Risultati per: Sindromi coronariche acute

Circulation, Volume 146, Issue Suppl_1, Page A13029-A13029, November 8, 2022. Introduction:Acute Myocardial Infarction (AMI) contributes to a significant cardiovascular related deaths in the general population. AMI is a life-threatening condition that occurs when the blood supply to the myocardium is abruptly cut-off due to blockage in coronary arteries resulting in tissue infarction. AMI is associated with high morbidity and mortality (up to 34-42%). We hypothesized that with recent advancements in reperfusion therapy and techniques for treating arrhythmias and pump failure, the mortality rates might show downward trends.Methods:In this retrospective observational study, death certificate data was retrieved from the Center for Disease Control and Prevention’s Wide-Ranging Online Data for Epidemiological Research (WONDER) database from 2001 to 2020. WONDER database identifies the underlying cause of death. Mortality for AMI including anterior, posterior, inferior wall, or unspecified (ICD-10 121.0; 121.1; 121.2; 121.3; 121.4; 121.9) as an underlying cause of death was queried from 2001 to 2020. This study duration was further divided into five-year periods. Crude mortality rate and age-adjusted mortality rate per 100,000 deaths (with a 95% confidence interval) were calculated for four U.S. census regions to explore regional variations (CR-1 Northeast; CR-2 Midwest; CR-3 South; CR-4 West).Results:The overall age-adjusted mortality rate (AAMR) decreased from 58.0 to 27.1 per 100,000 deaths (53.5%) in the years 2001-2005 to 2016-2020 as illustrated in the figure 1. AAMR showed a comparable downward trend in all 4 U.S. census regions (Figure 1).Conclusions:From 2001 to 2020 AAMR showed a downward trend which may indicate an improvement in AMI patient care with evolving guidelines based therapeutic interventions. Limitations of this study include intrinsic weakness of the WONDER dataset (Changes with ICD-9 to ICD 10 codes, and potential miscoding) which may need further discovery.

Circulation, Volume 146, Issue Suppl_1, Page A11306-A11306, November 8, 2022. Introduction:Adherence is often measured using proportion of days covered (PDC), where the single average PDC that is estimated conceals the heterogeneity of the adherence patterns, each of which may require unique solutions. Novel group-based trajectory methods allow one to distinguish subgroups of adherence patterns. We examined the magnitude of variation in PDC estimates in these subgroups.Methods:We conducted a retrospective cohort study of patients aged ≥65 years who had filled ticagrelor within 7 days post-ACS discharge in Ontario, Canada between 4/2014-3/2018. Longitudinal patterns of adherence were measured using group-based trajectory models over 1 year and compared with traditional adherence metrics using PDC for the entire cohort and for each trajectory group.Results:We identified 9,764 ticagrelor users (mean age 73.6; 65.4% men). Three distinct trajectory patterns of ticagrelor adherence were identified: a consistently adherent, a gradually nonadherent, and a rapidly nonadherent group, comprising 67.8%, 17.1% and 15.1% of the cohort, respectively. The 1-year mean PDC (±SD) was 80.8±29.2 for the whole ticagrelor post-ACS cohort. After differentiating by adherence trajectory group, mean PDC (±SD) was 97.4±4.5 % in the consistently adherent, while it was 69.1±15.6% and 20.2±11.6 over 1 year in the gradually and rapidly non-adherent trajectory groups, respectively.Conclusions:The overall ticagrelor adherence of ~80% 1-year post-ACS instills a false sense of comfort. The 3 distinct trajectory groups revealed divergent patterns not reflected by this overall mean estimate. The two-thirds of patients who were consistently adherent maintained nearly perfect ticagrelor adherence, while the rapidly non-adherent group only took ticagrelor on average for 2.5 months of the year. The trajectory method approach allows us to distinguish adherence subgroups, and better identify patients at risk of nonadherence who need targeted interventions.

Circulation, Volume 146, Issue Suppl_1, Page A12208-A12208, November 8, 2022. Introduction:The marked rise in left ventricular (LV) filling pressure (ie., pulmonary capillary wedge pressure [PCWP]) during exercise and its association with adverse prognosis in patients with heart failure with preserved ejection fraction (HFpEF) has stimulated interest in therapies to decrease LV filling pressures. Although reducing LV filling pressure may improve exercise hemodynamics, this may also reduce pulmonary perfusion (Qc) and increase ventilation-perfusion (V/Q) mismatch, manifesting as an increase in ventilatory inefficiency during exercise (ie., slope of the ventilation [V̇E] and carbon dioxide elimination [V̇CO2] relationship), which is a strong prognostic indicator of adverse outcomes in heart failure.Hypothesis:Reducing PCWP via acute nitroglycerin (NTG) treatment would increase the V̇E/V̇CO2slope when compared with a placebo treatment in patients with HFpEF.Methods:26 subjects were evaluated (age: 69±5y; BMI: 39.5±7.1kg/m2; V̇O2peak: 1.39±0.46L/min; 16 women/10 men). All subjects performed a six-minute constant-load cycling test at 20W with placebo or NTG treatment. PCWP was measured via a right-heart catheter, arterial blood gases were measured via a radial artery catheter, Qc was measured via direct Fick, and pulmonary gas exchange was measured via a customized breath-by-breath metabolic system. The V̇E/V̇CO2slope was calculated as the relation between the rest-to-20W change in V̇Eand the rest-to-20W change in V̇CO2.Results:PCWP decreased with NTG at 20W (placebo: 20.8±5.8 vs. NTG: 16.4±5.1 mmHg, p=0.001). Qc also decreased with NTG at 20W (placebo: 8.69±1.84 vs. NTG: 8.26±1.87 L/min, p=0.01). In contrast, the V̇E/V̇CO2slope increased with NTG (placebo: 37.5±5.8 vs. NTG: 39.6±7.0, p=0.01).Conclusions:These findings suggest that reducing LV filling pressure increases ventilatory inefficiency, possibly due to an increase in V/Q mismatch caused by a reduction in pulmonary perfusion. Since therapies to decrease LV filling pressure have gained considerable interest to improve exercise hemodynamics in HFpEF, further investigation is required to determine the clinical consequences of ventilation-perfusion mismatch and ventilatory inefficiency caused by a reduction in PCWP in these patients.

Circulation, Volume 146, Issue Suppl_1, Page A14255-A14255, November 8, 2022. Background:Ticagrelor, a potent P2Y12 inhibitor, was superior to clopidogrel in preventing mortality post acute coronary syndrome (ACS) without a major safety concern in the PLATO trial. Nevertheless, the real-world evidence of ticagrelor post ACS is conflicting and inconclusive. Therefore, we conducted a meta-analysis to assess the effectiveness and safety of ticagrelor versus clopidogrel post ACS using real-world data.Methods:We performed a meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched PubMed to identify observational studies exploring the effectiveness and safety of ticagrelor and versus clopidogrel in ACS until 12/01/2022. Two independent reviewers assessed the quality and risk of bias of the included studies. A random-effect model was used to combine data. Effectiveness outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction (MI), and stent thrombosis. Safety outcomes included major bleeding, gastrointestinal (GI) bleeding, and dyspnea.Results:A total of 26 observational studies comparing ticagrelor to clopidogrel post ACS were included. Compared to clopidogrel, ticagrelor significantly reduced all-cause mortality (odds ratio [OR], 0.68 [95% CI, 0.58-0.81], I2= 78%)) and cardiovascular mortality (OR, 0.64 [95% CI, 0.48-0.85], I2= 78%). Whereas there was no statically significant difference between ticagrelor and clopidogrel in MI and stent thrombosis (OR, 0.92 [95% CI, 0.81-1.05] I2=56%) and (OR, 0.61 [95% CI, 0.23-1.66], I2= 89%), respectively. Ticagrelor was associated with significantly higher major bleeding incidence (OR, 1.21 [95% CI, 1.06-1.39], I2=52%). However, GI bleeding and dyspnea were not significantly increased with ticagrelor use.Conclusions:Real-world data of ticagrelor use post ACS demonstrated that ticagrelor reduced all-cause mortality and cardiovascular mortality in comparison to clopidogrel. However, it was associated with increased major bleeding. Real-world evidence with long follow-up confirming the safety of ticagrelor in comparison to clopidogrel post ACS demonstrated in controlled trials is warranted.

Circulation, Volume 146, Issue Suppl_1, Page A15618-A15618, November 8, 2022. Introduction:Several studies have described trends toward increasing complexity and illness-severity of patients admitted to the cardiac intensive care units (CICU). This has necessitated the development of training pathways in critical care cardiology (CCC). Hybrid training in combinations of interventional cardiology (IC), advanced heart failure and transplant cardiology (AHFTC), and CCC have also gained interest. This review sought to outline current and proposed pathways for hybrid training in acute cardiovascular care.Methods:We performed a systematic review of articles describing training pathways for dual certification in CCC, as well as hybrid models for training in a combination of IC, CCC, and AHFTC. PubMed, EMBASE, and CINAHL were searched from 01/01/2000 to 04/28/2022. Pathways through pediatric and adult non-internal medicine specialties were excluded.Results:Of 2,236 citations, 18 studies were included in the final analysis. Most pathways included sequential CCC training, i.e. traditional cardiovascular fellowship and 1-2 additional years of critical care medicine, although integrated 4-year programs were noted to be emerging. Hybrid models for advanced training in two or more complementary subspecialties, including CCM, AHFTC, and IC, have been described, each with their own strengths and limitations. Additional expertise in advanced therapies such as mechanical circulatory support, the longitudinal AHFTC practice, and the combination of procedural and intensivist skills for management of diseases such as acute coronary syndromes were the stated benefits of these combined models. Alternatively, some advocate for incorporating focused CC training into a single year of IC or AHFTC fellowship. However, this may limit the time required to gain expertise in all areas of advanced training and is insufficient for board certification in CCM.Conclusion:Despite the growing need, there are limited dedicated pathways to train the contemporary acute care cardiologists. Further study is needed to consolidate training to encourage the growth and development of this field.

Circulation, Volume 146, Issue Suppl_1, Page A9886-A9886, November 8, 2022. Introduction:Pancreatic cancer (PC) has induced a higher risk of a hypercoagulable state that can further lead to various complications such as Acute Myocardial Infarction (AMI). There is a lack of data on the outcomes of PC patients following an episode of AMI.Method:A retrospective analysis was performed via the 2019 National Inpatient Sample (NIS). We identified a principal diagnosis of AMI and a diagnosis of PC (ICD-10 ‘C25.x’) at any level. Patient characteristics (sex, race, diabetes, mean age, hypertension, hyperlipidemia, and smoking history) were compared, and the risk of mortality in PC patients was estimated via multivariable regression analysis.Results:In total, 555 (0.1%) PC cases were found among all hospitalized cases of AMI in the United States in 2019. We also found that 63.1% were males, 46.8% had diabetes, 85.6% had hypertension, 58.6% had hyperlipidemia, 45.9% reported a smoking history, and 73.0% were Whites. Among the PC patients, 120 (22.4%) patients underwent PCI. Unfortunately, 65 (11.7%) patients with PC died (aOR 2.595, 95% CI 1.995-3.375, p

Circulation, Volume 146, Issue Suppl_1, Page A13934-A13934, November 8, 2022. Introduction:Although a higher protein intake has been related with lower mortality rates in general population, the association between protein intake and nutritional status/mortality in patients with acute heart failure has yet to be clarified.Methods and Results:We retrospectively analyzed 694 patients who were admitted due to acute heart failure in our hospital (mean age, 75±13 years; male 60%). The estimated protein intake was defined as a validated formula: [13.9 + 0.907*body mass index (kg/m2) + 0.0305*urinary urea nitrogen level (mg/dL)] using spot urine samples on admission. All patients were divided into three groups according to the estimated protein intake: low (≤43.6 g/day, n=232), middle (43.7 to 51.5 g/day, n=231), and high (≥51.6 g/day, n=231) group. The primary outcome of this study was regarded as all-cause mortality. Patients with low protein intake were older and had lower albumin compared with other two groups. A lower protein intake was associated with worse nutritional status evaluated using Geriatric Nutritional Risk Index (P

Circulation, Volume 146, Issue Suppl_1, Page A15435-A15435, November 8, 2022. Introduction:Women are less likely than men to be promptly diagnosed with acute coronary syndrome (ACS) and have worse post-ACS outcomes. These diagnostic failures are partially due to ACS findings on surface ECG manifesting differently in women, which may result in unnecessary delays in treatment. To narrow health disparities, we aim to investigate the sex-specific signatures of ACS as they appear on ECGs.Methods:This was a prospective observational cohort study of chest-pain patients evaluated for suspected ACS at 3 UPMC-affiliated tertiary care hospitals. After featurization, all ECG data were separately fed into 7 machine learning classifiers to predict ACS. We examined the results by sex. We also investigated two other methods: (1) building two independent models based respectively on the female and male subgroups and (2) building a model based on the initial total sample supplemented by the patients’ sex. We used Shapley values to explain the decision-making criteria of the models. We report the results for random forest, the best performing classifier.Results:Our sample consisted of 4132 patients (Age 59 ± 16; 47% female; 15% ACS). Machine learning models continue to disproportionately underperform in females across all classifiers evaluated. The sensitivity, specificity and false negative rate in the global model blinded to sex were 82.89%, 76.22% and 17.11% for men, and 67.39%, 74.16% and 32.61% for women (p

Circulation, Volume 146, Issue Suppl_1, Page A13784-A13784, November 8, 2022. Introduction:We investigated recurrent events following acute coronary syndrome (ACS) at our large integrated healthcare systemMethods:We performed a retrospective study of 4,898 patients treated for ACS within the Geisinger Health System between 2015-2021. Data was obtained via programmatic extraction from the electronic health record. The primary outcome was a composite of patients experiencing at least one major adverse cardiovascular event (MACE) in the follow-up period: ACS, coronary revascularization, or cerebrovascular. Descriptive statistics for MACE and prescription medications were performed.Results:Median length of time in the study was 2.6 years. Guideline directed medical therapies (GDMT) were >95% for aspirin, beta-blockers and high intensity statin and 88% for P2Y12 inhibitors. Despite this high level of care, 970 (19.8%) patients met the composite primary outcome with an incidence of 11.8 events/100 patient-years. During the study period, 6.6% of patients experienced a subsequent ACS event, 13.7% underwent revascularization and 5.9% had a cerebrovascular event; 4.7% of patients experienced 2 or more MACE events during the follow-up period.Conclusions:This data shows that the incidence of recurrent MACE after an initial ACS remains high despite GDMT. Identification of patient characteristics portending elevated residual risk and institution of therapies directed at these patients requires further study.

Circulation, Volume 146, Issue Suppl_1, Page A14147-A14147, November 8, 2022. BackgroundAcute pulmonary embolism (PE) is associated with an increased risk of short- and long-term mortality. Since interventricular septal systolic function contributes to a third of right ventricular (RV) cardiac output, we sought to investigate the potential value of septal strain in PE.MethodsThis was a retrospective cohort study of patients admitted with acute pulmonary embolism. Patients underwent echocardiography during admission and included left ventricular (LV) speckle tracking, by which global longitudinal strain (GLS) and regional strain were acquired. Multivariable adjustments were made for age, sex, simplified PE index (sPESI), abnormal cardiac biomarkers (troponin or proBNP) and RV systolic function. The endpoint was all-cause death.ResultsThe cohort consisted of 186 patients (mean age 68 years, 54% men), of whom 49 (26%) died during a median follow up of 3.5 years (IQR: 2.9-6.7 years). All LV systolic measures were univariable predictors of death (LVEF: HR: 1.04 (1.02-1.06), per 1% decrease; GLS: HR: 1.15 (1.07-1.22), per 1% absolute decrease; septal strain: HR: 1.15 (1.08-1.23), per 1% absolute decrease] (figure). RV systolic function was also associated with death [TAPSE: HR: 1.06 (1.01-1.12), per 1mm decrease). After multivariable adjustments, only septal strain remained significantly associated with outcome (HR: 1.09 (1.01-1.19), p=0.029, per 1% absolute decrease).Furthermore, septal strain significantly increased C-statistics when added to a base model of sPESI score, abnormal biomarkers and presence of hypotension (base model C-stat: 0.76; base model and septal strain C-stat: 0.83, p for increment = 0.006).ConclusionSeptal strain is associated with death in acute PE and provides prognostic information beyond conventional risk assessment.

Circulation, Volume 146, Issue Suppl_1, Page A13945-A13945, November 8, 2022. Introduction:Patients without standard modifiable cardiovascular risk factors (SMuRF; hypertension, diabetes, hypercholesterolaemia, smoking) have worse outcomes in Type 1 acute myocardial infarction (AMI). The relationship between type 2 AMI (T2AMI) and outcomes in patients with and without SMuRF is unknown. This study aimed to determine the prevalence, characteristics and clinical outcomes of patients hospitalized with T2AMI based on the presence of SMuRF.Methods:All hospitalizations with a primary discharge diagnosis of T2AMI in the National Inpatient Sample were stratified according to SMuRF status (SMuRF and SMURF-less). Primary outcome was all-cause mortality while secondary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE), major bleeding and ischemic stroke. Multivariable logistic regression was used to determine adjusted odds ratios (aOR) with 95% confidence intervals (95% CI).Results:Among 17,595 included hospitalizations, 1,345 (7.6%) were SMuRF-less. After multivariable adjustment, SMuRF-less patients were more likely to develop all-cause mortality (aOR 2.43, 95% CI 1.83 to 3.23), MACCE (aOR 2.32, 95% CI 1.79 to 2.90) and ischaemic stroke (aOR 2.57, 95% CI 1.56 to 4.24) compared to their SMuRF counterparts (Figure 1).Conclusions:T2AMI in the absence of SMuRF was associated with worse in-hospital outcomes compared to SMuRF-less patients. Further longitudinal studies are necessary to define the impact of SMuRF on longer term T2AMI outcomes.

Circulation, Volume 146, Issue Suppl_1, Page A14076-A14076, November 8, 2022. Introduction:Cardiac magnetic resonance (CMR) provides rich data on myocardial function, including indices such as strain, as well as tissue characterization. There is no published data on these values within 2 weeks of the diagnosis of myocarditis. We sought to describe these findings in children with acute myocarditis who underwent CMR early after presentation and determine relationships between these values.Methods:We retrospectively reviewed the clinical and imaging data of patients

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 A11951-A11951, November 8, 2022. Introduction:Cardiac contractility modulation (CCM) is a medical device therapy whereby non-excitatory electrical simulations are delivered to the myocardium during the absolute refractory period. We previously evaluated the effects of the standard CCM pulse parameters in isolated rabbit ventricular cardiomyocytes and 2D human induced pluripotent stem cell-derived cardiomyocyte (hiPSC-CM) monolayers, on flexible substrate.Hypothesis:In the present study, we sought to extend these results to 3D microphysiological systems to develop a human-based model to evaluate various clinical CCM pulse parameters in vitro.Methods:HiPSC-CMs were studied in conventional 2D monolayer format, on stiff substrate (i.e., glass), and as 3D human engineered cardiac tissues (ECTs). Cardiac contractile properties were evaluated by video-based analysis and custom force analysis. CCM pulses were assessed at varying clinical ‘doses’ using a commercial pulse generator. Robust response was observed at physiological Ca concentrations [1.8 mM] for 3D ECTs.Results:Under standard acute CCM stimulation 3D ECTs displayed enhanced contractile properties including increased peak contraction amplitude (i.e., force), and faster contraction and relaxation kinetics. Moreover, 3D ECTs displayed enhanced contractility in a CCM pulse parameter dependent manner. The observed effects subsided when the acute CCM stimulation was stopped and gradually returned to baseline. Under comparable conditions, conventional 2D monolayer hiPSC-CMs, on stiff substrate, displayed neutral response.Conclusions:These data represent the first study of acute CCM stimulation in a 3D hiPSC-CM model and provides a preclinical model to assess various CCM signals in human cardiac tissues prior to in vivo animal studies.

Circulation, Volume 146, Issue Suppl_1, Page A12393-A12393, November 8, 2022. Introduction:The American Heart Association and European Society of cardiology guidelines reclassified heart failure according to left ventricular ejection fraction, recognizing patients with mid-range EF (mrEF; 40% to 49%) as a distinct group. However, studies on the clinical characteristics of mid-range EF patients and the occurrence of cardiovascular events in acute MI patients are insufficient.Methods:We categorized 6,553 patients with acute myocardial infarction (AMI) from the Korea AMI-National Institutes of Health between November 2011 and December 2015 into three groups (reduced EF ; LVEF < 40% at admission, mild-reduced EF ; LVEF 40 to 49%, preserved EF ;LVEF ≥50%). The primary endpoint was defined as any death at two-year. Secondary endpoints were defined as any myocardial infarction, any revascularization, patient-oriented composite outcome(POCE).Results:Compared to patients with other two groups, the reduced EF group had a highest overall mortality, POCE, and any MI (24.7% vs 8.3% vs 4.6%, p < 0.0001, 33.0% vs 15.6% vs 12.4%, p

Circulation, Volume 146, Issue Suppl_1, Page A9885-A9885, November 8, 2022. Introduction:Atrial septal defect (ASD) is one of the most common congenital cardiac defects. It can also allow paradoxical emboli to move into the cerebral vasculature leading to Acute Ischemic Stroke (AIS). As there is a lack of adequate information on the additional risk factors for mortality in ASD patients following AIS, we queried the largest inpatient database in the United States for answers.Methods:Patients with ASD were identified among patients of ages 25 and more admitted with a principal diagnosis of AIS ICD-10 code (I63.x) in 2019 from the National Inpatient Sample(NIS). Various patient characteristics and procedures were also studied. A Multivariate regression model adjusting for several factors allowed our study to further evaluate potential risk factors for mortality among ASD patients.Results:Our study found 551,385 cases of AIS, amongst which 19,670 (3.6%) also had a diagnosis of ASD. ASD patients had a higher risk of requiring mechanical thrombectomy (aOR 1.239, 95% CI 1.167- 1.316, p