Risultati per: Sindromi coronariche acute

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

Circulation, Volume 146, Issue Suppl_1, Page 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 A13947-A13947, November 8, 2022. Introduction:Hepatocyte Growth Factor (HGF) is a cytokine promoting cell survival via its receptor c-met. Heparin injection is known to induce a massive release of native HGF in blood. Heparin is used at the acute phase of myocardial infarction (MI). However, HGF release at the acute phase of MI and its potential cardioprotective effect is unknown.Hypothesis:We aimed to assess HGF kinetics in a cohort of ST-elevation myocardial infarction (STEMI) and its potential cardioprotective effect.Methods:We prospectively included consecutive STEMI patients admitted in our hospital from 2016 to 2019. All patients underwent coronary angiography with revascularization. Sera were collected at 5 time points (admission, 4 hours (H4), H24, H48 and 1 month after STEMI). Samples were stored at -80°C. HGF levels were assess by ELISA. We used a mouse model of myocardial ischemia reperfusion (ligation of the left anterior descending coronary artery followed by reperfusion) to evaluate HGF effect.Results:We included 230 patients. We observed an intense and early peak of HGF as early as admission, before revascularization (8750 pg/ml, IQR [8021-9492]) followed by a rapid decrease within the first 48h (p

Circulation, Volume 146, Issue Suppl_1, Page A14862-A14862, November 8, 2022. Introduction:Individuals presenting with acute decompensated heart failure (ADHF) have varying response to diuretic therapy and short- and long-term prognosis.Hypothesis:If machine learning can risk stratify patients with ADHF and identify subgroups at risk for diuretic resistance.Methods:Participants with ADHF from the ROSE-AHF and CARRESS-HF clinical trials were included (n=451) and clustered using multivariable finite-mixture models based on diuretic efficiency (fluid output over first 72 hours per total intravenous loop diuretic dose). Differences in diuretic efficiency, in-hospital length of stay, and in-hospital mortality were assessed using linear and logistic regression models. Phenogroups were externally validated in trial (DOSE/ESCAPE, ATHENA-HF) and real-world (GWTG-HF) cohorts.Results:Clustering identified 3 phenogroups. Participants in phenogroup 1 (n=271, 60%) had worse diuretic efficiency [median(IQR) = 11.6(6.6-17.9) mL/mg) compared with phenogroups 2 (n=145, 32%) and 3 (n=35, 8%) [median(IQR) = 16.3(11.2-23.9) and 20.2(12.3-49.9) mL/mg, respectively; p

Circulation, Volume 146, Issue Suppl_1, Page A11914-A11914, November 8, 2022. Introduction.Resident tissue macrophages (RTM) are essential cellular hubs regulating tissue homeostasis beyond their classical immune surveillance functions. Of note, after acute myocardial infarction (AMI), cardiac RTM have been shown to inhibit fibrosis, promote angiogenesis, and foster the anti-inflammatory response to injury by interacting with other immune cell types, such as monocytes and T lymphocytes, to drive them towards pro-healing phenotypes.Hypothesis.Using Single Cell RNA Sequencing, we identified a new subpopulation of cardiac RTM characterized by the expression of VSIG4 (B7 family-related protein V-set and Ig domain-containing 4). In this work, we hypothesized that VSIG4+ RTM display protective function in the infarcted heart.Method and results.Visg4deficient mice showed adverse cardiac remodeling and worsened cardiac function at day 14 and 28 after the onset of ischemia when compared to their wild-type littermates. Echocardiography-based transthoracic injection of FACS-sorted cardiac VISG4+ macrophages into infarcted hearts 2 weeks post-AMI, improved cardiac function in both WT andVsig4-/- mice, underlying the protective role of VSIG4+ RTM in this pathological setting. Conversely, injection ofVsig4-/- macrophages impaired cardiac function in WT andVsig4-/- animals. VSIG4 deficiency is associated with a higher number of neutrophils, inflammatory monocytes and macrophages but also with a reduction in the amount of CCR5+ regulatory T lymphocytes in the cardiac tissue without any changes in blood, bone marrow and spleen. In cultured peritoneal macrophages, a prototypical example of RTM, IL4 and IL13 stimulation improved VSIG4 mRNA and protein levels through IL4 receptor alpha and IL13 receptor alpha1 activation. IL4 and IL13 treatment also increased secretion of CCL3 and CCL4, two chemokine ligands of CCR5, these effects were blunted in VSIG4 deficient macrophages.Conclusion.VSIG4+ RTM are key regulators of cardiac remodeling after AMI likely through their ability to hamper inflammation and recruit protective regulatory T cells in infarcted heart.

Circulation, Volume 146, Issue Suppl_1, Page A330-A330, November 8, 2022. Background:Multiple reports demonstrate decreased emergency department (ED) utilization for cardiovascular emergencies during COVID-19. It is possible this decrease had downstream effects on the later severity of cardiovascular disease, especially in patients with higher social vulnerability. The purpose of this study was to determine the effect of early COVID-19 mitigation strategies on hospital resource utilization and acute myocardial infarction (AMI) admissions by social vulnerability.Methods:We retrospectively analyzed patients transported by emergency medical services (EMS) with a diagnosis of chest pain and/or AMI from a large urban Midwest EMS and single hospital system from Jan 1-Dec 31, 2020. Hospital office, telehealth, ED visits for chest pain, and hospital admissions for AMI were identified using the electronic health record. The 3 phases of COVID-19 mitigation were compared (pre-mitigation-Jan 1stto Feb 28th, mitigation-March 1stto April 30th, and post-mitigation-May 1st-December 31st). The socioeconomic status theme of the Social Vulnerability Index (SVI) was determined. The primary outcome was rate of AMI per ED chest pain visit, which was compared between the highest and lowest SVI quartiles. Statistical comparisons were made using binary logistic regression and Chi-squared tests.Results:Overall, there was a similar increase in telehealth visits and a decrease in office visits during mitigation in both highest and lowest SVI quartiles. In the post-mitigation phase, patients with the highest social vulnerability had a 30% relative increase rate of AMI per ED chest pain visit (7.3% vs 5.5%, p=0.048) compared to patients with lower social vulnerability. This increase was not seen in the pre-mitigation (5.8% vs 6.1%) or mitigation (4.9% vs 5.4%, each p=ns) phases.Conclusions:After initial COVID-19 mitigation strategies were implemented patients with higher socioeconomic vulnerability presented to the ED with AMI at a higher rate than patients with a lower socioeconomic vulnerability, despite no differences in office, telehealth, or EMS transport. Understanding the complex effect of pandemic mitigation strategies on vulnerable populations can provide guidance for resource management in future crises.

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 A10489-A10489, November 8, 2022. Introduction:The optimal transfusion strategy for patients with ACS is unclear. Current data are inconclusive and there is a paucity of long term data; therefore, we performed a subgroup analysis of patients with AMI in the Transfusion Thresholds in Cardiac Surgery (TRICS-III) randomized controlled trial (RCT) to add evidence addressing this important clinical question, and interpret the results in the context of a systematic review and meta-analysis.Methods:The TRICS-III trial randomized patients undergoing cardiac surgery on cardiopulmonary bypass with a moderate-to-high risk of death to restrictive transfusion (transfuse at hemoglobin

Circulation, Volume 146, Issue Suppl_1, Page A13575-A13575, November 8, 2022. Introduction:Patients who present to the hospital with acute coronary syndromes (ACS) often have poor control of cardiac risk factors. Multiple studies have demonstrated that lipid lowering therapy is not appropriately initiated or intensified in these patients.Hypothesis:We hypothesized that an interruptive alert delivered via the electronic medical record would increase the initiation and intensification of lipid lowering therapies.MethodsUsing Epic EHR (Epic Systems, Verona, WI), an interruptive alert was designed to trigger upon opening the patient’s chart when the patients were admitted with an ICD code that indicated an ACS (i.e., STEMI, NSTEMI, or Unstable Angina). The alert included an order set to obtain a cholesterol panel or if a cholesterol panel had already been collected it would be displayed and suggest modifications to the patient’s current medication regimen. These alterations included statin intensification or the addition of ezetimibe.ResultsBetween September 1, 2021 and May 30, 2022 172 unique patients were identified. The mean age was 64.8 ±13.8 years, 64.5% were male, 74% were white, and 12% were black. The identified patients had multiple comorbidities including cerebrovascular disease (23%), heart failure (47%), peripheral vascular disease (30%), and being a current or former smoker (53%). The triggered order set had a direct effect on 42 (24%) patients, with 10 initiating ezetimibe and 32 having their statins intensified. The most common indicated reason for overriding the alert (n=99) was not meeting criteria. Of these 99 patients, 4 were ultimately started on ezetimibe, 57 had their statin intensified, and 23 were appropriately excluded (including patients with type II myocardial infarctions who were not the target of this intervention). Of note, 15 patients should have received intensified therapy but had their alert over ridden.ConclusionsThis targeted alert led to direct intensification of lipid lowering therapy in 24% of ACS patients with an additional 35% of patients identified by the alert also having therapeutic intensification. This alert will remain in place to allow for further assessment of its effects and can be easily translated to other clinical systems.

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

Circulation, Volume 146, Issue Suppl_1, Page A13057-A13057, November 8, 2022. Background:European Society Cardiology guidelines recommend that the 0-hour/1-hour (0-1h) algorithm using high sensitivity cardiac troponin T (hs-cTnT) improves the early triage of patients with chest pain. To avoid the unnecessary admission including coronary angiography leads to decrease in medical costs. However, the economic consequences of applying the algorithm are unknown.Purpose: We compared the medical expenses to be affected by the implementation of this algorithm.Methods:We compared two prospective cohort study (one hospital has been implemented the 0-1h algorithm (cohort A), and the other has not (cohort B)) using a de-identified electronic medical record based on the database of health claims in Japan. Eligible patients were measured of hs-cTnT because of chest pain. We excluded patients with STEMI, heart failure or terminal kidney function. The 0-1h algorithm stratified patients into “rule-out,” “rule-in,” and “observation” based on the measurements of hs-cTnT levels at baseline and absolute changes at 1hour. Resource utilization (RU) and predicted diagnostic accuracy of the 0-1h algorithm compared to usual care in the emergency department (ED) were estimated. We then assumed that we implemented the 0-1h algorithm in cohort B by applying the diagnostic accuracy of the 0-1h algorithm to cohort B and compared it with the collected data achieved within 30 days of the index visit.Results:Consecutive 472 in cohort A (69.6 +/- 14.1 years old, 59.5% male) and 427 in cohort B (65.8 +/- 14.4 years old, 59.0% male) were followed. The prevalence rates of AMI were 7.4% and 3.3%. The sensitivity and specificity for the 0-1h algorithm in cohort A were 100% (91.1%-100%) and 95.0% (94.3%-95.0%), compared to 92.9% (69.6%-98.7%) and 89.8% (89.0%-90.0%) for usual care in cohort B. Assuming that the 0-1 algorithm is implemented in cohort B with the same diagnostic accuracy, emergency CAG is expected to be reduced by 50%, with a reduction in healthcare costs of approximately $ 1,500 to $ 2,500 per person. As a result, the implementation of the 0-1hr algorithm is expected to reduce medical costs by $ 31,500 to $ 52,500 in cohort B.Conclusions:The 0-1h algorithm dose not only efficiently stratifies risks, but can also be expected to reduce medical costs.

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 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 A12221-A12221, November 8, 2022. Introduction:Recent innovations in mechanical circulatory support (MCS) enable physicians to deal with challenging cases with cardiogenic shock. As the number of MCS has increased, the excessive workload of clinical engineers (CEs) who manage MCS has become a serious problem. To overcome such situation, we introduced innovative remote monitoring system of circulatory assist pump catheters (Impella) called Impella Connect (IC) from 2020, which allows medical staff to monitor driving status and alarms of Impella in their mobile devices. Here we reported our experience of IC and the safety and efficacy of our protocol using IC for management of Impella.Methods:We identified 63 Impella cases for cardiogenic shock from 2018 to 2021 in our institution. We utilized Impella 2.5/CP in 53 cases and Impella 5.0 in 10 cases depending on their hemodynamic condition. Before introducing IC (nIC period: n=17), CEs were responsible for Impella management in all time periods and needed to work overtime to manage devices in night time. However, after introducing IC (IC periods: n=46), CEs were responsible only in daytime and non-MCS expert medical stuff were responsible in night time supporting by CEs’ remote monitoring with IC. We retrospectively evaluated the safety and efficacy of our management using IC.Results:Impella insertion was performed emergently in all cases and the 34 cases (53.9 %) were inserted in night time. Average support time was 6.5±0.6 days (nIC 7.7 vs. 6.0 days). We encountered 13 device trouble in nIC periods (purge system in 8, pressure sensor in 4 and pump malfunction in 1) and 14 in IC periods (purge system in 9, pressure sensor in 3 and pump malfunction in 2). Device trouble requiring intervention was not significantly different in both periods (nIC/IC 10 vs. 11 cases, p=0.85) and adverse event related to delayed or inappropriate response was not observed in both periods. The average of overtime working hours of CEs per month was significantly decreasing in IC periods (53.1±16.8 vs. 8.6±2.6 hours per month, p

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