Risultati per: Sindromi coronariche acute

Circulation, Volume 146, Issue Suppl_1, Page A10445-A10445, November 8, 2022. Background:The purpose of this study is to evaluate the role of viability on PET-MRI to predict improvement of echocardiographic findings such as regional wall motion index and left ventricular ejection fraction after successful percutaneous coronary intervention (PCI) for patients with acute myocardial infarction (AMI).Method:A total of 154 patients with AMI who was performed cardiac PET/MRI within 7 days after PCI were enrolled were enrolled. We performed TTE twice before and after in We performed TTE twice before and after PCI in 103 patients. We categorized these patients according to presence of viability on PET-MRI: group A (N=53, patients with viability on PET-MRI) and group B (N=50, patients without viability on PET-MRI) and compared. The primary end point is improvement of regional wall motion abnormality (RWMA) on TTE.Results:Clinical and angiographic findings were similar between the two groups during follow-up of 11months. Among 53 patients in group A, 30 patients (56.6%) showed the result of slight improvement of RWMA on TTE and among them 13 patients (24.5%) showed result of disappeared RWMA on TTE. In contrast, among 50 patients in group B, 22 patients (44%) showed the result of slight improvement and among them, only 4 patients (8%) showed result of disappeared RWMA on TTE. The proportion of patients who showed slight improvement of RWMA between two groups are not statistically significant (p=0.201). But, the proportion of patients who showed disappeared RWMA between two groups are statistically significant (p=0.024).Conclusions:PET/MRI is useful tool to detect viability in patients with AMI. It seems to be predictable to improve cardiac function for the patients with viability on PET-MRI.

Circulation, Volume 146, Issue Suppl_1, Page A9689-A9689, November 8, 2022. Objectives:To compare the efficacy peripheral intravenous (IV), central IV, and intracoronary (IC) administration of epinephrine in acute myocardial infarction (AMI) patients with cardiac arrest in the cath lab.Methods:Prospective, two-center cohort pilot study of AMI patients with cardiac arrest in the cath lab. Patients who received mechanical circulatory support, primary fibrinolysis, anti-arrhythmic/vasopressors prior to cardiac arrest, or those with prior CAD or a cardiac arrest that lasted < 60 seconds were excluded. Outcomes included return of spontaneous circulation (ROSC), stent thrombosis, and survival-to-discharge with a favorable neurological outcome.Results:158 patients were enrolled (Table 1). After adjusting for age and initial cardiac rhythm, the peripheral IV route had 5.5-fold lower odds (OR: 0.18, 95% CI: 0.07-0.49,p= 0.0007) of achieving ROSC compared with the central IV route, while the IC route had a similar odds compared to the central IV route (p= 0.9516). Among those who achieved ROSC, the IC route had a higher odds for stent thrombosis compared to the central IV route (OR: 5.7, 95% CI: 1.9-17.2,p= 0.0022), but not the peripheral IV route (p= 0.1277). The adjusted odds of achieving survival-to-discharge with a favorable neurological outcome were higher in the IC route compared to the peripheral IV route (OR: 7.8, 95% CI: 2.2 – 27.0,p= 0.0013), and similar in the IC and central IV routes (p= 0.0585) (Table 2).Conclusions:Epinephrine administration via central IV has a higher odds achieving ROSC than via peripheral IV and a lower odds of stent thrombosis than via the IC route in patients with AMI who suffer from cardiac arrest during PCI.

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 A10267-A10267, November 8, 2022. INTRODUCTION:Haemorrhagic stroke (HS) is an important cardiovascular cause of mortality worldwide. In Australia, long term temporal trends in HS hospitalisation rates and predictors of mortality are unknown.Methods:All New South Wales residents with first-ever HS from 2002-2017 were identified from the Centre-for-Health-Record-Linkage statewide databases. Mortality tracked to 31 Dec 2018 via the death registry were adjusted for age, sex, admission year, referral source, surgical evacuation of HS status, and comorbidities in multivariable regression analyses.Results:There were 35433 patients (51% male) admitted for HS. Age-adjusted mean (±SD) admission rates were higher for males than females (63.6±6.2 vs 49.9±4.4 admissions-per-100,000-persons-per-annum respectively, p

Circulation, Volume 146, Issue Suppl_1, Page A12866-A12866, November 8, 2022. Introduction:Myeloproliferative neoplasms (MPNs) are clonal stem cell neoplasms associated with increased thrombotic risk. However, long-term outcomes after acute coronary syndrome (ACS) and identification of MPN-specific risk factors have not been characterized.Methods:Single-center, retrospective cohort of patients with MPN admitted for ACS from 2000 to 2020 (n = 41). Primary outcomes were major adverse cardiac events (MACE) and bleeding. MACE was composite of cardiovascular (CV) death, myocardial infarction, ischemic stroke, and heart failure (HF) hospitalization. Patients with and without MACE and bleeding were compared to identify risk factors; univariable and multivariable Cox proportional hazards and competing-risk regression models were used.Results:Patient characteristics described in Table 1. After a median follow-up of 80 months, 28 patients had MACE and 14 experienced bleeding. Patients with MACE had shorter median time to index ACS event (35 mos vs 76) and higher rates of JAK2 mutation (82% vs 54%), history of HF (46% vs 15%), and median white blood cell count (WBC, 13 vs 8) at index event compared with patients without MACE. Patients with bleeding had higher rates of JAK2 mutation (93% vs 63%) and WBC (17 vs 10), and lower hydroxyurea use (50% vs 85%) compared with patients without bleeding. Cox and competing-risk regression results in Table 2.Conclusions:Patients with MPN and ACS are at high risk of MACE and bleeding. JAK2 mutation and elevated WBC count (≥ 20 K/μL) at time of index ACS were associated with MACE and bleeding. ACS event occurring within 12 months of MPN diagnosis was associated with MACE. Larger studies are needed to confirm our results.

Circulation, Volume 146, Issue Suppl_1, Page A9391-A9391, November 8, 2022. Acute myocardial infarction (AMI) is related to rupture of atheroma plaques containing pro-inflammatory cytokines, oxidized low-density lipoprotein (oxLDL) and MMP9, a microenvironment compatible with the presence of a pathogenic microbial community. Recently, infectious extracellular vesicles (iEVs) were discovered to be released in co-infections. Previously, we found iEVs positive for archaea DNA andMycoplasma pneumoniae(Mp) antigens in vulnerable plaques. Now, looking for serum particles biomarkers to differentiate atherosclerotic clinical outcomes we studied 168 patients (pts) from groups: Atherosclerotic (ATR), AMI, AMI with major severity (sAMI) and healthy (CTL)Methods:We quantified and characterized serum iEVs (0.79-1.34μm) through their content using theFlow Cytometrytechnique and for cytokines using CBA kit, for exosomes (

Circulation, Volume 146, Issue Suppl_1, Page A11336-A11336, November 8, 2022. Introduction:Acute myocardial infarction (AMI) is a leading cause of death in the US. More than 800,000 adults experience an AMI each year, and up to 20% of the patients are rehospitalized within 30 days. Predicting 30-day readmission accurately could help clinicians identify high-risk patients and tailor treatment accordingly.Hypothesis:The neural network will generate the best performing model for predicting 30-day readmissions following an AMI.Methods:The cohort included adults hospitalized with incident AMI (6,506) at Dartmouth Hitchcock Medical Center between 2011-2016. Patients who died before discharge (236) were excluded, leaving 6,270 patients. Our outcome was 30-day hospital readmissions. Candidate features were selected using an Extra Tree Classifier. Selected features included demographics and clinical characteristics. Multiple imputation using K-Nearest Neighbors was performed. Five machine learning models were implemented: logistic regression, LASSO, neural network, random forest, and XGBoost. Models were evaluated on a hold-out test-set, using AUROC.Results:Among the cohort, about 36% were female, the majority were white and non-Hispanic, and the 30-day readmission rate was 6.2%. Neural network was the best performing model with an AUROC of 0.80 (95% CI: 0.75, 0.84). However, the XGBoost and random forest models performed similarly with AUROCs of 0.80 (95% CI: 0.76, 0.85) and 0.79 (95% CI: 0.75, 0.84), respectively. The logistic regression and LASSO models performed poorly, with AUROCs below 0.5, respectively. Important predictor variables were major depression, race, and antidepressant at discharge.Conclusions:Neural network, random forest, and XGBoost models predicted 30-day readmission following an AMI with good performance. Across these models, depression was an important feature for predicting 30-day readmissions. Results reinforce the importance of mental health among patients hospitalized for AMI.

Circulation, Volume 146, Issue Suppl_1, Page A12162-A12162, November 8, 2022. A 68 year old female with hyperlipidemia and tobacco use presented with acute, substernal, chest pressure that occurred during yard work. She had no prior history of coronary artery disease or stable angina. Electrocardiograms (ECG) did not have ischemic changes but high sensitivity troponin was elevated at 285 ng/L and peaked at 1308 ng/L. Therapy was started for acute coronary syndrome and nitroglycerin drip for continued discomfort. Echocardiogram showed ejection fraction of 61% and akinesis of the infero-septum at the mid-ventricle. Coronary angiogram showed diffuse narrowing of the large first septal branch artery (S1) concerning for coronary intramural hematoma. No other significant coronary artery disease was present. Cardiac magnetic resonance (CMR) confirmed hypokinesis of the septum and subendocardial delayed enhancement in the interventricular septum at the mid ventricle suggestive of an isolated septal perforator infarct. She was conservatively managed and discharged 48 hours later. Four days later she had recurrent chest pressure and was re-admitted. Her ECG showed J-point elevation in the anteroseptal leads. Repeat coronary angiogram showed unchanged type 2 spontaneous coronary artery dissection of S1 and a small coronary cameral fistula between the distal septal branch and the right ventricle. The diagnosis of spontaneous coronary artery dissection of the first septal branch is rare and may be missed on angiogram. CMR in addition to invasive coronary angiography aides in the evaluation of this rare cause of acute myocardial infarction and changes clinical management decisions including observation time and evaluation for fibromuscular dysplasia.

Circulation, Volume 146, Issue Suppl_1, Page A12945-A12945, November 8, 2022. Background:Non-alcoholic liver disease (NAFLD) is among leading causes of chronic liver disease. Recent evidence suggests an association of NAFLD with cardiovascular diseases; however, few studies have analyzed national level database for this relationships. We aimed to assess the trends and predictors of acute myocardial infarction (AMI) among NAFLD patients in the United States.Methods:The National Inpatient Sample (NIS) database from 2016 to 2019 was queried using international classification of disease (ICD-10) diagnostic codes to identify patients with primary diagnosis of NAFLD and secondary diagnosis of AMI. Basic demographic variables were analyzed to determine the disparities in prevalence of AMI among NAFLD patients. Univariate logistic regression model was used to compare the odds of development of AMI among NAFLD patients using demographic characteristics. Multivariate logistic regression analysis was done to determine whether NAFLD is an independent predictor of AMI.Results:A total of 58,519 patients had a diagnosis of NAFLD and of these, 5,448 had AMI. Of these, 61% were males, 82% were aged 50 years and over, 68% were white, 8% Black, 16% Hispanic, Asian or Pacific Islander. Females were less likely to have AMI [OR 0.46, 95% CI 0.43-0.48]. Patients

Circulation, Volume 146, Issue Suppl_1, Page A10073-A10073, November 8, 2022. Introduction:With the increasing burden of Acute Myocardial Infarction(AMI) on Medicare, there is a paucity of information on the incidence of Acute Ischemic Stroke(AIS) in those patients and their risk factors.Methods:Patients with a principal diagnosis of AMI covered by Medicare from the 2019 National Inpatient Sample were extracted. Multiple variable regression allowed us to estimate the adjusted odds ratio (aOR) of AIS among patients while acknowledging various possible factors.Results:A total of 378,390 cases of AMI covered by Medicare were found, amongst which 6110 patients,1.6%, also experienced AIS. The mean age of AIS cases was 75.34 years, while it was 74.31 years in non-AIS patients. Patients with AMI are more likely to have a diagnosis of AIS during their hospitalization if they are females (aOR 1.195, 95% CI 1.134-1.260, p

Circulation, Volume 146, Issue Suppl_1, Page A12969-A12969, November 8, 2022. Introduction:Disparities in healthcare outcomes are well described among patients of different races and ethnicities including pediatric cardiology. Multicenter studies examining these outcomes are lacking in pediatric acute care cardiology. We hypothesize that Black and Hispanic patients admitted to pediatric acute care cardiology units have increased hospital and acute care encounter length of stay (LOS) and complication rates compared to their White and non-Hispanic peers.Methods:Utilizing the Pediatric Acute Care Cardiology Collaborative registry, we examined all acute care cardiology unit encounters from 2/1/2019 to 7/30/2021 ending in discharge to home or death. Hospitalizations were categorized by race and ethnicity. In-hospital complications included health-care acquired infections, iatrogenic incidents, pneumonia, sepsis, seizures and stroke. Data were analyzed for differences in LOS and complication rates using chi-square and ANOVA testing. We used Bonferroni correction to establish a significance threshold of 0.007.Results:Analysis included 30,404 hospitalizations from 29 centers. There were 16,233 White (70%), 4,533 Black (19%), 919 Asian (4%) and 1,629 other races (7%) encounters. There were 23,592 (78%) non-Hispanic and 4,583 (15%) Hispanic encounters. Black patients had higher rates of premature birth (21.4%) and low birth weight (10.7%), compared to White patients (15.6% and 5.9% respectively, p

Circulation, Volume 146, Issue Suppl_1, Page A14759-A14759, November 8, 2022. Introduction:Donor-derived cell-free DNA (%ddcfDNA) is a reliable non-invasive biomarker of acute rejection (AR). High-sensitivity cardiac troponin T (hs-cTnT) has been shown to be an easy to perform, low-cost, biomarker of myocyte injury.Hypothesis:We hypothesized that hs-cTnT correlates with %ddcfDNA in heart transplant patients and complements %ddcfDNA to improve the non-invasive diagnosis of AR.Methods:The Genomic Research Alliance for Transplantation (GRAfT) is a multicenter, prospective, longitudinal cohort study of heart transplant patients transplanted between 2015 and 2021. The %ddcfDNA was quantitated with shotgun sequencing; hs-cTnT was measured on the Roche instrument. AR was ISHLT grade ≥2R acute cellular rejection (ACR) or pAMR ≥1 antibody-mediated rejection (AMR).Results:This analysis included 171 patients from the GRAfT cohort (mean age 52.3±12.4 yrs; 41% Black; 31% Female). Of the 1,030 simultaneous measurements of hs-cTnT and %ddcfDNA, 662 were paired with an endomyocardial biopsy. Median hs-cTnT was 1451 ng/L (IQR: 865-1931) on post-operative day 1 and decayed to 26 ng/L (IQR: 18-56) at approximately 90-days. The Spearman correlation between %ddcfDNA and hs-cTnT was ρ=0.52 (p

Circulation, Volume 146, Issue Suppl_1, Page A11659-A11659, November 8, 2022. Introduction:The prevalence of cardiovascular disease (CVD) has increased in patients with cancer, contributing significantly to mortality among cancer survivors. Cardiotoxicity of anti-cancer drugs may play a role in the development of CVD among cancer survivors, including incidence of acute myocardial infarction (AMI). We analyzed AMI rates in patients with non-small cell lung cancer (NSCLC) treated with one of four cancer regimens.Methods:We used national data from the Veterans Affairs (VA) Corporate Data Warehouse and VA Cancer Registry. We identified 9,619 veterans diagnosed with NSCLC during 2015-2019 who initiated one of four oncological therapies: chemotherapy, immune checkpoint inhibitors (ICI) with chemotherapy, ICI monotherapy, or tyrosine kinase inhibitors monotherapy (TKI). Patients were categorized according to the first therapy received. We identified subsequent hospitalizations for AMI within two years of initiating the oncological treatment. We estimated AMI rates per 100 patient-years and risk adjusted relative hazard ratio (HR) of AMI by treatment type using Cox Regression Model to adjust for age, AMI history, comorbidities, malignancy stage, and histology.Results:Among 9,618 veterans identified, 5,510 (57.3%) initiated treatment with chemotherapy, 2,820 (29.3%) ICI with chemotherapy, 829 (8.6%) with ICI monotherapy, and 459 (4.8%) with TKI. Over a follow-up period of 2 years, 158 (1.6%) patients experienced an AMI and 5,917 (61.5%) died. The incidence of AMI per 100 patient-years (95% CI) was as follows; chemotherapy 0.86 (0.70-1.06), ICI with chemotherapy 0.77 (0.58-1.03), ICI monotherapy 0.91 (0.52-1.60), and TKI 0.43 (0.16-1.15). When compared to chemotherapy alone, adjusted HR (95% CI) for ICI with chemotherapy, ICI monotherapy, and TKI were 1.09 (0.91-1.31), 1.02 (0.75-1.38), and 1.50 (0.94-2.37), respectively. When compared to TKI or ICI with chemotherapy, the ICI monotherapy cohort did not have a statistically significant adjusted HR for AMI risk.Conclusion:Among Veterans with NSCLC, the incidence of AMI was low and there was no difference in risk between the initial oncological regimens. The high competing risk of mortality in our cohort may also have contributed to the lack of between-group differences.

Circulation, Volume 146, Issue Suppl_1, Page A14633-A14633, November 8, 2022. Introduction:Acute coronary syndrome (ACS) occurring in the presence of a bleeding diathesis can make clinical decision-making difficult. We present a case of a non-ST elevation MI in the presence of an acquired factor VIII deficiency with an inhibitor present.Case:A 66-year-old male with a medical history significant for coronary artery disease and COPD presented with a 4-day history of persistent, profuse bleeding after attaining a laceration on his arm. Shortly after admission, he reported pressure-like chest pain relieved by sublingual nitroglycerin. His 5th generation troponin level was 61 ng/L on presentation and peaked at 600 ng/L 36 hours later. The EKG revealed ST depressions in leads V3 and V4 and T-wave flattening in leads V5 and V6. Transthoracic echocardiography revealed preserved ejection fraction but could not exclude wall motion abnormalities due to poor windows. Hematology was consulted due to uncontrolled bleeding, and the patient was diagnosed with acquired factor VIII deficiency with an inhibitor present. Low-dose heparin infusion was initiated. He was taken for a diagnostic left heart catheterization, which revealed left main with moderate obstruction, left anterior descending (LAD) with 70% proximal stenosis, and a small diagonal branch with 90% stenosis. The patient had been previously offered evaluation for coronary artery bypass graft(CABG) surgery but declined. CABG work up was ultimately deferred in favor of percutaneous coronary intervention based on literature review extrapolated from hemophiliac patients. The patient’s hematologic care is ongoing with recombinant antihemophilic factor, porcine sequence, prednisone, cyclophosphamide, and rituximab administration.Discussion:Choosing the type of coronary revascularization in coagulopathic patients poses a significant challenge. To avoid complications, a multidisciplinary approach to short- and long-term anticoagulation management is necessary. In this case we decided to use existing data that is based on hemophilia patients in the past with myocardial infarction where dual antiplatelet therapy is limited to 1 month with factor 8 activity maintained above 30%. Then transition to aspirin alone for maintenance with factor 8 levels maintained above 10%.

Circulation, Volume 146, Issue Suppl_1, Page A12855-A12855, November 8, 2022. Introduction:Nonalcoholic fatty liver disease (NAFLD) has become the most common liver disease worldwide. NAFLD patients have an increased risk of cardiovascular disease. Matrin-3 is a DNA- and RNA-binding protein, and its mutation causes amyotrophic lateral sclerosis in humans. Among these patients, 76% have hepatic steatosis. However, the role of matrin-3 in NAFLD has not been previously studied.Methods and Results:We found that matrin-3 expression is induced in fatty livers of humans and mice. Matrin-3 liver specific knockout mice (LKO) displayed increased levels of plasma triglycerides compared with matrin-3 floxed mice, while the body weights of the two groups of mice are similar after 16-week high-fat diet. Moreover, histological staining and triglyceride assay revealed that LKO mice had a 1.57- and 1.58-fold increase in hepatic lipid area and triglyceride levels, respectively, which associate with an increased liver/body weight ratio. Transcriptome and bioinformatics analysis identified 622 differentially expressed genes in LKO livers. Among them, 142 are target genes of constitutive androstane receptor (CAR), a transcription factor controlling the expression of many genes involved in xenobiotic and lipid metabolism. We also found that the expression of CAR and many CAR target genes was reduced in LKO livers. These data suggest that matrin-3 is important in CAR expression and matrin-3 knockout impairs CAR signaling. Interestingly, matrin-3 LKO mice had increased acute phase response and levels of phosphorylated Stat3 in the livers, indicating increased liver injury and inflammation. Mechanistically, impaired CAR signaling reversed the suppression of Plin2, Plin3, and Plin5 proteins that stabilize lipid droplet and inhibit lipolysis, and it reversed the suppression of interleukin 1 receptor type 1 that activates Stat3 signaling in LKO livers. Lastly, CAR expression positively correlates with matrin-3 expression in human livers (r=0.85,P=0.0002, n=13).Conclusion:matrin-3-CAR axis is an important mechanism to maintain lipid homeostasis and limit acute phase response in fatty livers. It can be potentially targeted to ameliorate hepatic steatosis and inflammation and reduce the risk of cardiovascular disease in NAFLD patients.

Circulation, Volume 146, Issue Suppl_1, Page A12732-A12732, November 8, 2022. BackgroundCardiac Sarcoidosis (CS) is a disease with variable presentation causing significant morbidity and mortality. Concurrent signs of myocardial injury as evidenced by troponin elevation add to the complexity of an already challenging diagnosis.CaseA 48-year-old female with no significant past medical history presented with episodes of presyncope for 2 months. ECG showed a bifascicular block. Troponin I was elevated to 7.29 ng/mL. 2D echo showed Left Ventricular (LV) systolic dysfunction with an LVEF of 40%. Heparin drip was initiated for a possible NSTEMI. Coronary angiography showed no evidence of epicardial coronary artery disease but showed an anomalous right coronary artery which on CT angiogram later showed no hemodynamically significant stenosis. Telemetry monitoring captured intermittent complete atrioventricular blocks. A biventricular implantable cardioverter-defibrillator was inserted. Due to concerns for infiltrative cardiac disease, a cardiac magnetic resonance (CMR) was done showing findings consistent with cardiac sarcoidosis (CS). CT scan of the chest showed radiographic evidence of pulmonary sarcoidosis, however, she declined further invasive workup. She was then started on systemic corticosteroids. 2D echo 6 months later revealed improvement in the LVEF to 55%.DiscussionOur case encompasses the variable presentation of CS including cardiac conduction abnormalities and LV systolic dysfunction. Concomitant troponin elevation in CS can mimic myocardial ischemia making the diagnosis more challenging. This highlights the importance of appropriate diagnostic acumen in approaching a case like this. Current guidelines now include non-invasive means for diagnosis including the use of CMR/PET CT, especially since endomyocardial biopsy has a low sensitivity. Treatment strategies aim to mitigate the long-term effects of CS on the heart, however, there is a paucity of data for appropriate pharmacological regimen.