Risultati per: Sindromi coronariche acute

Circulation, Volume 146, Issue Suppl_1, Page A14875-A14875, November 8, 2022. Introduction:Topological data analysis (TDA) is an emerging mathematical technique that imposes structure on a dataset and examines the shapes (or topological features) that arise. The TDA algorithm Mapper Plus is proposed to study the spatial characteristics of clinical data for the purpose of patient classification. This is a data-driven and hypothesis-free approach to clinical risk stratification.Hypothesis:The hypothesis is that Mapper Plus can classify distinctive subsets of patients receiving optimal treatments post-acute myocardial infarction (AMI). Our goal is to identify subgroups who remained at risk of having a future adverse event (AE) i.e., death, heart failure hospitalization, or recurrent MIMethods:A single-center, retrospective analysis of 31 clinical variables from the electronic health record (EHR) was conducted on 798 AMI subjects. Risk was defined as high or low in relation to the average probability of survival without AE for the entire cohort at the 1 year mark.Results:TDA identified six subsets of patients. Four subsets (n=597) had > 1-fold change on the probability of survival free of AEs; these became the low-risk subgroup. Two subsets (n=344) had < 1-fold change on the probability of survival free of AEs; these became the high-risk subgroup. Because Mapper Plus allows for subject overlap across subgroups, 143 subject (18%) were shared between the high (n=201, 25%)- and low-risk (n=454, 57%) subgroups and were extracted into a 3rd intermediate risk subgroup (see figure).Conclusions:TDA significantly stratified AMI patients into 3 subgroups with distinctive incidences of AE up to 3 years post AMI. This is a new framework for EHR-based risk stratification that requires no additional patient interaction, is agnostic to prior knowledge, and is driven by the topological features of the included data. Further studies will be needed to validate TDA across different patient cohorts before it can be applied to clinical practice.

Circulation, Volume 146, Issue Suppl_1, Page A11257-A11257, November 8, 2022. Introduction:The interventricular septum may play an important role in circuits that lead to ventricular tachycardia and ventricular fibrillation.Hypothesis:Among patients with ST-segment myocardial infarction elevation (STEMI), those presenting with cardiac arrest are more likely to have septal ischemia, defined as ST-elevation > 1 mm in V1, than those with other clinical presentations.Methods:A single-center retrospective review was conducted for all patients presenting with a STEMI from January 1, 2016-December 31, 2021. This identified a total of 60 consecutive patients with pre-intervention cardiac arrest and the first 60 patients in this time frame who presented without cardiac arrest. Both groups had had similar baseline characteristics. (Table 1).Results:A higher proportion of patients presenting with cardiac arrest had evidence of septal ischemia (Figure 1,29/60 versus 17/60, p

Circulation, Volume 146, Issue Suppl_1, Page A11986-A11986, November 8, 2022. Introduction:Patients with peripheral artery disease (PAD) are at high risk for adverse cardiovascular events, including acute myocardial infarction (AMI). Though AMI care has improved, in-hospital outcomes for patients experiencing an AMI with comorbid PAD are not well described in recent practice. We hypothesized that patients with PAD would have higher rates of bleeding and mortality during AMI hospitalization.Methods:We assessed clinical characteristics and in-hospital major bleeding and mortality rates of patients admitted with AMI and comorbid PAD at 646 hospitals in the NCDR Chest Pain MI Registry from 1/2019 to 9/2021. Major bleeding and mortality were compared for patients with vs. without PAD using multivariable logistic regression.Results:Compared with patients admitted for AMI without PAD (n = 307,550), those with PAD (n = 24,585) were older, had more comorbidities including tobacco use, diabetes, prior AMI and heart failure, and more frequently presented with NSTEMI vs. STEMI. Patients with PAD had higher crude rates of in-hospital major bleeding (9.7% vs. 6.3%) and mortality (8.1% vs. 4.7%); in exploratory analyses, rates of other adverse in-hospital events were also higher (Figure). After multivariable adjustment, PAD was associated with an increased risk of major bleeding (adjusted OR [aOR] 1.23 [95% CI 1.17-1.30]). PAD was also associated with greater risk of in-hospital mortality (aOR 1.28 [95% CI 1.21-1.37]), particularly among patients over age 65 (aOR 1.32 [95% CI 1.23-1.42] for ≥65 years vs. 1.06 [95% CI 0.96-1.18] for patients

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 A9234-A9234, November 8, 2022. Background:Perceived discrimination is associated with several risk factors for acute myocardial infarction (AMI), but little is known about the association between discrimination and health status outcomes post-AMI.Methods:We analyzed the 1- and 12-month health status of 2,670 young (≤ 55 years) adults recovering from an AMI enrolled in the VIRGO study (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients). Perceived discrimination was assessed using the Everyday Discrimination Scale (EDS). General health status was measured using the Short Form 12 Physical and Mental Component Scores (PCS and MCS). Disease-specific health status was measured using the following domains of the Seattle Angina Questionnaire (SAQ): treatment satisfaction (TS), quality of life (QL) and dichotomous forms of the physical limitation and angina frequency domain scores (score < 100). Lower scores indicate worse health status. Multivariable linear regression of the PCS, MCS, TS, and QL scores and multivariable logistic regression of the dichotomous forms of physical limitation and angina frequency were used to assess their adjusted associations with perceived discrimination.Results:Nearly 35.0% of the cohort reported discrimination (EDS > 0). At 1-month post-AMI, increased EDS score was significantly associated with lower MCS, TS, and QL scores and higher odds of physical limitation and angina after adjustment(Figure). At 12-months post-AMI, increased EDS score retained its significant associations with lower MCS and QL scores and higher odds of physical limitation and angina, but not its association with TS(Figure). The EDS score was not associated with PCS at either 1- or 12-months post-AMI.Conclusions:Perceived discrimination was associated with worse mental health and disease-specific health status one year after AMI after adjusting important confounders. Further work to understand the source and how to mitigate perceived discrimination is needed.

Circulation, Volume 146, Issue Suppl_1, Page A14940-A14940, November 8, 2022. Introduction:Failure of multidrug therapy and the multifactorial nature of kidney injury has paved the path way regenerative medicine with over 45 clinical trials using stem cells-based therapy underway. Neonatal cardiac mesenchymal stem cells (nMSC) are one of the most potent stem cells due to their secretome. HYPOTHESIS: SOD2 and anti-inflammatory miRNAs (miR-214 & 95p) in paracrine secretions (secretome) of nMSC provides renoprotection in a rodent model of glycerol-induced AKI.Methods:nMSC were generated from neonatal myocardium using enzymatic digestion and antibodies-based selection. Secretome was collected by conditioning nMSCs for 72 hours in serum free basal medium. Human kidney cells (HKC) were used forin vitroanti-oxidation assays using cisplatin. THP-1 cells were used for anti-inflammatory assessment. CD1 mice were used for glycerol-induced AKI model. Mice were subjected to AKI via IM glycerol (9mg/kg). nMSC-derived secretome was intravenously administered immediately after, or 4 hours post-glycerol. Blood urea nitrogen (BUN) and creatinine were analyzed in serum. Cell survival/KIM1 was assessed by immunohistology/FACS. Other experiments utilized cisplatin toxicity in HKC.Results:Administration of nMSC secretome (5 or 10mg/kg) at the same time or 4-hours post-glycerol administration significantly reduced serum creatinine and BUN in a glycerol induced AKI animal model. Caspase-9 and KIM1 expression was significantly decreased in tubular cells as compared to placebo at a dose of 10mg/kg. KIM-1 was significantly downregulated as compared to placebo following nMSC-secretome administration. Western blot analysis of HKC treated with cisplatin in presence of nMSC-secretome showed significant reduction in NFkb and pERK expression (p

Circulation, Volume 146, Issue Suppl_1, Page A13524-A13524, November 8, 2022. Background:With the increasing recreational use of Cannabis in the United States, there is limited data on the impact of Cannabis use on young females. Therefore, we aimed to assess the risk and outcomes of cardiovascular and cerebrovascular events in young females with Cannabis use disorder (CUD).Method:The National Inpatient Sample (2019) was assessed to identify young, female hospitalizations (age 18-44 years) with CUD using relevant ICD-10 codes. Baseline characteristics and comorbidities were compared between two cohorts, CUD + and CUD -. The primary outcome was acute cardiovascular and cerebrovascular events evaluated using a multivariable regression analysis adjusting for confounders.Result:Of 1,72,36,228 young female hospitalizations, 2% had CUD+ (n=340560). CUD+ arm consisted of younger (median age-34 vs 59), black patients (28.2vs15.5%) and had a higher rate of drug abuse (62.1% vs 3%), smoking (50.7% vs 12.4%) and alcohol abuse (13.9% vs 2.5%) when compared to CUD- cohort (p

Circulation, Volume 146, Issue Suppl_1, Page A13841-A13841, November 8, 2022. Background:Considering preliminary reports suggesting associations between peripheral atherosclerotic disease (cannabis arteritis) and acute ischemic stroke (AIS) with cannabis use disorder (CUD), we sought to study the burden and impact of CUD on AIS risk and outcomes in the elderly with PVD.Methods:The National Inpatient Sample (2016-2019) was used to identify geriatric PVD admissions with vs. without CUD . We compared the burden and risk of AIS admissions with vs. without CUD and subsequent in-hospital mortality using adjusted multivariable regression analyses.Results:Of 5,115,824 total geriatric admissions with PVD (50.6% males, 77.5% white), 21,405 had CUD. The prevalence of DM was lower in the CUD cohort (19.7% vs 33.7%) with comparable rates of HTN and smoking between groups [Table 1]. Concomitant drug use was higher in CUD vs non-CUD cohort. There was AIS period prevalence of 5.2% in CUD vs 4.0% in non-CUD cohorts (p

Circulation, Volume 146, Issue Suppl_1, Page A13880-A13880, November 8, 2022. Introduction:There are conflicting data on COVID-19 outcomes in pregnant women. Using the AHA COVID-19 CVD Registry we evaluated COVID-19 outcomes in pregnant vs non-pregnant women with COVID-19.Methods:Women 18-40 years old hospitalized from March 2020 to December 2021 with symptomatic COVID-19 were included (n=2,068), with 110 (5.3%) pregnant at admission. Women with unknown pregnancy status were excluded. Vaccine data were limited (2.8% of participants), therefore omitted from analysis. Baseline demographics and symptoms at presentation were compared between pregnant and non-pregnant women (Table). Rates of death, mechanical ventilation, ICU admission, hospital stay ≥5 days, myocardial infarction, stroke, DVT, PE, and a composite of all outcomes were determined. Multivariable Cox regression analyses were performed, adjusting for comorbidities and prior CVD.Results:Pregnant women hospitalized with COVID-19 had fewer comorbidities than non-pregnant women (Table). There were no deaths in the pregnant group and 44 (2.3%) in the non-pregnant group. Fewer pregnant women were hospitalized ≥5 days (29.1% vs 41.2% non-pregnant); this difference was not statistically significant after multivariable adjustment [adjusted HR (95% CI), 0.67 (0.43-1.02)]. There were no significant differences between the groups in the composite outcome [adjusted HR (95% CI), 0.72 (0.48-1.07)] or its components (Table).Conclusions:Pregnant women hospitalized with symptomatic COVID-19 had fewer comorbidities compared with non-pregnant women. There were fewer deaths and lower rates of hospitalization ≥5 days in pregnant vs non-pregnant women which was no longer statistically significant after multivariable adjustment. The potential for residual confounding due to healthier pregnant women presenting with milder COVID-19 illness or being admitted for non-COVID-19 indications compared to non-pregnant women must be considered when interpreting these findings.

Circulation, Volume 146, Issue Suppl_1, Page A10852-A10852, November 8, 2022. Introduction:Acute coronary syndrome (ACS) is a potential life-threatening emergency; therefore, rapid diagnosis and life-saving reperfusion therapies are essential to prevent adverse outcomes. Patients with suspected ACS experience an array of symptoms, which cause patients to seek care (9-1-1 or self-transport) to the emergency department [ED]). Little is known, however, about the prognostic value of symptom characteristics experienced in the very early period of evolving ACS and its impact on adverse patient outcomes. The purpose of this study was to determine if early symptom changes reported in the prehospital period are associated with adverse outcomes.MethodsAdults >21 years of age with non-traumatic chest pain and/or anginal equivalent symptoms transported by ambulance were included. Cardiac symptoms were measured prospectively with the ACS Symptom Checklist, a validated 13-item tool that takes approximately one-minute to complete. Trained EMS personnel administered the ACS Symptom Checklist during ambulance transport (T1) and research specialists measured symptoms again in the ED (T2), after acute triage care was completed. Symptom changes were categorized as an increase, decrease, or both from T1 to T2. Changes in symptoms between T1 and T2 were defined as stable (0-3 symptoms) or dynamic ( >4 symptoms). Adverse hospital outcomes included death, reinfarction, and/or new onset heart failure.ResultsTo date, a total of 280 patients presenting to the ED by ambulance with suspected ACS have been enrolled (mean age 60.1+15.5 years; 51.2% female; 14.3% final diagnosis of ACS). Of 255(91.1%) patients with complete data, 143(51.1%) experienced stable symptoms and 112(40%) experienced dynamic symptoms. Patients with stable changes had significantly higher rates of adverse outcomes compared to patients with dynamic changes (11.9 versus 2.9%, p=0.007). Patients reporting shortness of breath at T1 or T2 were over 4 times likely to experience an adverse event (p=0.003, p=0007).ConclusionsPatients with suspected ACS who have stable symptom changes were more likely to have an adverse hospital outcome. The underlying mechanism of plaque rupture in ACS may account for these differences in symptom characteristics but needs further study.

Circulation, Volume 146, Issue Suppl_1, Page A14904-A14904, November 8, 2022. Background:Post-transcatheter aortic valve replacement readmissions are increasingly the major focus of quality improvement efforts. Limited data exist about patient post-TAVR readmitted for acute coronary syndrome (ACS).Methods:The National Readmission Sample was queried from 2011-2017 for relevant ICD-9 and ICD-10 codes to identify patients who underwent TAVR who presented with ACS as primary diagnosis after indexed admission for TAVR. We identified 30-day and 90-day readmission rate, characteristics, mortality and in-hospital outcomes.Results:A total of 104,920 patients underwent TAVR. We identified 623 (0.6%) patients with primary diagnosis of ACS post-TAVR. From the patients who presented with ACS, 31% (n=193) and 41% (n=256) occurred within 30 days and 90 days of TAVR, respectively. Within 30-day and 90-day readmission for ACS post-TAVR, average age was 80.2 years and 80.3 years with 66.7% and 61.1% being male, respectively. Baseline characteristics are highlighted on Table 1. Mortality in patients post-TAVR who were readmitted in 30 days and 90 days for ACS was 14.8% and 9.3%, respectively.Conclusions:Although readmissions after TAVR in patients with ACS is relatively low (0.6%), they are associated with higher in-hospital mortality rate than the general population who present with ACS (~7 to 8%) and pose a higher health care burden.

Circulation, Volume 146, Issue Suppl_1, Page A9825-A9825, November 8, 2022. Background & Aim:Longitudinal data on prescription rates (PR) of guideline-directed medical therapy (GDMT) in patients with acute heart failure (HF) are scarce. We investigated GDMT patterns in patients with reduced (HFrEF), mildly reduced (HFmrEF), and preserved (HFpEF) ejection fraction (EF) and determined mortality risk.Patients & Methods:943 acute HF patients, consecutively recruited between 2015 and 2019, with EF measured while in hospital. PR of betablockers (BB), renin angiotensin system inhibitors (RASi), mineralocorticoid receptor antagonists (MRA), and diuretics were recorded on admission, at discharge, and 6-month follow-up.Results:Little more than one third of patients had HFrEF (Table). Patients with HFpEF were older and more often female. Irrespective of EF, comorbidity burden was high (Table). Mortality at 12 months was similar across HF phenotypes. TheFigureshows that PR of all disease-modifying drug classes increased from admission to discharge irrespective of HF phenotype. PR of MRA were highest in HFrEF. After 6-months, in HFrEF patients, PR of BB (-9%), RASi (-8%), and diuretics (-10%) had decreased again to admission levels. Similar patterns were apparent in HFmrEF and HFpEF including PR of diuretics (Figure). Treatment discontinuation of one or more disease modifying drug classes after discharge was frequent (38% in HFrEF, 29% in HFmrEF, 39% in HFpEF). Post-discharge discontinuation was associated with an age-adjusted increase of 12-month mortality risk (OR 10.9, 95%CI 7.6–15.7): for BB 24.5 (16.0–37.5); for RASi 17.6 (11.1–28.0); for MRA 12.3 (6.9–22.1); for diuretics 27.7 (18.3–42.1), with comparable impact across HF phenotypes.Conclusion:In this cohort of patients with AHF, prescription patterns of GDMT were often changed along the HF trajectory, yet similar across HF phenotypes and time. Irrespective of HF phenotype, stopping GDMT was associated with a consistently increased mortality risk.

Circulation, Volume 146, Issue Suppl_1, Page A9865-A9865, November 8, 2022. Introduction:Our objective was to investigate the frequency and distribution of new ischemic brain lesions detected by diffusion-weighted imaging (DWI) on brain MRI after aortic arch surgery.Methods:This was an imaging sub-analysis of the ACE CardioLink-3 randomized controlled trial which compared the safety and efficacy of innominate vs axillary artery cannulation during elective proximal aortic arch surgery. All participants in the trial underwent pre- and post-operative MRI. New ischemic lesions were defined as lesions on post-operative DWI that were not visible on the pre-operative DWI.Results:Of 102 patients who underwent surgery, 71 (70%) had new ischemic lesions on DWI and the total lesion number across all participants was 391. The average lesion number in patients with at least one ischemic lesion was 5.5±4.9, and were similar in the right (3.3±2.7) or left (3.6±2.8) hemispheres (p=0.49). The most common lesion patterns were single or multiple cortical infarcts. Half of the lesions (n=183, 47%) were in the middle cerebral artery territory, while 24% were in the infratentorium. 42% of patients had lesions distributed in both anterior and posterior circulation, 21% in anterior circulation only, and 7% in posterior circulation only. Besides, 20% had lesions in watershed areas. There were no differences in distribution between patients in the innominate vs axillary artery cannulation groups. In multivariable regression models, more severe white matter hyperintensity on pre-operative MRI (odds ratio per 1-score increase of Fazekas scale 1.80; p=0.02) and lower nadir temperature during operation (odds ratio per 1°C decrease, 1.14; p=0.05) were associated with having any new ischemic lesion, while older age (risk ratio per 1-year increase 1.02; p=0.03) and lower nadir temperature (risk ratio per 1°C decrease, 1.06; p=0.06) were associated with higher lesion numbers.Conclusion:In patients who underwent elective proximal aortic arch surgery, new ischemic brain lesions were common, and mostly identified as scattered cortical infarcts in the middle cerebral artery territory. Advanced age, underlying small vessel disease, and lower nadir temperature during operation were risk factors of presence and burden of new ischemic lesions after surgery.

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 A13038-A13038, November 8, 2022. Introduction:Hemolysis is a frequent complication in cardiogenic shock patients supported with Impella and can lead to acute kidney injury (AKI). We assessed the association between three hemolysis biomarkers, lactate dehydrogenase (LDH), plasma-free hemoglobin (pfHb), and haptoglobin, and AKI to determine the optimal biomarker in predicting AKI.Methods:Cardiogenic shock patients on Impella support (CP or 5.0) for more than 24 hours from 6/1/2016 to 9/1/2020 at the University of Washington Medical Center were retrospectively enrolled. By institutional protocol, the three biomarkers were measured daily while patients were on Impella support. The association between each biomarker and the development of stage 2 or worse AKI (creatinine increase of ≥ 100% or requiring hemodialysis) within 24 hours of biomarker collection was assessed using logistic regression. Plots of AKI probability over the range of values of each biomarker were constructed using natural splines.Results:Out of 251 included patients (mean age 56.2 ± 15.8 years, 78% male, 69% white), 128 (51%) developed stage 2 or worse AKI. LDH and pfHb values had statistically significant associations with the development of stage 2 or worse AKI within 24 hours of each measurement (OR 1.016 [95% CI 1.009-1.022] per 100 IU/L of LDH, OR 1.092 [95% CI 1.067-1.117] per 10 mg/dL of pfHb, p-value < 0.001 for both) while haptoglobin values did not (p-value 0.6). The association with AKI was stronger for pfHb compared to LDH (McFadden’s R20.12 for pfHb vs 0.03 for LDH). The association of each biomarker and AKI is illustrated in Figure 1.Conclusions:In cardiogenic shock patients supported with Impella, higher LDH and pfHb values were associated with AKI while haptoglobin values were not, and pfHb had a stronger association with AKI than LDH. Our results support the use of pfHb to detect hemolysis and risk of impending AKI in patients supported with Impella.Figure 1.Probability of stage 2 or worse AKI based on biomarker values.

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