligand 1 (PD-L1) is a key immune receptor, which modulates immune system and maintain the stability of coronary plaques. Akt is one of the signaling that exert its cardioprotective effect through regulating PD-L1. In the present study, we overexpressed PD-L1 and Akt in adipose-derived mesenchymal stem cells (AdMSC) and determined the protection against MI.Methods and Results:Adult Wistar rats were randomly separated into four groups: sham, MI, treatment of AdMSC or AdMSC overexpressed with PD-L1 and Akt (AdMSC-PDL1-Akt) immediately after MI. MI was induced by LAD ligation and ADMSC were injected into the heart around the area at risk. After 4 weeks, rats were examined by echocardiography, pressure-volume analysis, infarct size measurement, and immunohistochemistry to evaluate the efficacy of the ADMSCs on myocardium. Results demonstrated AdMSC-PDL1-Akt was more resistant to ROSin vitro, and could restore MI-induced contractile dysfunctionin vivoby increasing ESPVR (P=0.048) and PRSW (P=0.015). AdMSC-PDL1-Akt could also protect hearts from MI-increased infarct size (P=0.002). Immunohistochemistry staining with caspase 3 and NFκB were upregulated in MI hearts and significantly reversed in AdMSC-PDL1-Akt group (P

Circulation, Volume 146, Issue Suppl_1, Page A11931-A11931, November 8, 2022. Background:Plasma volume status (PVS), a measure of plasma volume, has been evaluated as a prognostic marker for chronic heart failure. However, the significance of PVS in patients with acute decompensated heart failure (ADHF) admitted to the cardiovascular intensive care unit (CICU) remains unclear. Therefore, we examined the relationship between PVS and the long-term mortality.Method:Of 389 consecutive patients admitted to our CICU for ADHF from January 2018 to December 2020, a total of 206 patients (74.9 ± 12.9 years, 64.6% male) were enrolled, excluding those who received red blood cell transfusion, underwent dialysis, were discharged directly from the CICU, or died in the hospital. We measured PVS during the CICU stay and at discharge using the Kaplan-Hakim formula, and examined the association with all-cause mortality during the observation period (1037 days).Result:The group with decreasing PVS at 3 points, at admission to the CICU, at transfer to the GW, and at discharge, had a 3-year mortality rate of 0%. Cut-off values to predict long-term mortality were 10% and 9% for PVS at transfer to the GW and discharge according to ROC curve, respectively. All patients were divided into 2 groups by cut-off values, respectively, and the high PVS group had a significantly higher mortality rate (Figure 1, 2). In COX regression analysis, significant poor prognostic factors were PVS at transfer to the GW (HR=1.086 [1.04-1.13], P

Circulation, Volume 146, Issue Suppl_1, Page A11227-A11227, November 8, 2022. Introduction:Contrast agents in echocardiography are used frequently to enhance endocardial border visualization and assessment of structural heart disease. Sulfur hexafluoride lipid type A injectable suspension is a generally well-tolerated class of contrast. Anaphylaxis to these agents is exceedingly rare. We now report the first case of acute coronary syndrome in the setting of echo contrast anaphylactic shock.Case:A 49-year-old woman was hospitalized for an ST-elevation myocardial infarction (STEMI) for which a drug-eluting stent had been placed in the left anterior descending artery (LAD). An echocardiogram was performed to evaluate for structural heart disease. Shortly after administration of echo contrast the patient developed sudden-onset tachypnea and suffered a pulseless electrical activity cardiac arrest. She was treated for anaphylactic shock with epinephrine and high-dose steroids and achieved return of spontaneous circulation. Following the arrest an electrocardiogram revealed an anterolateral STEMI. The patient immediately underwent repeat angiography which revealed a 100% in-stent thrombosis of the LAD. The occlusion was successfully revascularized with a drug eluting stent with an Impella CP (Abiomed, Danvers MA) support. Subsequent laboratory exam demonstrated an elevated blood tryptase level consistent with an anaphylactic event.Discussion:We present a unique case of anaphylactic shock with acute coronary syndrome following administration of sulfur hexafluoride echo contrast. The incidence of anaphylaxis to echo contrast is less than one per million, and therefore it may not be immediately recognized as a mechanism of shock. Any prior reactions to polyethylene glycol should be noted before using these agents as this ingredient is thought to be the cause of anaphylaxis. In our case, diagnosis of anaphylaxis was confirmed by measuring the serum tryptase level. Tryptase is released from mast cells during allergic events, so this laboratory test with high specificity for anaphylaxis can be a useful tool in challenging cases such as this. Additionally, mast cell and platelet activation secondary to anaphylaxis may be an important mechanism of acute coronary syndrome with in-stent thrombosis.

Circulation, Volume 146, Issue Suppl_1, Page A10864-A10864, November 8, 2022. Introduction:Right ventricular (RV) systolic dysfunction has been identified as a prognostic marker for adverse clinical events in patients presenting with acute pulmonary embolism (PE). However, problems exist in identifying RV dysfunction using conventional echocardiography. Strain echocardiography is an evolving imaging modality which measures myocardial deformation and can be used as an objective index of RV systolic function.Hypothesis:We hypothesized that RV strain analysis is prognostic of mortality in patients with acute PE.Methods:Retrospective cohort study of 177 patients with acute PE between 2010 and 2017. Strain analysis was retroactively applied. All echocardiograms were completed within 48 hours of diagnosis. RV global longitudinal strain (RVGLS) was applied using TomTec®. The primary outcome was all-cause mortality at 30 days and in-hospital mortality. T-test statistical analysis was performed. Receiver operating characteristic (ROC) curves and Kaplan-Meier curves were used for evaluation.Results:Study quality was sufficient to perform RVGLS analysis in 157 patients (90.2%). Mortality at 30 days and in-hospital mortality occurred in 12.7% and 8.9% of patients respectively. Comparing 30-day mortality, there was a significant reduction in RVGLS compared to survivors (13.0% ± 3.0% vs 19.6% ± 3.5%, p < 0.001). In-hospital mortality as well showed a significant difference (13.1% ± 3.3% vs 19.3% ± 3.7%, p < 0.001). Using ROC curves, we chose a RVGLS value of 17.5% (sensitivity 90%, specificity 74%) to predict 30-day mortality. Patients with RVGLS worse than 17.5% had 18 times higher risk of 30-day mortality compared to patients with RVGLS better than 17.5% (HR 18.4, 95% CI= 4.2-79.7, p < 0.001. Figure).Conclusions:RV strain have significant prognostic value in patients with acute PE, and identifying those at higher risk of death. Assessment of RV strain has promise for clinical applications.

Circulation, Volume 146, Issue Suppl_1, Page A11098-A11098, November 8, 2022. Introduction:Severity of end-organ dysfunction correlates with outcomes in acute myocardial infarction-related cardiogenic shock (AMI-CS). The epidemiology of end-organ dysfunction in heart failure-related cardiogenic shock (HF-CS) has not been well described.Methods:Cardiac intensive care unit (CICU) admissions with CS in the Critical Care Cardiology Trials Network Registry (2017-2021) were identified and categorized as AMI-CS and HF-CS (de novoor acute-on-chronic HF). Admissions for each CS sub-type were characterized as having respiratory, kidney, liver, and/or neurologic dysfunction using definitions adapted from the Sequential Organ Failure Assessment score (Fig A). Outcomes were assessed by burden of non-cardiac organ dysfunction: no end-organ dysfunction (NEOD), single system end-organ dysfunction (SEOD), or multi-system end-organ dysfunction (MEOD).Results:A total of 2,911 CS admissions from 35 CICUs were identified, most of which were for HF-CS (71%, N = 2,068). The proportions of patients with NEOD, SEOD, and MEOD were 25%, 36%, 39% for HF-CS vs. 16%, 35%, 49% for AMI-CS (p

Circulation, Volume 146, Issue Suppl_1, Page A10724-A10724, November 8, 2022. Background:Right Heart Catheterization (RHC) is an important tool in the assessment of hemodynamic status in patients with right heart failure (RHF), however is underutilized.Objective:To evaluate the use of RHC in RHF with the primary outcome as mortality and secondary outcome as length of stay (LOS) using the National Inpatient Sample (NIS).Methods:Using 2018 NIS database, we queried for adults over 18 years with the diagnosis of acute RHF and RHC as a procedure using the ICD-10 code via STATA program. Multivariate logistic regression method was used to adjust for age, gender, race, Charlson comorbidity index, cardiogenic shock, septic shock, respiratory failure, acute coronary syndrome, heart failure, atrial fibrillation/flutter, acute kidney injury, chronic kidney disease, end-stage renal disease. Using a 95% confidence interval (CI), a p-value less than 0.05 was considered statistically significant.Results:A total of 49010 admissions was recorded for acute RHF of which 4795 underwent RHC. 360 patients (7.5%) died in the RHC group versus 4615 (10.4%) in the non-RHC group.16.9% of patients in the RHC group had cardiogenic shock versus 7.3% in the non-RHF group. On univariate analysis, patients undergoing RHC had decreased odds of mortality compared to patients without RHC [Odds ratio (OR) = 0.69, p=0.003] and patients undergoing RHC had increased LOS compared to patients without RHC [OR= 3.15, p=0.012]. The mean LOS for the RHF group was 13.3 days versus 7.5 days in the non-RHF group. On multivariate analysis, those undergoing RHC had decreased odds of mortality compared to those without RHC [OR= 0.47, p=0.000] and LOS was longer for those undergoing RHC [OR= 3.15, p=0.008]. All the outcomes were statistically significant.Conclusion:Right heart catheterization, when used in acute right failure, showed decreased odds of mortality when compared to patients receiving non-invasive medical management only however, no difference in length of stay was observed.

Circulation, Volume 146, Issue Suppl_1, Page A15628-A15628, November 8, 2022. Background:Acute myocardial infarction may concomitantly occur with acute ischemic stroke. The incidence,complications and outcomes of acute Non- ST elevation Myocardial infarction in acute ischemic stroke are not well studied.Methods:We examined hospitalized patients (n = 1,726,265) with acute ischemic stroke that were included in National Inpatient Sample 2016-2019. Acute ischemic stroke and NSTEMI were defined by using International classification of disease (ICD -10). STEMI patients were excluded. Multivariable logistic regression analysis was used to examine association of NSTEMI with outcomes. A subgroup analysis of NSTEMI patients that underwent PCI (with or without angioplasty) was also performed.Results:Of the total stroke patients, 27630 (1.6%) patients (mean age 73.5, 52.2% females) had NSTEMI diagnosed during the hospitalization. Of these, 3890 (6.32%) died in NSTEMI group and 57670 (93.68%) died in non NSTEMI group. The commonest complications in NSTEMI group were cardiogenic shock 25% , cardiac tamponade 13.8% , and septic shock 12.1%. NSTEMI in stroke patients were associated with several complications and mortality (OR 2.73, 95% CI 2.57-2.90, p value

Circulation, Volume 146, Issue Suppl_1, Page A11912-A11912, November 8, 2022. Introduction:Pregabalin, a structural analog to λ-aminobutyric acid, is prescribed for neurological disorders. Through actions to cause sodium/water retention, the agent may increase the risk of acute heart failure (AHF).Methods:We performed a retrospective cohort study using a repository of healthcare records obtained from a large U.S. academic healthcare system. HF patients were identified between 1/1/2016-12/31/2020. Patients who had initiated treatment with pregabalin were compared to patients with no post-HF pregabalin over a 365-day post-pregabalin period or post-HF period. Study outcomes were per-patient per-year (PPPY) emergency department (ED) admissions or PPPY hospitalizations, time-to first ED admission, and time-to hospitalizations. Outcomes encounters were adjudicated by a HF diagnosis (ICD-10, I50.x) at any position. We tested the association between the pregabalin exposure and outcomes using generalized linear regression and Cox-proportional hazard regression approach.Results:The study cohort included 483 pregabalin-HF patients and 21,150 pregabalin-naïve HF patients. The pregabalin-HF patients age was (mean±SEM: 62.2±0.7 vs. 66.2±0.1 years,p

Circulation, Volume 146, Issue Suppl_1, Page A13604-A13604, November 8, 2022. Introduction:Sodium-Glucose Cotransporter-2 inhibitor (SGLT2i) use during or immediately following Acute Heart Failure (AHF) exacerbation has shown clinical benefit including improved symptoms, lower frequencies of re-hospitalization for heart failure and death. However, effects of SGLT2i use immediately following acute kidney injury (AKI) on mortality and renal recovery in this setting are unknown.Hypothesis:Among patients admitted with AHF who sustain in-hospital AKI, exposure to SGLT2i in the immediate post-AKI period would be associated with better outcomes.Methods:Adult patients admitted across 5 hospitals between January, 2020 and April, 2022 with acute heart failure (NT-pro-BNP >500ng/L and receipt of IV diuretic within 24 hours of admission) and KDIGO-defined AKI during hospitalization were included. Advanced CKD (eGFR ≤15 ml/min/1.72m2) and those prescribed SGLT2i > 10 days after AKI were excluded. AKI recovery and death were compared between the exposed and unexposed cohorts using a time-varying Cox-regression analysis after adjusting for potential confounders.Results:In this retrospective cohort of 3599 individuals admitted with AHF that developed AKI during hospitalization, 293 patients received SGLT2i within the 10 days post-AKI. The median (IQR) time to AKI after admission was 24 (1.41-64.48) hours. 36.52% of the SGLT2i exposed had renal recovery pre-SGLT2i exposure. For the SGLT2i-exposed (pre-renal recovery) vs. unexposed groups, rates of 14-day renal recovery were not significantly different (adj. HR 0.99, 95% CI 0.82-1.19, p=0.90). However, the post-AKI SGLT2i-exposed group had a lower risk of death at 30 days (adj. HR 0.39, 95% CI 0.19-0.79, p=0.009) after adjustment for potential confounders.Conclusion:In a retrospective cohort of patients hospitalized with AHF with in-hospital AKI, exposure to SGLT2i within 10 days post-AKI was associated with decreased mortality and no significant delay in renal recovery.

Circulation, Volume 146, Issue Suppl_1, Page A15637-A15637, November 8, 2022. LongCovid or Post-Acute Sequelae of COVID-19 (PASC) is a diagnosis given to patients who experience a wide range of debilitating chronic symptoms after infection with SARS-CoV-2. The majority of individuals are PCR negative, indicating microbiological recovery. There are currently few LongCovid/PASC blood-based biomarkers. We used fluorescence microcopy to identify unique fibrin/amyloid micro-thrombosis and hyperactivated platelets in individuals with PASC. These fibrin/amyloid microclots may impede blood flow to tissue.Methods:Whole blood was collected in citrate tubes from 30 matched healthy subjects and 30 PASC subjects. Platelet poor plasma (PPP) was prepared by centrifugation and stored at -80 °C. PPP was then exposed to thioflavin T (ThT), a fluorescence marker known to bind to and open hydrophobic areas on damaged amyloidogenic protein. Samples were viewed with fluorescence microscopy using a 63x/1.4 Oil DIC M27 objective (excitation wavelength 450nm-488nm, emission 499nm- 529nm). After a double-trypsin PPP digestion method, proteomic analysis of the PPP samples was performed.Results:Significant microclot load was observed in the PPP of participants with PASC compared to healthy participants (Fig. 1). Proteomic analysis revealed the presence of inflammatory molecules within digested microclots.Conclusion:Preliminary results suggest that the presence of microclots in PPP may be used as a diagnostic biomarker for the PASC. Characterization of inflammatory molecules and antibodies trapped within microclots might provide insight into the pathogenesis of PASC and serve as a basis for novel treatment strategies or preventative medicine.Figure:Representative specimensA)Microclots in healthy plasma.B)Microclots in PASC plasma.

Circulation, Volume 146, Issue Suppl_1, Page A12375-A12375, November 8, 2022. Introduction:Patients presenting with acute chest pain may carry an increased risk of cardiovascular events even though myocardial infarction (MI) is excluded. Whether there are gender-related differences in the prognostic value of biomarkers in this patient population is unclear.Methods:We performed a post hoc analysis of the WESTCOR trial that included 1319 patients (779 male and 540 female) admitted with acute chest pain without MI. Biomarkers included peak high sensitivity cardiac troponin T (hs-cTnT), peak high sensitivity cardiac troponin I (hs-cTnI), N-terminal proB-type natriuretic peptide (NT-proBNP), growth differentiation factor 15 (GDF-15) and C-reactive protein (CRP), all from Roche Diagnostics. Cox regression analysis was performed for ln-transformed biomarkers in unadjusted models and models adjusting for age, hypercholesterolemia, current smoking, diabetes, hypertension, previous MI and eGFR