Beta Blockers to Improve Post-MI Outcomes in Patients Without HF.

Section 6: Nonpharmacologic Management and Health Care Maintenance in Patients With Chronic Heart Failure

Outcomes In Patients On Chronic Inotropic Support Who Are Not Candidates For Advanced Heart Failure Therapies

Introduction: Cocaine is the second most commonly used illicit drug in the US, and the most frequent illicit substance to precipitate an emergency room visit. Cocaine is associated with acute and chronic complications affecting the cardiovascular system. Although Beta blockers (BB) have been shown to improve outcomes in patients with ACS, current ACC/AHA guidelines call for avoidance of BB in patients presenting with chest pain and suspected MI with recent cocaine use due to concern for precipitating coronary vasoconstriction. Recently new data has emerged on beta blockade following cocaine intoxication, demonstrating improved cardiovascular hemodynamics and patient outcomes. In this study we looked at clinical outcomes of patients with cocaine chest pain that received BB therapy. Methods: All patients presenting to the Thomas Jefferson University Hospital Emergency Department (ED) with a chief complaint of chest pain from April 2007 to September 2008 were included (n=5432). Retrospective chart review was conducted on 37 individuals with cocaine positive urine drug screen that received BB. Data was collected on gender, previous history of MI, outpatient BB therapy, and cardiovascular outcomes (hypertensive emergency, MI, stroke, cardiac arrest or death). Results: Of the 37 patients that were cocaine positive and received BB therapy, 33 were male, 18 had a prior MI, and 24 were on outpatient BB therapy. There were no reports of hypertensive emergency, stroke, cardiac arrest or death following BB therapy. Four patients were diagnosed with MI, but in all cases the troponin assay was positive prior to BB administration. When compared with cocaine positive patients who did not receive a BB, there was no significant increase in negative cardiovascular outcomes following BB therapy. Conclusions: We found no increase in adverse events or negative cardiovascular outcomes following Beta blocker therapy in patients with cocaine associated chest pain. This study adds to the body of evidence showing BB may not be harmful in patients with cocaine associated chest pain and myocardial ischemia. Given the strong evidence supporting BB use in ACS, further study is warranted to investigate whether BB therapy may be beneficial in certain cocaine chest pain patients.

Section 5: Management of Asymptomatic Patients with Reduced Left Ventricular Ejection Fraction

Management of Acute Coronary Syndromes

PO-05-201 ONE-YEAR LONG-TERM FOLLOW UP FOR POST-ACUTE SEQUELAE OF COVID-19 POTS PATIENTS

Recent studies have linked beta-blocker (BB) use in critical care settings with improved survival outcomes, potentially due to beta-adrenergic receptor (β-AR) blockade and associated anti-inflammatory effects. Given the immune system’s role in the development of graft-versus-host disease (GVHD)—a major complication of allogeneic hematopoietic stem cell transplant (allo-HCT)—we conducted a single-center retrospective review to assess the impact of BB use on acute GVHD (aGVHD) and other survival outcomes in patients undergoing their first allo-HCT. We analyzed 10 years of data (January 2010 to May 2020), including 105 patients who received a BB for more than four days before and after HCT, and 669 control patients who did not receive a BB. Patients on BBs had a lower incidence of aGVHD (55.2% vs. 65.8%, p = 0.036); however, this difference was not statistically significant in multivariate analysis (p = 0.150). When stratified by BB mechanism, outcomes varied: non-selective BBs were associated with lower post-HCT weight (p = 0.034), and vasodilating BBs showed a borderline reduction in length of stay (LOS) (p = 0.054). While our findings confirm the pharmacological safety of BBs in this population, they do not support their routine use for modifying allo-HCT outcomes. Future prospective studies with larger cohorts are needed to further explore the role of BBs in peri-HCT management and to clarify their clinical implications and therapeutic potential.

To investigate the impact of gender on early outcomes of patients with acute ST-segment elevation myocardial infarction (STEMI) who were treated with primary percutaneous coronary intervention (PCI) as their reperfusion strategy. The present study included consecutive patients with STEMI treated with primary PCI in our hospital from November 2003 to December 2012. Gender difference and predictors of 30 day all-cause death were examined among 957 patients, 197 of whom were women (20.6%). The impact of gender on 30 all-cause death was further evaluated by a propensity-matched analysis to adjust the differences in baseline characteristics between men and women. Compared with men, women were older ((69.4±10.2) years old vs. (60.6±12.6) years old, P<0.001), more likely to have hypertension (72.1% (142/197) vs. 54.6% (415/760), P<0.001) and diabetes (45.2% (89/197) vs. 32.4% (246/760), P = 0.001), but less likely to be treated with β-blockers (85.3% (168/197) vs. 92.0% (699/760), P = 0.006) and angiotensin converting-enzyme inhibitors/angiotensin-receptor blockers (82.2% (162/197) vs. 88.4% (672/760), P = 0.024). Symptom-to-balloon time was longer in women than in men (330 (240, 600) minutes vs. 270 (180, 450) minutes, P < 0.001). Multivariate linear regression analysis of log-transformed symptom-to-balloon time revealed that female gender was an independent predictor of longer symptom-to-balloon time (β = 0.141, 95% confidence interval (CI) 0.053-0.228, P = 0.002). Women with STEMI had higher unadjusted 30 day all-cause death (12.6% vs. 4.2%, P < 0.001) than men. Female gender independently predicted 30 day all-cause mortality both with (hazard ratio (HR) = 3.497, 95% CI 1.485-8.234, P = 0.004) and without (HR = 2.495, 95% CI 1.170-5.323, P = 0.018) the adjustment for baseline characteristics by propensity-matched analysis. Even with primary PCI as their reperfusion strategy, women with STEMI had higher 30 day all-cause death than men. Aggressive control of cardiovascular risk factors, adequate medical treatment and shortening of delay in reperfusion therapy might further improve the outcomes of female STEMI patients undergoing primary PCI.

The interaction between chronic medications on admission and the association between serum potassium level and outcome in patients with acute heart failure (AHF) are unknown. Observational intercontinental study of patients admitted with AHF. 15954 patients were included from 12 cohorts in 4 continents. Main outcome was 90-day mortality. Clinical presentation (medication use, hemodynamics, comorbidities), demographic, echocardiographic, and biochemical data on admission were recorded prospectively in each cohort, with prospective adjudication of outcomes. Positive and negative linear relationships between 90-day mortality and sK+ above 4.5mmol/L (hyperkalemia) and below 3.5mmol/L (hypo-kalemia) were observed. Hazard ratio for death was 1.46 [1.34-1.58] for hyperkalemia and 1.22 [1.06-1.40] for hypokalemia. In a fully adjusted model, only hyperkalemia remained associated with mortality (HR 1.03 [1.02-1.04] for each 0.1mmol/l change of sK+ above 4.5mmol/L). Interaction tests revealed that the association between hyperkalemia and outcome was significantly affected by chronic medications. The association between hyperkalemia and mortality was absent for patients treated with beta blockers and in those with preserved renal function. In patients with AHF, sK+ > 4.5mmol/L appears to be associated with 90-day mortality. B-blockers have potentially a protective effect in the setting of hyperkalemia.

Myocardial bridging with systolic compression of the left anterior descending coronary artery (LAD) may be associated with myocardial ischaemia. The clinical outcome in patients with surgical treatment for symptomatic myocardial bridging remains undetermined. This study assessed the middle- and long-term results of surgical treatment for symptomatic myocardial bridging. From 1997 to 2006, 37,463 patients received selective coronary angiography in the Fuwai Cardiovascular Hospital, Beijing, China. Of these, 484 patients had angiographic diagnosis of myocardial bridging. Of the 484 patients, 35 underwent surgery for treatment of myocardial bridging with significant systolic arterial compression. Among the surgical treatment patients, 24 presented with other cardiac disorders, and the remaining 11 symptomatic patients with isolated myocardial bridging were included in the follow-up study. The angiographic prevalence of myocardial bridging was 1.3% in this study. The coronary angiographies of the 11 patients revealed myocardial bridging in the middle segment of LAD causing systolic compression > or = 75% (ranging from 75% to 90%). The mean age of patients was 48.4 years. Surgical myotomy was performed in 3 patients and coronary artery bypass grafting (CABG) in 8 patients. Eight patients were operated on with an off-pump approach and 3 with a cardiopulmonary bypass technique after median sternotomy. Conversion to on-pump CABG surgery was necessary in 1 patient because of perforation of the right ventricle. The left internal mammary artery was used in all patients with CABG. The acute clinical success rate was 100% with respect to the absence of myocardial infarction, death or other major in-hospital complications. All of the patients were followed up clinically. The median follow-up was 35.3 months (range: 6 to 120 months). Nine patients were free from symptoms and one of them continued taking beta blockers. The remaining 2 patients with myotomy had atypical chest pain. One received coronary angiography again and no stenosis was found two years after operation; while exercise testing was performed in the other patient and revealed no evidence of myocardial ischaemia. None of the patients sustained a myocardial infarction or other major adverse cardiac events (death or vessel revascularization) during follow-up. Myocardial bridging is a relatively common angiographic finding. Surgical myotomy or CABG should be limited to patients who are refractory to oral medication. Surgical relief of myocardial ischaemia due to systolic compression of intramyocardial coronary arteries can be accomplished with low operative risk and excellent middle- and long-term results.

Characteristics, Management, and Outcomes of Cocaine-Positive Patients With Acute Coronary Syndrome (from the National Cardiovascular Data Registry)

5037Drug treatment with beta-blockers and long-term outcome in patients with takotsubo syndrome: results from the takotsubo Italian network

Influence of Comorbid Risk Factors and Prehospital Medications on Patients With Heart Failure in Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Prevalence, management and impact of chronic obstructive pulmonary disease in atrial fibrillation: a systematic review and meta-analysis of 4,200,000 patients.

792 Acute Coronary Syndrome in Patients With Normal or Non-Obstructive Coronary Artery Disease: Patient Characteristics and Long-Term Outcomes