Risultati per: Sindromi coronariche acute

Circulation, Volume 146, Issue Suppl_1, Page A13774-A13774, November 8, 2022. Introduction:We aim to investigate the association between heart failure (HF) during hospitalization with acute coronary syndrome (ACS) and the long-term cancer risk.Methods:This prospective study included 571 patients admitted to 3 Italian hospitals and with ACS discharged alive and free from cancer. They were followed for 24 years or until death.Results:All except for three patients completed the follow-up, representing 6416 person-years. Patients’ mean age was 66 ± 12 years and 70% were males. Baseline clinical HF was diagnosed in 192 (34%) patients. During follow-up, 129 patients (23%) developed cancer; of them, 103 with no HF [27% of patients without HF] and 26 had baseline HF [14% of patients with HF].The incidence rates for cancer were 21 and 18 per 1000 person-years for patients without and with baseline HF, respectively (p = 0.61).The risks for cancer associated with HF were (HR: 0.96; 95% CI: 0.62-1.47; p=0.84). Similar associations were observed among men, women, and patients younger than 75 years of age. Yet, in patients older than 75 years the unadjusted risk was (HR: 0.30; 95% CI: 0.09-0.92; p=0.04). Although, the fully adjusted risk was (HR: 0.39; 95% CI: 0.12-1.30; p=0.13). The unadjusted HRs for cancer development were (HR: 0.88; 95% CI: 0.45-1.74; p=0.73) and (HR: 0.91; 95% CI: 0.48-1.71; p=0.77) for patient with HFrEF and HFpEF respectively.We observed a positive interaction between age and LVEF for the risk of cancer onset (HR: 1.002; 95% CI: 1.0003 -1.004; p=0.02) in the unadjusted model. Results were the same in fully adjusted model.Conclusions:This prospective study of unselected ACS patients showed a lack of association between clinical heart failure at admission for ACS and the long-term cancer risk. A positive independent interaction between age and LVEF for the long-term risk of cancer was also observed.Figure 1:Cumulative hazards of cancer according to HF status (A) and interaction between age and LVEF for the risk of cancer (B) 24-years after ACS.

Circulation, Volume 146, Issue Suppl_1, Page A10643-A10643, November 8, 2022. Introduction:Many patients with incident atrial fibrillation (AF) are diagnosed in the setting of a potentially transient precipitant. Despite substantial rates of AF recurrence and stroke in this population, prior registries and survey data suggest lower usage of oral anticoagulants (OAC). Here, we examined use of OAC on the basis of precipitated versus non-precipitated AF among patients enrolled in the VITAL-AF trial.Methods:VITAL-AF (clinicaltrials.gov NCT03515057) was a cluster randomized trial of 16 primary care practices evaluating point-of-care AF screening using single-lead ECGs among individuals aged ≥ 65 years (n=30,715). The primary outcome of newly diagnosed AF at one year occurred in 503 patients. For each incident AF event, we performed manual chart review to classify if diagnosis occurred in the setting of an acute precipitant, if the episode was transient, and if OAC was initiated. AF was considered transient if there was documented return to sinus rhythm within three months of initial diagnosis. OAC initiation required both evidence of a new prescription and corresponding provider documentationResults:Of the 503 cases of incident AF diagnosed during the VITAL-AF study period, 125 (24.9%) occurred in the setting of an acute precipitant. The mean age of patients with newly diagnosed AF was 78.3 ± 9.0 years, 46% were female, 11% were non-white, and the mean CHA2DS2-VASc score was 4.2 ± 1.6, which were similar between those with and without a precipitant. Patients with acute precipitants of AF were more likely to have transient episodes (94% vs 76%, p=0.001) and less likely to be started on OAC (60% vs 82%, 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 A227-A227, November 8, 2022. Introduction:Cardiac arrest (CA) survivors have significant impairments and poor functional outcomes at hospital discharge. We assessed if discharge disposition to acute inpatient rehabilitation after CA-related hospitalization is associated with improved functional recovery at 12 months relative to alternative acute care hospital discharge dispositions.Methods:Adults with the return of spontaneous circulation after in-hospital or out-of-hospital CA between 2/1/2016- 1/31/2020 admitted to intensive care units in a single tertiary care center were enrolled in an observational, prospective cohort study. A series of logistic regressions were used to assess acute inpatient rehabilitation associations with good functional recovery patterns, defined as persistent Modified Rankin Score (mRS) 0-2, or absence of any worsening of mRS at 12 months relative to discharge mRS. The model included demographics, individual and structural-level Social Determinants of Health, and pertinent clinical characteristics.Results:Of 201 included patients (24% Hispanic and 19% Black; average age 56±16 years; 40% women), 63% (n=127) reported good functional recovery pattern. Patients who went to acute inpatient rehabilitation were significantly more likely to experience good recovery pattern (54.3% vs 37.8% with poor recovery pattern, 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 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 A13636-A13636, November 8, 2022. Introduction:Postoperative acute kidney injury (AKI) is common after vascular surgery and is associated with increased morbidity and mortality.Hypothesis:It is hypothesized that patients with persistent postoperative AKI have increased complications, mortality and hospital cost.Methods:A single center retrospective cohort of patients undergoing non-emergent major vascular surgery (lower extremity bypass, endovascular and open aortic surgery), between 2014-2019 was analyzed. Development of postoperative AKI (defined as > 50% or 0.3 mg/dl increase in serum creatinine relative to reference after surgery and before discharge) was evaluated. Patients were divided into 3 groups: no AKI, non-persistent AKI (< 48 hours) and persistent AKI ( >48 hours). Multivariable regression analyses were then used to evaluate the association between AKI status and postoperative complications, 90-day mortality, and hospital cost.Results:A total of 1,881 patients undergoing 1,980 vascular procedures were included. Thirty five percent of patients developed postoperative AKI. Patients with persistent AKI were more likely to have longer ICU and hospital stays, as well as more mechanical ventilation days. In risk-adjusted logistic regression analysis, persistent AKI was a major predictor of 90-day mortality (OR 4.4, 95% CI 2.5-7.6). Risk-adjusted average cost was higher for patients with any type of AKI. The incremental cost of having any AKI ranged from $5,500-$12,400, even after adjustment for comorbidities and other postoperative complications. The risk-adjusted average cost for patients stratified by type of AKI was higher among patients with persistent AKI compared to those with no or non-persistent AKI (Fig.1).Conclusions:Persistent AKI after vascular surgery is associated with increased complications, mortality and cost. Strategies to prevent and aggressively treat AKI in the perioperative setting are imperative to optimize care for this population.

Circulation, Volume 146, Issue Suppl_1, Page A12429-A12429, November 8, 2022. Introduction:As Chimeric Antigen Receptor T cell (CAR-T) therapy gains advantage in the management of diffuse large B cell lymphoma (DLBCL), accumulating evidence shows that it frequently accompanies cardiac dysfunction. Previous retrospective studies indicated the potential involvement of cytokine release syndrome (CRS) in cardiac dysfunction after CAR-T therapy, but no prospective study has reported the time course of cardiac dysfunction and its association with prognosis. Purpose: To prospectively examine the sequential changes in cardiac markers over time after CAR-T therapy and to clarify their association between the grade of CRS, cardiac markers, and prognosis.  Methods:In this prospective study, 30 DLBCL patients who underwent CAR-T therapy were enrolled. Before and after the treatment, the level of cardiac biomarkers and echocardiographic index were sequentially collected. We classified all patients into two groups according to the severity of CRS after CAR-T therapy, namely Low-CRS group (CRS

Circulation, Volume 146, Issue Suppl_1, Page A14012-A14012, November 8, 2022. Introduction:Ischemic stroke (IS) or intracranial hemorrhage (ICH) has been reported during direct oral anticoagulant (DOAC) therapy. However, data regarding the DOAC level upon acute stroke is lacking.Hypothesis:The DOAC level upon acute IS or ICH may be associated with stroke outcomes.Methods:Patients aged ≥ 20 years, under DOAC therapy and developed acute ischemic or hemorrhagic stroke were enrolled. The DOAC level upon hospital arrival was measured with ultra-high-performance liquid chromatography with tandem mass spectrometry. The primary outcome was the composite outcomes included IS, ICH, major bleeding or death at 3 months. The secondary outcome included modified Rankin Scale (mRS) 0 to 3 at 3 months.Results:During 2018 to 2022, a total of 105 patients who developed IS and 26 patients who developed ICH during DOAC therapy were enrolled. Among the IS cohort, 45 (42.9%) had DOAC level

Circulation, Volume 146, Issue Suppl_1, Page A331-A331, November 8, 2022. Background:Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is one of effective therapeutic modalities for patients with cardiogenic shock (CS) and acute coronary syndrome (ACS). While VA-ECMO maintains end-organ perfusion, it increases damaged left ventricular (LV) wall tension. Combined treatment of VA-ECMO and a micro-axial Impella pump, referred to as ECPELLA, simultaneously provides systemic circulatory support and LV unloading. However, it remains unknown whether LV unloading effect on ECPELLA support further reduces mortality compared to currently available VA-ECMO+IABP support.Purpose:Investigate whether ECPELLA can reduce mortality in ACS patients with severe cardiogenic shock who required VA-ECMO.Methods:From January 2012 to May 2022, 100 consecutive patients with ACS and CS who received VA-ECMO before or after percutaneous coronary intervention were enrolled. Patients were divided into two groups; 39 patients in the ECPELLA; and 61 patients in the VA-ECMO with IABP. We assessed peak serum CPK-MB levels and 30-day mortality.Results:There were no significant differences in age, rate of male sex, coronary risk factors, ST-elevated ACS, left main trunk (LMT) lesion, multi-vessel disease (MVD), number of coronary lesions, extracorporeal cardiopulmonary resuscitation, and the time from onset to reperfusion between two groups. The ECPELLA had lower peak CPK-MB levels compared to VA-ECMO with IABP, but the difference did not reach statistical significance (p=0.056). Kaplan-Meier analysis revealed that the ECPELLA had significantly lower 30-day mortality (p=0.0016). Multivariable Cox proportional hazard analysis revealed that ECPELLA (HR: 0.22 95% confidence interval:0.11-0.45; 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 A11269-A11269, November 8, 2022. Introduction:There have been efforts to accurately measure adherence to ticagrelor to identify suboptimal medication therapy in the first year post-ACS as nonadherence during this crucial period is a major obstacle to optimizing clinical outcomes. Our study aims to examine ticagrelor adherence and persistence using different methods to better understand adherence patterns.Methods:We conducted a retrospective cohort study of patients aged ≥65 years who had filled a ticagrelor prescription within 7 days post-ACS discharge in Ontario, Canada between 4/2014-3/2018. We estimated mean proportion of days covered [PDC], the proportion of patients with “good” adherence of PDC≥80%, both at 1 year and the proportion of patients who were persistently taking ticagrelor at 1-year, using permissible gaps between prescriptions of 3, 7, 14 and 30 days.Results:There were 9,763 ticagrelor users (mean age 73.6; 65.4% men). The mean 1-year PDC (±SD) was 80.8±29.2, while only 73.0% of the cohort showed good adherence (PDC≥80%). Using a permissible gap definition of 14 days, only 55.7% of patients were persistent with ticagrelor in the year post-ACS. The 1-year persistence rates were as high as 62.6% with an allowable gap of 30 days and as low as 49.7% for a 7-day gap and 39.3% for a 3-day gap.Conclusions:Adherence and persistence estimates varied widely based on the definition used. While the PDC estimates implied reasonable 1-year ticagrelor adherence, PDC methods overestimated continuous use of ticagrelor, yet persistence methods with small gaps were likely too stringent. Readers of adherence and persistence studies should pay close attention to the methods and definitions used.

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

Circulation, Volume 146, Issue Suppl_1, Page A12220-A12220, November 8, 2022. Introduction:The clinical significance of right bundle branch block (RBBB) or bifascicular block (BFB) in the setting of ST-elevation myocardial infarction (STEMI) is uncertain. Informed by studies demonstrating higher rates of complete occlusion of the infarct-related artery in patients presenting with RBBB, the latest guidelines on STEMI management suggest patients with persistent ischemic symptoms and RBBB be considered for emergent coronary angiography. However, there has been little study of the prognostic implication of either RBBB or BFB in the setting of undifferentiated acute chest pain, and even less of the degree of ST-elevation in concomitant RBBB.Methods and Results:A total of 7626 patient encounters presenting to the Baylor St. Luke’s Medical Center between July 2018 and July 2020 with a chief complaint of “chest pain” were identified via electronic health record query. Of these encounters, 211 (2.8%) patients were found to have RBBB. Of that cohort, 18 (8.5%) presented with acute coronary syndrome, with STEMI accounting for 6 (2.8%), non-STEMI 9 (4.3%), and unstable angina 3 (1.4%). New or presumed new RBBBs were found in 59 (28%) of total RBBB patients, of which only 5 (8.5%) were found to have acute coronary syndrome and only 2 (3.4%) STEMI specifically. Similarly, 90 (42.7%) patients with chest pain and RBBB were found to have a BFB. New or presumed new BFBs were found in 40 (19%) patients, of which only 4 (10%) were also found to have acute coronary syndrome. No patients with new-onset BFB had STEMI. Furthermore, real-time diagnosis of anterior STEMI was complicated in two patients presenting with acute coronary syndrome by the masking of ST elevation in leads V1-3 by concomitant RBBB.Conclusions:In a large cohort of undifferentiated patients who presented with chest pain and RBBB or BFB (regardless if new or presumed new), only a small fraction had acute coronary syndrome, and even fewer STEMI. These data suggest patients with undifferentiated chest pain and RBBB on ECG with clinical suspicion for acute myocardial infarction and any degree of ST-elevation in leads V1-3 be considered for emergent coronary angiography rather than RBBB or BFB without ST-segment elevation.

Circulation, Volume 146, Issue Suppl_1, Page A11958-A11958, November 8, 2022. Introduction:Although there is robust evidence for the superiority of contemporary femoropopliteal (FP)-specific devices to traditional therapy using non-coated balloon or bare metal stent, cohesive reports on the incidence of acute thrombotic occlusion (ATO) after endovascular therapy (EVT) with contemporary FP devices are scarce. This study investigated the incidence of ATO and its predictors after contemporary FP-EVT for peripheral artery disease.Methods:We retrospectively examined 763 limbs (chronic limb-threatening ischemia [CLTI]: 44%, involving popliteal arterial lesion: 44%) in 644 patients (mean age: 75±9 years, male: 71%, hemodialysis: 34%) who successfully underwent EVT with contemporary FP devices (drug-coated balloon [DCB]: n=235, scaffold: n=528 [drug-coated stent: n=220, stent graft: n=158, drug-eluting stent: n=150]) from June 2012 to July 2020. The outcome measure was ATO defined as acute onset of claudication and/or signs of CLTI in combination with angiographic evidence of occlusive thrombus formation within the treated segment. Cox proportional hazards regression models were used to identify baseline characteristics associated with the incidence of ATO after contemporary FP-EVT.Results:The 24-month incidence of ATO in the overall population was 4.3±0.8% (DCB: 1.0±0.7% versus scaffold: 5.8±1.1%, P

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